Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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Chapter 47  Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction
used on the anterior skin of the earlobe and a vertical linear
closure on the posterior surface if this helps attain the desired
lobule configuration.10 The Z-plasty may be widened to an
L-plasty,4 and can be performed with or without recon-
struction of the pierced canal in a similar way and closed
with simple interrupted sutures. If a canal is desired, a
small flap at the superior end of the split is preserved and
turned over and stitched on the anterior and posterior aspects.
Both Z-plasty and L-plasty repairs prevent notching at the
inferior border of the earlobe because the line of scar con-
tracture is broken up. Enlarging the arms of the L-plasty14
(Fig. 47.7) creates a triangular flap on the anterior surface
of one edge. The posterior surface of the other edge is cut
in the same way with a similar amount of tissue excised. The
resulting triangular flaps overlap. Sutures are placed on the
anterior and posterior sides with the consequent Z-suture
line at the inferior rim of the earlobe. This technique also
staggers the scar on the free border of the earlobe to avoid
notching.
A single layer side-to-side closure with Z-plasty at the
inferior margin of the earlobe15 (see Fig. 47.6) allows redirec-
tion of the vector of the wound contraction to decrease the
risk of notching. Tip stitches are not required because the
tips of the flaps are very small. The scar line of the Z-plasty
is concealed within the inferior rim of the earlobe and stitched
with simple interrupted sutures. If a canal is desired, a small
flap as described above can be created.
Two V-flap variants may be of use.16 In one, a 3-mm
V-shaped socket is cut from the fat on one side of the split
earlobe. On the other side of the split earlobe, an inverted
V-shaped joint is cut into the fat to receive the opposite side.
The flaps are stitched with simple interrupted sutures (Fig.
47.8). An alternative to this is the partially incised V-plasty17
which augments the earlobe’s thickness as two de-epithelial-
ized triangular areas are defined along the edges of the split.
The base of the triangle is placed on the inferior rim of the
earlobe and its apex pointed to the superior part of the split.
These two triangular areas are de-epithelialized and the raw
areas are moved to overlap each other, resulting in an increased
thickness of the earlobe. The suture lines are placed on the
anterior and posterior surface and they run obliquely rather
than overlap each other (Fig. 47.9).
Rotational flaps can be used if the lower border and the
lateral edge of the lateral part of the split are excised to
distances that will fit a rotational flap from the medial part
of the split (Fig. 47.10).18
Repair of the completely split earlobe with preservation
of the pierced canal
There are several techniques to repair the split earlobe with
preservation of the pierced canal – for example, the skin
edges can be joined below the pierced canal, or a flap can be
used to create an epithelialized canal. These techniques may
be used in the repair of partially split earlobes if desired.
Earrings, or a non-absorbable material such as 1-0 or 2-0
nylon sutures, are used to maintain the newly formed canal.
Preservation of skin at apex of the split earlobe allows the
split to be preserved with a side-to-side closure similar to that
shown in Figure 47.5, except that the untraumatized upper
pole of the canal is left in situ.1
Creation of a flap from a lateral portion of a split lobe6 uses
skin at the upper end of one side of the split to form a flap
eversion and reduce the risk of notching. Simple inter-
rupted or mattress sutures may be used for the rest of the
surgical line (Fig. 47.5). Undermining the wound edges 1 mm
prior to approximation to maximize wound eversion can be
useful.12
A small Z-plasty of the earlobe at the inferior pole of the
repair may diminish scar formation and contraction, further
reducing the risk of notching (Fig. 47.6).10,13 Z-plasty may be
Repair of partially split earlobe with punch technique
Figure 47.3  Punch technique to de-epithelialize the split area
(Tan’s technique).
Repair of partially split earlobe with parallel flaps
Figure 47.4  Parallel flaps are created on the anterior and
posterior surfaces of the earlobe (Reiter & Alford’s technique).10

784
Part 4  Special Procedures
Postoperative care
Regular daily wound care is advised and suture removal is
performed 7–14 days after the procedure.
Pitfalls and their management
The potential complications of split earlobe repair include
bleeding, infection, notching of the earlobes, hypertrophic
scars, and keloids. Methods to manage these complications
are summarized below.
(Fig. 47.11) whose superiorly based skin is trimmed to the
appropriate length, turned, and sutured to the opposite side
of the split to form a pierced canal. A suture-free floor of the
newly formed canal minimizes the risk of split recurrence.
This can be combined with a Z-plasty as described above to
prevent notching.3,19 Many variations on these techniques
have been described.20–25
Optimizing outcomes
Modifications to optimize outcomes include avoiding cross-
hatching of the inverted ‘V’ excision at the superior end of
the complete split and at both ends of the partial splits. ‘Dog
ear’ removal at the apex of the split compensates for the
length differences. When a partial split is nearly complete and
the excision of epithelialized tract at the inferior border is
difficult, the tissue at the inferior margin of the split may be
discarded and the repair carried out as for a completely split
earlobe. If repiercing is considered, it should be delayed at
least 6 weeks, though a pierced canal that allows the weight
of the earring to be carried directly on the repair scar may
result in a recurrence of the split. The repierced site should
not be placed directly over the repair scar line. Wearing heavy
earrings should be avoided.
A
B
C
D
E
F
Repair of completely split earlobe
Figure 47.5  Use of vertical
or horizontal mattress
sutures to close the area.
(A,B) Split earlobe. (C)
Repair of rim with vertical
mattress sutures and
remainder of split with simple
interrupted sutures. (D)
Repair of rim with horizontal
mattress sutures and
remainder of defect with
simple interrupted sutures.
(E) Repair of entire split with
vertical mattress sutures. (F)
Repair of entire split with
horizontal mattress sutures.
Pitfalls and their management
 Bleeding is managed by external compression.
 Infection requires antibiotics and wound care.
 Notching of earlobes can occur and will require scar revision.
 Hypertrophic scars can be treated with intralesional
corticosteroids, silicone gel sheeting, cryotherapy, or laser
therapy.26,27
 Keloids (see Chapter 41) require combination therapy,
including some or all of the following: surgical excision,
intralesional corticosteroids, intralesional interferon, silicon gel
sheeting, cryotherapy, and laser therapy.27–37

785
Chapter 47  Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction
Z-plasty at the inferior margin
Figure 47.6  Side-to-side closure with Z-plasty at the rim of the
lobe (Casson’s technique). Note how points A and B transpose.
L-plasty: anterior and posterior
Figure 47.7  Interlocking L-plasty flaps formed by partial
incision anteriorly and posteriorly (Harahap’s technique).
Interlocking V-incisions
Figure 47.8  Interlocking V-incisions of the medial and lateral
portions of the split earlobe (Kalimuthu’s technique).
Partially incised V-plasty: anterior and posterior
Figure 47.9  Partially incised V-plasty of the anterior and
posterior flaps (Arora’s technique).

786
Part 4  Special Procedures
Summary
Symmetrical and rounded earlobes give the ears a good aes-
thetic appearance. An individually tailored approach to the
repair of a split earlobe and an understanding of surgical
techniques and wound healing improve the chances of a cos-
metically acceptable outcome.
Rotational flap
Figure 47.10  De-epithelialization of the wound edges (Effendi’s
technique).
Creation of flap from lateral portion of the split lobe
Figure 47.11  Creation of a flap from the lateral portion of
the split lobe forms a tract for the earring (Pardue’s
technique).
One-needle technique
Figure 47.12  One-needle technique for ear piercing.
 EAR PIERCING
Introduction
Several techniques of earlobe piercing are available, such as
the intravenous cannula stent, the needle, and the spring-
loaded piercing gun.38–45 Ear piercing in the cartilaginous
portion of the ear may be complicated by chondritis, cartilage
necrosis, and auricular deformity.
Preoperative preparation
The evaluation should include taking a history of hypertrophic
scar or keloid formation, finding out about allergic reactions
to metallic components of earrings, and asking about the
desired site of piercing. Patients with earlobes less than 4 mm
in thickness should be informed about the increased risk of
developing split earlobes and the need to be careful about the
weight of earrings.10 Nickel-free stainless steel earrings are
preferred; these should be cold sterilized in alcohol for 30
minutes. With respect to the instruments, a 16-gauge or
18-gauge needle will be required.
Both sides of the earlobes are cleansed with antiseptic and
the desired piercing site is marked. Local anesthesia to the
earlobe is provided by lidocaine injection with a 30-gauge
needle. An ice cube or cooling spray on the earlobe may be
used to numb the area prior to any piercing procedure.
Technical aspects
Needle techniques
One-needle technique
The points on the anterior and posterior surface of the ear-
lobes where the earrings are to be placed are marked with
gentian violet or a marking pen. The marking should be made
in the middle of the earlobe and the patient should be allowed
to see and approve this mark using a hand-held mirror. The
earlobe is anesthetized with 1% lidocaine. A 16-gauge or
18-gauge needle is inserted at the posterior surface of the
earlobe in a plane perpendicular to it (Fig. 47.12). The needle
is directed and advanced anteriorly to exit at the marked
point on the anterior surface of the earlobe. The post attached

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Chapter 47  Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction
to the earring stud is then inserted into the barrel of the
needle, and this is then drawn back through the earlobe. The
needle is removed from the earring post, which protrudes
from the posterior surface of the earlobe. The earring clasp
is attached to the earring post.43
Two-needle technique
The desired piercing sites are marked anteriorly and posteri-
orly on the earlobe, and anesthetized. A 30-gauge needle is
inserted through the earlobe in the anterior-to-posterior
direction. Local anesthesia may be injected with the insertion
of the 30-gauge needle.45 A 16-gauge or 18-gauge is slipped
over the 30-gauge needle at the posterior aspect of the
earlobe. Both needles are drawn toward the anterior surface
of the earlobe, and the 30-gauge needle is then removed from
the other needle. The earring post is inserted into the lumen
of this remaining needle, and drawn posteriorly through the
earlobe. The needle is removed and the earring clasp is fas-
tened onto the earring post (Fig. 47.13).
Ear-piercing kits
Commercial ear-piercing kits are more convenient but offer
no advantages over these methods. Two available ear-piercing
kits are the Steri-Quick ear-piercing kit (Roman Research,
Norwell, MA) and the Debut Prestige ear-piercing kit (H&A
Enterprises, Inc, Whitestone, NY). Embedded earrings may
be associated with the use of ear-piercing guns. Care must be
taken to ensure that the earring clasp is not too tightly fixed
against the earlobe.
Modifications
Some patients have asymmetric earlobes, with one earlobe
more pendulous than the other. The piercing sites of both
earlobes should be adjusted to prevent one earring from
appearing higher than the other.
To avoid drooping of the earrings, the needle is advanced
slightly superiorly toward the anterior surface of the earlobe
in the one-needle technique or directed slight inferiorly
toward the posterior surface of the earlobe in the two-needle
technique.
Two-needle technique
Figure 47.13  Two-needle technique for ear piercing.
Optimizing outcomes
The aim of ear piercing is accurate placement of the earrings
and to ensure that the patient is satisfied with the piercing
site. Therefore it is important that both earrings are on the
same horizontal level. The pierced canal should become fully
re-epithelialized so that earrings can be worn without diffi-
culty. There should be no evidence of allergic reaction, of
infection, of hypertrophic scars or of keloids.
Postoperative care
The earrings should be kept in place until the tract is well
formed, which usually occurs in 2–3 weeks. The patient
should be advised to clean both sides of the ears underneath
the earrings with sterile saline or hydrogen peroxide twice a
day for 2 weeks or until the tract has epithelialized, and to
rotate the earrings twice a day to prevent the formation of
adhesions. The piercing earrings may be removed and another
pair inserted after 4–6 weeks. People should be warned that
long-term wearing of heavy earrings is best avoided due to
the likelihood of developing split earlobes – especially if they
have thin earlobes.
Pitfalls and their management46–79
Pitfalls and their management
 Use scrupulous aseptic technique and select appropriate
earrings to reduce complications such as infection and
embedding of earrings in the earlobe.
 Advise patients on daily wound care and prescribe local and
systemic antibiotics if infection occurs.
 Recommend that patients use nickel-free posts to avoid
development of allergic contact dermatitis.
 Screen out patients who have thin earlobes, because they are
most at risk for split earlobes and elongation of the piercing
tract.
Embedded earrings
Earrings may become embedded in the earlobe, especially
when the earlobes are thick. This complication occurs more
frequently with the use of spring-loaded ear-piercing instru-
ments.60,61 Patients present with a tender cyst or keloid-like
nodule within the earlobe.62,63 Embedded earrings can be
avoided by using aseptic technique, confining ear piercing to
the earlobe, using earrings with larger clasps and longer posts,
not securing the clasp too tightly against the earlobe, and
removing the earrings if infection develops.
Management includes the removal of the embedded ear-
rings under local anesthesia. An incision may be required to
assist the extraction. Thereafter, the area should be cleansed
daily and topical antibiotics applied. Earrings can be rein-
serted after the swelling and tenderness have disappeared. In
some cases, the ear may need to be repierced at a later date.
Infections
Local bacterial infection is the most common complication of
ear piercing. Purulent drainage, swelling, persistent redness,
and delayed healing are evident. Staphylococcal sepsis, toxic

788
Part 4  Special Procedures
cosmetic outcome. The equipment to be prepared in advance
includes a general dermatologic surgery tray with a #15 sur-
gical blade, a chalazion clamp, non-absorbable 5-0 or 6-0
suture for cutaneous closure, and absorbable 5-0 or 6-0 suture
for subcutaneous closure. Antiseptic cleansing of both sides
of the earlobes is required. Local anesthesia is then injected
into the earlobe.
Technical aspects
A chalazion clamp can be used to stabilize the earlobe and
control bleeding. Simple interrupted sutures may be used to
close the resulting defect. At the earlobe margin, a Z-plasty
may be used to reduce scar contraction and subsequent
notching of the earlobe.
Wedge excision may be performed on the medial, lateral,
or inferior portion of the enlarged earlobe; the preferred loca-
tion is the inferior portion of the enlarged earlobe because of
the superior vascular supply. Closure after removal of excess
tissue is similar to that shown in Figure 47.5.
Elliptical excision
The ellipse may be performed at the inferior, medial, or
lateral border of the earlobe as shown in Figure 47.14. One
approach allows the scar line to be hidden on the posterior
surface of the earlobe.95–98
Lateral earlobe excision techniques are shown in Figure
47.15.98 A notch may develop with any of these techniques
as the end of the suture line remains on the lateral free margin
of the earlobe.
Medial earlobe excision techniques prevent notching
because the end of the suture line is on the anterior margin
of the earlobe. Techniques are shown in Figure 47.16.99–105
Care must be taken to avoid pulling the earlobe outward, as
this results in an increased angle between the earlobe and
the jawline and the scar line may be visible. L-plasty with a
superiorly based wedge106 is a technique suitable for the
shock syndrome, acute poststreptococcal glomerulonephritis,
osteomyelitis, viral hepatitis, and tuberculosis have been
reported.46,47,61–63,80–82 Management includes daily wound care
and the removal of earrings so that drainage can occur. Topical
and systemic antibiotics should be given. The tract may be
occluded after the infection subsides. Repiercing should only
be performed after complete healing of the wound.
Piercing of the auricular cartilage may lead to perichondrial
infection, auricular chondritis, cartilage necrosis, and result-
ant auricular deformity.83–85 The responsible organisms most
commonly found in these patients are Pseudomonas aerugi-
nosa and Staphylococcus aureus.48,84,86,87 Management of these
infections includes an appropriate systemic antibiotic. Inci-
sion and drainage, wound debridement, and subsequent
auriculoplasty may be required.86,88
Hypersensitivity and allergic contact dermatitis
Ear piercing is an important risk factor for nickel sensitiza-
tion.89–92 Therefore it is recommended that patients start with
earring posts that are nickel free and made of either stainless
steel or 24-carat gold. The use of an intravenous catheter as
an earring-post sheath allows nickel-sensitive individuals to
wear earrings in pierced ears on a limited basis.93 A sarcoidal-
type allergic contact granuloma due to palladium has been
reported.94
Hypertrophic scars or keloid formation
Hypertrophic scars may be treated with intralesional corti-
costeroids, silicone gel sheeting, cryotherapy, pulsed-dye
laser, or a combination of these methods.26,27 For keloids,
these treatments may be combined with surgical excision,
intralesional interferon, and external compression (see also
Chapter 41).27–37
Elongation of the ear-piercing tract and
split earlobes
These complications are likely to occur in patients who have
earlobes of less than 4 mm in thickness and who wear heavy
earrings.10
Summary
Patients who undergo ear piercing should be screened care-
fully. The thickness of the earlobe should be evaluated. The
lack of aseptic technique and improper postoperative care
contribute significantly to the complications associated with
ear piercing.
 EARLOBE REDUCTION
Introduction
Earlobes lengthen, droop, and broaden as a result of gravity
and aging, or dermatitis. Unusually large earlobes may occur
congenitally. Several techniques for reducing the size of the
earlobes have been described.
Preoperative preparation
Patient evaluation should include taking a history of hyper-
trophic scars or keloids, and inquiring about the patient’s
wishes about the size of the earlobes and expectations of the
Anterior
Posterior
Crescentic excision of redundant earlobe
Figure 47.14  Crescentic excision to remove redundancy
(McCoy, Stark, and Tipton’s technique).

789
Chapter 47  Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction
Joseph's
Denecke's
Tanzer's
Enna's and
Delgado's
Lewis's
Earlobe reduction techniques at the lateral portion of the earlobe
Figure 47.15  Techniques for earlobe reduction at the lateral portion of the earlobe.
Earlobe reduction techniques used at the medial portion of the earlobe
Eitner's
Miller's and
Guerrero-Santos's
Rubins's
Loeb's
Constant's
Lassus's
McCollough's
Figure 47.16  Techniques for earlobe reduction at the medial portion of the earlobe.

790
Part 4  Special Procedures
10. Reiter D, Alford EL. Torn earlobe: a new approach to management with
a review of 68 cases. Ann Otol Rhino Laryngol 1994;103:879–884.
11. Vujevich J, Obagi S. Repair of partial earlobe cleft using a ‘purse-string’
repair. Dermatol Surg 2006;32:969–971.
12. Apesos J, Kane M. Treatment of traumatic earlobe clefts. Aesthetic
Plast Surg 1993;17:253–255.
13. Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in dermato-
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14. Harahap M. Repair of split earlobes. A review and a new technique. J
Dermatol Surg Oncol 1982;8:187–191.
15. Casson P. How do you repair a split earlobe? J Dermatol Surg 1976;
2:21.
16. Kalimuthu R, Larson BJ, Lewis N. Earlobe repair: a new technique. Plast
Reconstr Surg 1984;74:299–300.
17. Arora PK. Reconstruction of the middle-aged torn earlobe: a new
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18. Effendi SH. Reconstruction of the middle-aged torn earlobe: a new
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19. Walike J, Larrabee WF Jr. Repair of the cleft ear lobe. Laryngoscope
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20. Buchan NG. The cleft ear lobe: a method of repair with preservation
of the earring canal. Br J Plast Surg 1975;28:296–298.
21. Argamaso RV. The lap-joint principle in the repair of the cleft earlobe.
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22. Zoltie N. Split earlobes: a method of repair preserving the hole. Plast
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23. Elsahy NI. Reconstruction of the cleft earlobe with preservation of the
perforation for an earring. Plast Reconstr Surg 1986;77:322–324.
24. Fayman MS. Split earlobe repair. Br J Plast Surg 1994;47:293.
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26. Ketchum LD, Cohen IK, Masters FW. Hypertrophic scars and keloids.
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27. Babin RW, Ceilley RI. The freeze-injection method of hypertrophic
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28. Griffith BH, Monroe CW, McKinney P. A follow-up study on the treat-
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29. Ashbell TS. Prevention and treatment of earlobe keloids. Ann Plast Surg
1982;9:264–265.
30. Griffith BH. The treatment of keloids with triamcinolone acetonide.
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31. Hirshowitz B, Lerner D, Moscona AR. Treatment of keloid scars by
combined cryosurgery and intralesional corticosteroids. Aesthetic Plast
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32. Shons AR, Press BH. The treatment of earlobe keloids by surgical exci-
sion and postoperative triamcinolone injection. Ann Plast Surg
1983;10:480–482.
33. Brent B. The role of pressure therapy in management of earlobe keloids:
preliminary report of a controlled study. Ann Plast Surg 1978;1:579–
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34. Salasche SJ, Grabski WJ. Keloids of the earlobes: a surgical technique.
J Dermatol Surg Oncol 1983;9:552–556.
35. Pollack SV, Goslen JB. The surgical treatment of keloids. J Dermatol
Surg Oncol 1982;8:1045–1049.
36. Kantor GR, Wheeland RG, Bailin PL, et al. Treatment of earlobe keloids
with carbon dioxide laser excision: a report of 16 cases. J Dermatol Surg
Oncol 1985;11:1063–1067.
37. Shepherd JP, Dawber RP. The response of keloid scars to cryosurgery.
Plast Reconstr Surg 1982;70;677–682.
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simultaneous repair of split earlobe and reduction of the
earlobe size (Fig. 47.17).
Optimizing outcomes
The enlarged earlobe is reduced according to the patient’s
desired size and shape. The scar line is concealed within the
crease of the earlobe. No notching occurs.
Postoperative care
The wound must be cleaned daily. Sutures can be removed
after 7–14 days.
Pitfalls and their management
These are the same as for repair of the split earlobe.
Summary
Reduction of the earlobe is a simple surgical procedure giving
pleasing results with the techniques described above.
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Earlobe reduction at the inferior portion of the earlobe
Figure 47.17  Inferiorly based earlobe reduction with an L-plasty
with superiorly based wedge (Fearon’s technique).

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Chapter 47  Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction
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by high ear-piercing: case report. Ann Plast Surg 2003;50:82–84.
89. Nakada T, Iijima M, Nakayama H, et al. Role of ear piercing in metal
allergic contact dermatitis. Cont Dermatitis 1997;36:233–236.
90. McDonagh AJ, Wright AL, Cork MJ, et al. Nickel sensitivity: the influ-
ence of ear piercing and atopy. Br J Dermatol 1992;126:16–18.
91. Nielsen NH, Menne T. Nickel sensitization and ear piercing in an unse-
lected Danish population. Glostrup Allergy Study. Cont Dermatitis
1993;29:16–21.
92. Dotterud LK, Falk ES. Metal allergy in north Norwegian schoolchildren
and its relationship with ear piercing and atopy. Cont Dermatitis
1994;31:308–313.
93. Cornetta AJ, Reiter D. Ear piercing for individuals with metal hyper-
sensitivity. Otolaryngol Head Neck Surg 2001;125:93–95.
94. Thijs L, Deraedt K, Goossens A. Granuloma possibly induced by pal-
ladium after ear piercing. Dermatitis 2008;19:E26–E29.
95. Tipton JB. A simple technique for reduction of the earlobe. Plast Recon-
str Surg 1980;66:630–632.
96. McCoy FJ, Macrotia. In: Masters FW, Lewis JR Jr, eds. Symposium on
aesthetic surgery of the nose, ears and chin. St Louis: Mosby 1973;
160–164.
97. Stark RB. Plastic surgery. New York: Harper and Row; 1962.
98. Barsky A. Principles and practice of plastic surgery. Baltimore: Williams
& Wilkins; 1950.
99. Miller CC. Cosmetic surgery: the correction of featural imperfections.
Philadelphia: Davis; 1925.
100. Rubin LR, Bromberg BE, Walden RH, et al. An anatomic approach to
the obtrusive ear. Plast Reconstr Surg 1962;29:360–370.
101. Loeb R. Correction of hypertrophy of the lobule of the auricle. Rev
Latinoam Cir Plast 1965;9:186–192.
102. Guerrero-Santos J. Correction of hypertrophied earlobes in leprosy.
Plast Reconstr Surg 1970;46:381–383.
103. Constant E. Reduction of the hypertrophic earlobe. Plast Reconstr Surg
1979;64:264–267.
104. Lassus C. Another technique for the reduction of the earlobe. Aesth
Plast Surg 1982;6:43–45.
105. McCollough EG, Hom DB. Correction of the enlarged earlobe: auricu-
lar lobuloplasty – an adjunctive face-lift procedure. Laryngoscope
1989;99:1193–1194.
106. Fearon J, Cuadros CL. Cleft earlobe repair. Ann Plast Surg 1990;24:252–
257.
47. Ahmed-Jushuf IH, Selby PL, Brownjohn AM. Acute post-streptococcal
glomerulonephritis following ear piercing. Postgrad Med J 1984;60:73–
74.
48. Turkeltaub SH, Habal MB. Acute Pseudomonas chondritis as a sequel
to ear piercing. Ann Plast Surg 1990;24:279–282.
49. Mamtani R, Malhotra P, Guptal PS, et al. A comparative study of urban
and rural tetanus in adults. Int J Epidemiol 1978;7:185–188.
50. Van Sciver AE. Hepatitis from ear piercing. JAMA 1969;207:2285.
51. Johnson CJ, Anderson H, Spearman J, et al. Ear piercing and hepatitis.
Non-sterile instruments for ear piercing and the subsequent onset of
viral hepatitis. JAMA 1974;227:1165.
52. Hayes MO, Harkness GA. Body piercing as a risk factor for viral hepa-
titis: an integrative research review. Am J Infect Control 2001;29:271–
274.
53. Morgan LG. Primary tuberculosis inoculation of an earlobe. J Pediatr
1952;40:482–485.
54. Olmstead PM, Finn M. Botryomycosis in pierced ears. Arch Dermatol
1982;118:925–927.
55. Cortese TA, Dickey RA. Complications of ear piercing. Am Fam Physi-
cian 1971;4:66–72.
56. Fisher AA. Ear piercing and sensitivity to nickel and gold. J Am Acad
Dermatol 1987;17:853.
57. Christensen OB. Nickel dermatitis. An update. Dermatol Clin
1990;8:37–40.
58. Fisher AA. Ear piercing and nickel allergy. Cont Dermatitis 1986;14:328.
59. Boss A, Menne T. Nickel sensitization from ear piercing. Cont Derma-
titis 1982;8:211–213.
60. Muntz HR, Pa-C DJ, Asher BF. Embedded earrings: a complication of
the ear-piercing gun. Int J Pediatr Otorhinolaryngol 1990;19:73–76.
61. Cockin J, Finan P, Powell M. A problem with ear piercing. BMJ
1977;2:1631.
62. Saleeby ER, Rubin MG, Youshock E, et al. Embedded foreign bodies
presenting as earlobe keloids. J Dermatol Surg Oncol 1984;10:902–
904.
63. Smith RB. Earring clasp as a foreign body in the earlobe. Plast Reconstr
Surg 1978;62:772.
64. Cheng LH. Keloid of the ear lobe. Laryngoscope 1972;82:673–681.
65. Cosman B, Wolff M. Bilateral earlobe keloids. Plast Reconstr Surg
1974;53:540–543.
66. McLaren LR. Surgery of the external ear. J Laryngol Otol 1974;88:23–
38.
67. Jay AL. Ear-piercing problems. BMJ 1977;2:574–575.
68. Pardue AM. Repair of torn earlobe with preservation of the perforation
for an earring. Plast Reconstr Surg 1973;51:472–473.
69. Harahap M. Repair of split earlobes. A review and a new technique. J
Dermatol Surg Oncol 1982;8:187–191.
70. Buchan NG. The cleft ear lobe: a method of repair with preservation
of the earring canal. Br J Plast Surg 1975;28:296–298.
71. Iwatsuki K, Tagami H, Moriguchi T, et al. Lymphadenoid structure
induced by gold hypersensitivity. Arch Dermatol 1982;118:608–611.
72. Iwatsuki K, Yamada M, Takigawa M, et al. Benign lymphoplasia of the
earlobes induced by gold earrings: immunohistologic study on the cel-
lular infiltrates. J Am Acad Dermatol 1987;16:83–88.
73. Aoshima T, Oguchi M. Intracytoplasmic crystalline inclusions in dermal
infiltrating cells of granulomatous contact dermatitis due to gold ear-
rings. Acta Derm Venereol 1988;68:261–264.
74. Ellis DA. Complication and correction of the pierced ear. J Otolaryngol
1976;5:247–250.
75. Mann RJ, Peachey RD. Sarcoidal tissue reaction – another complication
of ear piercing. Clin Exp Dermatol 1983;8:199–200.
76. Van den Nieuwenhuijsen IJ, Calame JJ, Bruynzeel DP. Localized argyria
caused by silver earrings. Dermatologica 1988;177:189–191.

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PART 5
Office-based Surgery:
Physical and
Regulatory

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795
48
Design of the Surgical Suite, Including
Large Equipment and Monitoring Devices
Ross M Levy MD and C William Hanke MD MPH FACP
Summary box
 Design and plan the suite about 12–18 months in advance of
the anticipated starting date for using the suite.
 Consult experts in medical office design and construction.
 Decide which type of surgical facility is right for your practice.
 Decide if accreditation should be pursued.
 A bigger facility can often be better in the long term.
 Ensure patient privacy.
 Plan for plenty of storage.
 Ensure that walls and floors are washable.
 Equip surgical rooms with power operating tables.
 Plan for maximum use of light.
 Consider used equipment.
 Be prepared for emergencies.
 Study reimbursement trends.
 INTRODUCTION
Well-designed surgical office space is critical for the comfort
of the surgeon, staff, and patients, for office efficiency, and
ultimately for practice success. Identifying and designing the
proper space for your practice requires a significant invest-
ment, not only in time and money but also emotionally. As
such, it is important to plan carefully and seek expert design
and architectural advice early in the process. This chapter is
intended to serve as a starting point in the process of design-
ing a surgical suite and will review the various types of out-
patient surgical facilities as well as design, planning, and
reimbursement considerations.
 TECHNICAL ASPECTS AND PRACTICAL
APPLICATIONS
Types of outpatient surgical facilities
Traditionally all surgery, other then very minor procedures,
was performed in a hospital operating room. From 1984 to
2000, the number of outpatient surgeries performed increased
by more than 20-fold.1,2 This shift, which occurred for a
variety of reasons including cost containment and patient and
surgeon convenience,1,2 expanded the number of venues in
which surgery is currently performed beyond the traditional
hospital-based operating room.
Dedicated surgical rooms in the standard medical office are
a common location for minor surgical procedures. Many der-
matology offices have a specific room, often designated the
‘procedure’ or ‘minor surgery’ room, where any procedure
more invasive that skin biopsy is performed. The typical
layout has the advantage of being easy and relatively inexpen-
sive to construct and has flexibility for a general dermatologist
(Fig. 48.1). It is ideal for a practitioner who has a primarily
medical-based practice with some minor surgical procedures
such as excisional or laser surgery. For a general dermatology
office, this setup can allow multiple physicians to use common
procedure rooms on an as-needed basis. Disadvantages are
that this design will not work for a primary surgical practice.
In addition, if one anticipates that the surgical component of
the medical practice may grow over time, this type of design
may not be ideal.
A step up from the dedicated surgical room in a standard
medical office is the office-based surgery practice (Fig. 48.2).
Offices can be designed with multiple surgical rooms depend-
ing upon the size desired and the number of practioners. The
layout can be similar to the floor plan shown in Figure 48.1
with multiple rooms centered around a common space such
as a laboratory (for Mohs micrographic surgery) or a clean/
dirty room. Smaller rooms that can be used for consultations
or follow ups can be admixed with office-based surgery
rooms. This office design is more suited to surgical-based
practices, such as Mohs micrographic or cosmetic surgery.
When designing an office-based surgical suite, consideration
should be given to constructing the suite with the possibility
of upgrading to a licensed ambulatory surgery center (ASC)
if so desired in the future. (See below for further discussion
on ASCs.)
Office-based surgery practices can be accredited or non-
accredited. Accreditation is a process in which office policies,
procedures, and facilities are critically evaluated by an outside
source.3 Accreditation is a way to demonstrate the delivery
of high-quality care to the public and medical community.
Others believe that the added expense and preparation time
for accreditation are not worth the benefit.3 Some third-party
payers will allow facility fees for procedures performed in
accredited offices,3 but usually ASC licensure and certifica-
tion are necessary if facility fees are to be collected. Some
states have regulations on office-based surgery, specifically
with respect to requiring accreditation or state-mandated
inspections. Usually these regulations exclude facilities that

796
Part 5  Office-based Surgery: Physical and Regulatory
tend to be extensions of a dermatologic surgery practice in
which the ASC is a separate entity within the larger medical
office. Most dermatologic surgery practices with ASCs will
have one or two operating rooms that are used only part of
the time. This is in contrast to the larger partially or fully
hospital-owned freestanding ASCs that may have as many as
10–15 operating suites with a large full-time staff. The tradi-
tional ownership structure of joint-venture ASCs involves a
hospital- (or national management company)-owned majority
stake (51–90%) and a physician-owned minority stake (10–
49%).4 As the majority owner, the hospital controls the facil-
ity and usually processes the billing. The ownership interests
of the minority stake are spread among many physicians.
Therefore, the ASC is not overly dependent on one physi-
cian’s volume.4 More recently, hospitals have begun to take
a minority stake in ASCs and physicians have emerged as the
primary shareholders. ASCs have become extensions of the
physicians’ practice, with ASC ownership and dividend dis-
tribution taking on a group practice dynamic.4
Specific requirements for ASCs vary greatly from state to
state. ASC licensure occurs on the state level.5 State licensure
is separate and distinct from Medicare certification. Gener-
ally, facility fee reimbursement from third-party payers
requires both state licensure and Medicare certification.
Accreditation is a separate issue and is usually optional.
However, some third-party payers require accreditation for
reimbursement. In some states, accreditation is given deemed
status for Medicare certification.
Many of the general specifications for ASCs require exten-
sive preplanning. This may not be feasible in some office
suites. Some of the requirements include a separate entrance,
a separate waiting room, a dedicated recovery room, auto-
matically-activated fireproof doors, and a ceiling sprinkler
system. Other ASC design features include 1-hour firebreaks
administer only local anesthesia. Currently, accreditation is
not required in any state when only local anesthesia is used in
offices.3 The specifics of office accreditation in dermatology
are beyond the scope of this chapter and are covered in more
detail in Chapter 49. The pursuit of accreditation should be
carefully weighed when opening a new surgical practice.
Office accreditation is likely to become a more important
issue in the future and may be mandated at some point.
ASCs, which are the most sophisticated of outpatient sur-
gical facilities, have garnered attention in recent years. ASCs
can be broadly classified as physician owned, partially hospi-
tal owned, and fully hospital owned. Dermatologists are most
familiar with physician-owned, office-based ASCs. These
Exam 3
Exam 4
Exam 5
Minor surgery
Dermatology office floor plan
Lab
Exam 2
Exam 1
Blood draw
chair
Figure 48.1  A floor plan with
a dedicated minor surgery
suite in a standard medical
office. This is a smaller
surgical suite than that
shown in Figure 48.2. Note
that the suite is at the end of
the corridor. There is a
separate laboratory room
available for cleaning and
sterilization of instruments. It
may be wise to plan a wall in
the laboratory room to
separate the ‘clean’ and
‘dirty’ materials to avoid
cross-contamination.
(Courtesy of Midmark
Corporation, Versailles, OH.)
Surgery
Sample office surgery layout
Figure 48.2  Office-based surgery suite. (Courtesy of Midmark
Corporation, Versailles, OH.)

797
Chapter 48  Design of the Surgical Suite, Including Large Equipment and Monitoring Devices
Size
The maxim ‘bigger is better’ tends to hold true when refer-
ring to the surgical suite. In general, one should overesti-
mate the amount of office space during the design process
in order to account for growth and storage. Procedure rooms
vary in size and, depending on the level of care and accredi-
tation requirements, minimal square footage requirements
may exist. The generally accepted minimum size for a proce-
dure room is 12 × 12 feet (3.7 × 3.7 m), but 20 × 20 feet
(6 × 6  m) offers advantages. This may not be a practical
use of space for some dermatologic surgeons. The size of
procedure rooms may be determined by requirements for
type of anesthesia administered and type of accreditation
required.
Cabinets, operating tables, and other equipment will take
up a large amount of space. The surgical room must be well
ventilated and temperature control is essential because lights
can produce extensive ‘waste’ heat. Windows are desirable
and supply additional light, but must be secured to comply
with aseptic technique. Often windows are tinted to protect
patient privacy, depending on how accessible they are to the
outside. If laser procedures are to be performed in a proce-
dure room with windows, blinds or other window covers
must be used.
Infrastructure
Plumbing and wiring
Multiple electrical outlets are essential, especially if a room
is utilized for multiple procedures such as reconstruction,
electrosurgery, and light-based procedures. Even if light-
based technology is not currently part of one’s practice, it is
wise to wire all of the surgical rooms for 220 volts in the
event that lasers or other special equipment are added in
the future. Each room should be plumbed for a sink unless
the room is an ASC, in which case the sink needs to be
outside the procedure room. Sinks require additional piping
and drainage in each room.
In anticipation of a centrally placed power table, an outlet
can be wired into the floor, eliminating power cords running
across the floor to the wall socket. Some tables have addi-
tional outlets built into them, which can be helpful when
using electrical accessories. Floor outlets should be placed out
of the walkway to prevent tripping. They should be designed
with an elevated lip to prevent cleaning solutions or water
from causing an electrical short during mopping.
Consideration should be given to the installation of ceiling
sprinklers. They are expensive, but are a safety feature that
may qualify the office for decreased insurance rates. When
wiring the office, hard-wired fire detectors that will connect
to a security system are ideal. Other wiring considerations
include security elements (motion detectors) to deter break-
ins, camera cables for visual monitors, phone lines, and
computer wiring.
It is useful to plan for as much general lighting in the oper-
ating and examination rooms as possible. Fluorescent over-
head lights can be fitted with special reflectors to create a
shadowless light. Additional lights can also be focused on the
examination table. Fluorescent floodlights can be installed to
decrease heat production. Articulating lights with adjustable
focal lengths can be worth the added expense. Emergency
in the walls, 2-hour firebreaks in the floor, and a back-up
emergency power source for key equipment (generator or
battery power). Sinks are not permitted in the operating
room of an ASC, but are allowed in the recovery room.
Exceptions in the fire safety code may be allowed for offices
that use only local anesthesia. Medicare and independent
accrediting agencies usually require that the fire safety code
for ASC construction be followed. Most local zoning boards,
states, and office accrediting agencies require that a physi-
cian’s office meet the commercial building code standards,
which are less expensive. From the dermatology perspective,
the benefit of incorporating an ASC into a surgical practice
is the opportunity to offer a higher level of care and the ability
to collect a facility fee. These and other specific reimburse-
ment issues are discussed later in this chapter.
The last outpatient surgical venue is the hospital outpatient
department (HOPD). This is a term for ambulatory offices
owned wholly by a hospital. Any outpatient surgical service
of a hospital, such as dermatologic surgery, would be consid-
ered a HOPD. The design of the HOPD surgical suite is
similar to the office-based surgery practice. The Joint Com-
mission usually accredits these facilities as they are consid-
ered part of the hospital. Physicians and staff are typically
employees of the hospital or hospital-owned practice group.
Design
Planning
The process of planning, designing, and building a new surgi-
cal office, including state licensure, Medicare certification,
and accreditation, takes approximately 12–18 months.5 It is
helpful to divide the process into stages: 1) financial analysis;
2) legal issues and design; 3) construction and staffing; 4)
licensing and other requirements; and 5) accreditation (if
pursued).5 The scope of the project, the physician’s familiar-
ity with the process, and the dependence on external consult-
ants will determine the length of each stage. The entire
process usually takes longer than one anticipates and meticu-
lous planning and flexibility are necessary.
The hiring of contractors, architects, and consultants is part
of the process. Multiple consultants should be interviewed
and estimates should be requested from all of them. The
disparities may be considerable. The architect should be
knowledgeable enough to guide the physician through the
design and construction of an office or ASC. Many architects
and contractors specialize in medical offices. An architect and
contractor who are familiar with code requirements for
medical offices and surgical centers will eliminate the need
for expensive revisions later to meet specifications.5 Around
$150 per square foot is typical for construction unless the
facility is in a prime location in a major urban area. The
architect’s fee can be 6–10% of the construction cost. Some
consultants will provide detailed guidance through the entire
process, but can be quite expensive. However, a good con-
sultant will often generate savings that exceed their fees.
When consultants are engaged, the physician should still
remain involved in the process, particularly if building an
ASC or seeking office accreditation. The physician must
become familiar with all the rules and regulations, because
enforcement will rest with the physician in charge. Precon-
struction planning is essential because changes can be very
expensive.

798
Part 5  Office-based Surgery: Physical and Regulatory
out. Suction machines are prone to break down, but because
of infrequent use, have an overall long life. Savings can be
made with prudent shopping. If buying new, discounts of
10% or more can be obtained at conventions. These same
discounts may be extended at other times if requested. For
sample costs, see Table 48.1, and for a list of equipment
suppliers, see Appendix 1.
It is important to consider the pieces of large equipment
that will be needed over time. For example, if you are plan-
ning to own and operate a comprehensive laser center, extra
storage and electrical outlets will be required. Similarly, crash
carts are available in many varieties, and can be fairly bulky.
It is wise to determine in advance which one you will pur-
chase and where it will be stored.
Operating tables
The operating table is an integral component of any surgical
suite. The surgeon must be able to achieve close proximity
to the operative field while the patient must be comfortable.
Tables with thin padding will become uncomfortable for
prolonged procedures. One way to evaluate a table prior to
purchasing it is to lie on it in the surgical position for 10–15
minutes. There is no better way to simulate how a patient
will feel on a particular operating table than by testing it
oneself. Additionally, physicians from other specialties can be
consulted to determine how satisfied (or more importantly
dissatisfied) their patients are with specific tables.
There are two basic types of table, the hydraulic and the
electric-powered nylon screw tables. Hydraulic tables are
powered by a pump, which forces hydraulic fluid (consisting
of mineral oil) through hydraulic pistons. Electric-powered
tables are powered by a central rotating nylon screw. The
main advantage of hydraulic tables is that they last a long
time; however, they are somewhat slow to move. The electric
tables can be moved much faster, but the screw eventually
needs to be replaced. There are multiple options for each
kind of table, ranging from essential to elective. The number
of mobile joints or ‘break’ points is quite important for patient
positioning and comfort (Fig. 48.3). Options include back,
foot, and table elevation as well as tilt and head articulation
(which is usually manual). Some tables come with a perma-
nent foot elevation, making table access difficult especially
for elderly or disabled patients.
Another important feature is how low the table can descend
toward the floor to allow easy access, especially for handi-
capped patients and transfers from wheelchairs. This pre-
exit lights, and illuminated exit signs, separately powered, are
required for fire codes for any publicly accessed building.
Room structure
Walls should to be light in color and washable. A washable
off-white or beige latex or washable vinyl wall covering is an
alternative to the sterile white color of most operating rooms.
Repainting and recovering will be necessary every few years.
Patient privacy should be a major concern, especially with
the new Health Insurance Portability and Accountability Act
of 1996 guidelines. Special acoustic insulation can be installed
in the walls and on top of the ceiling tiles so that conversa-
tions are private. Curtained areas for privacy while changing
can be installed in almost any examination room.
Floors covered with linoleum are advisable. It is inevitable
that blood, chemicals, and marking dye will occasionally be
spilled in the operating room. Recent studies show that car-
peting does not increase the risk of bacterial contamination,
but may decrease dust particles in the air.6,7 Stained or soiled
carpet can be very difficult to clean, giving the room a ‘dirty’
appearance and creating a biohazard. Therefore, carpet cannot
be recommended in the surgery suite. Linoleum is more
costly than carpet, particularly if installed as a single sheet
extending up the wall, which is the preferable way to assure
sanitization. Ceramic tiles can also be used, but the grout lines
between tiles can be difficult to maintain and keep clean.
Although ceramic tiles are attractive, they can be slippery
when wet. Ceramic tiles and grout are less durable than
linoleum over time, requiring more frequent maintenance.
Doors to the procedure room must be wide enough to allow
for entrance of wheelchairs and stretchers. A 48-inch (1.222-
m) door offers the greatest access, although 44 inches
(1.12 m) is the minimum. Hallways need to be wide enough
to allow stretchers or wheelchairs to turn. It can be difficult
to achieve this width when remodeling an existing building,
in which hallways are narrower. Ideally, during suite design,
doorways from the office to at least one operating room
should be in a straight line without a need to turn.
Nine-foot (2.74-m) ceilings offer the advantage of compat-
ibility with many commercial lighting fixtures that are
designed to be suspended from this ceiling height. Once
again, it may be difficult to find pre-existing office space with
9-foot ceilings. Ceilings in ASCs should be washable, but this
is not required in a non-ASC office operating room. Sus-
pended ceilings are acceptable but require more maintenance
to replace soiled or stained tiles.
The structural requirements for ASC procedure rooms are
more stringent than the standards for procedure noms com-
monly used in office-based surgery. While the specific differ-
ences are beyond the scope of this chapter, if one is planning
an ASC, it is critical to make sure the rooms are constructed
according to specifications.
Equipment
Large equipment will be a significant investment when design-
ing a new office. One can often find used equipment in excel-
lent condition for a significant discount compared to the cost
of the same item new. Furthermore, large office equipment
has a long life span. For example, hydraulic power tables will
last many years; they may need only periodic reupholstering
and minor servicing. Replacement bulbs can be found for
almost any light. Stainless steel cabinets and sinks rarely wear
Table 48.1  Estimated costs of new and used large
equipment
ITEM
COST NEW (US$)
COST USED (US$)
Power table
7000–14 000
3000–5000
Double
overhead
lights
3400–7500
1000–2000
Matching
cabinets with
sink
4000–10 000
500–1000
Suction machine
3000–3500
1500–2000
Pulse oximeter
700–7000
300–2000

799
Chapter 48  Design of the Surgical Suite, Including Large Equipment and Monitoring Devices
often be obtained at a discounted rate if purchased with a
table. Added features for stools include back support and arm
rests, which can be helpful for facial surgery. Standing versus
sitting for surgical procedures is a personal preference. If one
prefers to stand while operating, it is useful to be able to sit
down with the patient preoperatively to review treatment
options and risks.
Operating room lights
Proper lighting is an integral component of a successful surgi-
cal suite. Ceiling-mounted lights are the gold standard. A
mobile operating room light on a floor stand takes up valuable
floor space and is the least useful light source for an operating
room. The only role for a mobile light is that of ancillary
lighting in emergency situations. Costs vary widely, as do
quality and candlepower. Lights must be reliable, have ade-
quate candlepower, and not ‘drift out’ of position. Less
expensive lights may have adequate power but will tend to
have greater drift, which can be frustrating. There are a few
design types to consider. The first has multiple lights set in a
concave ‘head.’ Each of the smaller inset lights has a slightly
different angle, to provide a widely lighted area with minimal
shadows. The second type of light has a single central bulb
with a reflective concave surface providing a field of light. A
third option is that of smaller lights that are dual mounted
to give illumination and limit shadows (Fig. 48.4). Lights need
to be adjustable during the procedure. This may be accom-
plished by using sterile disposable handle covers, or autoclav-
able handles that can be screwed on.
Storage and cabinets
A common mistake in the design of a surgical suite is not
planning enough storage space. Whether it is in the form or
cabinets, closets, or small open spaces in rooms or halls, there
can never be too much storage space (Fig. 48.5). One must
always consider growth when designing a surgical suite and
as such it is always better to plan for too much storage than
too little. It is likely that one will utilize extra storage space;
conversely, too little storage space is often a reason for a
practice to move to another location. Surgical rooms need an
adequate amount of storage so that equipment and supplies
are always at hand. This prevents staff from coming and going
during a procedure and prevents delays in obtaining urgently
cludes having to lift patients from the standing position onto
the surgical table. In addition, for surgeons who prefer to sit
while operating, it is crucial to ensure that the table is low
enough to allow for a comfortable operating position. The
table itself should adjust to the desired work level for the
surgeon and provide a comfortable working position for any
particular procedure.
Finally, the tilt adjustment moves the table back, allowing
the patient to be put in the Trendelenburg position, which is
helpful in managing vasovagal reactions. For this reason alone,
all surgical tables should allow the patient to be put in the
Trendelenburg position with the head below the heart. Addi-
tionally, patients find the ‘tilt’ position very comfortable
because they do not get the sensation that they are sliding off
the table. Variations of these positions allow flexibility in
patient positioning and comfort according to individual needs.
Dermatologic surgery can be performed on all areas of the
skin surface and therefore it is crucial to have a table that
allows optimal exposure of the surgical field while maximiz-
ing both patient and surgeon comfort. The programmable
control feature available on many newer models allows the
table to be placed in exactly the same position on demand.
This feature is useful because surgical sites are never in
exactly the same location and patients vary in size. Although
foot controls can add clutter to the floor, they enable the
operating surgeon to adjust the patient’s position once a
sterile surgical environment has been prepared and the case
is underway.
Some tables come with a narrow head rest, as compared
with the table width. This can be a useful option when the
surgeon needs to be close to the head and neck. Other options
include an adjustable arm board for procedures on the arm
and hand, and the ability of the table to rotate. These options
can be useful in smaller suites or when operating on a site
distant from the electrosurgery unit, such as the leg.
Adjustable operating stools with foot or hand pedals can
Figure 48.3  Rotating power table with three break points, and
programmable hand and foot controls. (Courtesy Midmark
Corporation, Versailles, OH.)
Figure 48.4  Double-headed light: one back illuminated, one
spot. (Courtesy of Midmark Corporation, Versailles, OH.)

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Part 5  Office-based Surgery: Physical and Regulatory
Suction
Suction is useful to help maintain hemostasis intraoperatively
in situations that might impair field visualization and surgical
outcome. When operating in deep cavities, suction is essential
to be able to visualize vital neurovascular and anatomic struc-
tures that might be injured. Suction can also be useful to
evacuate postoperative hematomas.
In the non-hospital setting, wall suction may be expensive
to install and maintain. Portable suction units are quite ade-
quate and many brands and models are available. Disposable
supplies for suction units include presterilized suction tubing
and tips. The suction tips include commercially available can-
nulas or sterile eyedroppers, which are small enough to gain
access to almost any location. The use of suction in the prac-
tice of dermatologic surgery is variable, with some surgeons
using it during all procedures and others using it occasionally.
Despite differences in regularity of use, having at least one
suction machine present in the surgical suite can prove inval-
uable for emergencies.
Waste disposal
Waste disposal is an often overlooked but very important
issue in every surgical suite. Standard garbage cans with a
foot-lift top are generally not appropriate for contaminated
waste. However, steel cans with foot-lift tops are specifically
needed instruments or equipment. Glass-front cabinets can
be useful to showcase supplies for ready access. Many of the
medical suppliers offer matching modular cabinets, which are
adequate. Vendors will sometimes help with office design.
Supply carts
Metal supply carts can be obtained inexpensively from hard-
ware suppliers and can be adapted for a variety of uses. The
top can be used as a supply tray or surgical tray, and equip-
ment such as electrosurgery units and blood pressure cuffs
can be mounted on the sides (Fig. 48.6). The additional
shelves can be used to store frequently used supplies. An
added feature of supply carts is that they are mobile and can
thus be moved throughout the room, bringing electrosurgery
and other supplies closer to the surgical site.
Surgical sink
Surgical sinks with foot pedal controls are important compo-
nents of the surgical suite. These may be positioned in the
hall, which is a requirement for an ASC, or in the procedure
room itself. A sink depth of 18–24 inches (46–61  cm)
decreases splash and allows an adequate stream of water
while scrubbing. The foot pedals prevent recontamination of
the hands when turning off water controls. Foot-operated
soap dispensers work in a similar fashion. These sinks are
available from a number of surgical suppliers.
Figure 48.5  Matching cabinets (casework) with built-in sink.
The water is foot operated, as is the soap dispenser. The glove
dispenser, paper towel dispenser, and trashcan are located
nearby. A mirror is available for patients to use when taking off
make-up and arranging their clothing.
Figure 48.6  A ‘customized’ metal cart with wheels. Note that
the electrosurgery unit and manometer are mounted. Supplies
and small equipment on the cart can be moved to distant
operative sites.

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Chapter 48  Design of the Surgical Suite, Including Large Equipment and Monitoring Devices
an adverse event much later than a pulse oximeter. Pulse
oximeters work on the principle of Beer’s law, by determin-
ing the concentration of a given solute in a solvent based on
the amount of light that is absorbed at a specific wavelength.8
Unbound hemoglobin has an absorption peak at 660  nm,
whereas hemoglobin with bound oxygen absorbs at 940 nm.
The pulse oximeter uses two light-emitting diodes and a light
sensor, allowing the oximeter to calculate the saturation of
oxygen via a computer algorithm. The oximeter also has a
plethysmographic function, which provides for timed meas-
urements during arterial pulsations and subtraction of the
background venous blood saturation.9
The oximeter is clipped on the ear or fingertip and can
display cardiac rhythm as well as oxygen saturation. Newer
units display respirations, body temperature, and blood pres-
sure as well as end-tidal carbon dioxide levels when the
appropriate cuffs and probes are attached (Fig. 48.8). Pulse
oximeters have automatic alarms to indicate critical values.
Despite the annoying ‘beeping’ that can occur, disabling the
automatic alarm mitigates their ability to prevent an emer-
gency situation.
A pulse oximeter may not work if the patient is hypovo-
lemic, has serious tricuspid regurgitation, cannot hold the
finger still, or if electrosurgery is in use. A used pulse oxime-
ter may be acceptable if verified to be in proper working
order. A printer unit is optional, and should be obtained if
considering office accreditation or ASC status. Regular print-
outs for quality control will be important for record keeping.
If one is planning to use conscious sedation, one should prob-
ably also plan for office accreditation (which is covered
further in Chapter 49). Office accreditation may become
mandatory for the use of intravenous sedation in the office
setting in the future.
Other important monitoring equipment includes manual
blood pressure cuffs and stethoscopes. These are relatively
inexpensive items that should be available in every surgical
office. It is important to train multiple personal in the use of
these items, especially for emergency situations.
Ideally, a surgical suite should have a dedicated ‘crash cart’
containing resuscitative equipment including an ambulatory
designed for biohazard waste. Kick buckets are stainless steel,
short waste receptacles on wheels that are easily moved for
ready access and disposal of contaminated waste. These are
often small and need to be changed between surgical cases.
Kick buckets are in each surgical suite and placed directly
under or near the Mayo stand or instrument table.
Surgical tray stands
Mayo stands are the working surface of the surgical suite,
providing easy access to surgical instruments or other equip-
ment needed at the surgical field (Fig. 48.7). The options to
consider in making a selection are: size, movement of the
platform, mechanism for raising and lowering the platform,
the ‘legs’ or base of the stand, and the rolling mechanism.
Choices are largely based on personal preference. A stand
with a circular base is useful in that a kick bucket can fit
within the base for space efficiency.
Monitoring and emergency equipment
Monitoring and emergency equipment is vital to the surgical
suite. While the majority of dermatologic procedures are
performed under local anesthesia, it is important to docu-
ment routine vital signs on most surgical patients. For those
surgeons performing larger surgeries and/or those who use
conscious sedation, monitoring and resuscitation equipment
is essential.
A pulse oximeter is useful in elderly patients and those with
respiratory disease, and is required if conscious sedation is to
be used in the office. The pulse oximeter has revolutionized
anesthesia, and makes procedures safer. Automatic blood
pressure cuffs may be an adjunct, but are not a substitute for
a pulse oximeter. Automatic blood pressure cuffs will detect
Figure 48.7  Mayo stand with wheels.
Figure 48.8  Pulse oximeter. These units cost from $1000 to
$7000, depending on their complexity. (Courtesy of Welch-
Allyn, Skaneateles Falls, NY.)

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Part 5  Office-based Surgery: Physical and Regulatory
Room and equipment maintenance
Surfaces and equipment should be cleaned and be free of
debris after a procedure. A multitude of cleaners can be used
such as glutaraldehyde, alcohol, and 4% chlorhexidine gluco-
nate, which are all effective. A 10% bleach solution has gained
popularity because it can kill numerous organisms, including
the human immunodeficiency virus (HIV). However, 10%
bleach will pit and corrode instruments and should therefore
not be used in instrument cleaning. Other commercial
medical cleaners are acceptable (see Chapter 2).
General room cleaning should be carried out daily, with
attention to floors and fixtures. A regularly scheduled clean-
ing of walls should be performed monthly and as needed for
gross contamination. The best method of decreasing coloniza-
tion of the surgical suite is to keep known ‘dirty’ cases out of
the room. Abscesses should be drained in another room, not
in the designated operating room. Care should be taken not
to transfer materials or equipment back to the surgical suite
before they have been fully cleaned.
Equipment maintenance is critical to a successful surgical
suite. Equipment is an expensive investment and ensuring
proper maintenance will increase longevity and decrease
expenses. Smaller equipment should be checked monthly and
routine diagnostics performed. Larger equipment, such as
lasers, will have service contracts, which often pay for them-
selves in 1–2 repairs. Warranties should be reviewed prior to
purchase of equipment.
Reimbursement
Reimbursement fees for medical care and surgical procedures
can be broadly divided into two components: the professional
fee and the technical (or facility) fee. The professional fee
encompasses the charge for the physician’s services. In certain
cases, a technical fee can also be billed by the facility for any
non-physician costs such as use of operating suites, supplies,
and staff. The term ‘split billing’ is sometimes used to describe
when a procedure is billed for both a professional and techni-
cal fee. In this situation, the professional fee is reduced.
However, because of the addition of a technical fee, the net
result is greater overall reimbursement.
Only certain facilities are permitted to bill a facility fee.
These include hospitals and HOPDs, licensed and certified
ASCs, and some accredited offices. Hospitals and HOPDs
receive their facility fee via the hospital outpatient prospec-
tive payment system (OPPS), which is based upon ambula-
tory payment classification groups. In order to be paid
technical fees via the hospital OPPS, HOPDs must be con-
sidered a ‘department’ and qualify for ‘provider-based status,’
which means that the HOPD is owned fully by a hospital.11
Interestingly, the facility fee reimbursement for a specific
procedure varies depending upon the type of facility. In
general, HOPDs receive higher reimbursement rates than
ASCs for identical procedures. The rationale behind this is
that the costs associated with a particular procedure are
higher in a hospital environment than in an ASC.5,12 For
example, the Centers for Medicare and Medicaid Services
proposed a new payment system for 2008 that sets the
ASC reimbursement level at approximately 37% less than
that of HOPDs (Federated Ambulatory Surgery Association
2007 sheet). Active lobbying of Congress is ongoing and
legislation has been introduced to increase payments to
ASCs.
ventilation bag, oxygen, a defibrillator, and the appropriate
medications to handle emergencies. The minimal emergency
kit includes equipment and medications for anaphylactic
reactions and other common emergencies (Fig. 48.9). Sur-
geons who perform large, complex procedures, with or
without conscious sedation, should have a more complete
resuscitative equipment cart. While the presence of these
items in the surgical suite is important, they are not useful in
emergency situations unless they are used properly. As such,
physicians performing procedures should maintain basic car-
diopulmonary resuscitation (CPR) and advanced cardiac life
support certification, especially if using conscious sedation.
In addition, it is wise to have multiple medical personnel in
the office trained in both basic and advanced cardiac life
support.
One should consider purchasing an automatic external
defib­rillator (AED). These units are easy to operate, and
instruction in their use is now part of basic CPR training.
These devices are available in airports and restaurants, and
should be available in physicians’ offices. According to the
American Red Cross, each minute that defibrillation is
delayed reduces the chance of survival by 10%.10
Room arrangement
Easy access to equipment is as important as the design of the
space that it occupies. The operating table should be posi-
tioned in such a way so that free movement around the room
and full access to the surgical suite are possible with the table
fully extended. As such, the best position for the table is
usually in the center of the room. All the equipment should
be mobile or portable (i.e. placed on a Mayo stand) so that
it can be moved into position as needed. Fixed equipment
can be limiting in skin surgery because surgical sites can be
anywhere on the body. Much of the large equipment in the
surgical suite will require proximity to an electrical outlet.
This should be taken into consideration in the design of the
suite so that there are numerous outlets in each procedure
room. Items that are electrically powered but frequently
used, such as an electrosurgery device, can be attached to a
mobile cart or proprietary stand. These devices often come
with long power cords. It is wise to confirm the length of the
cord before purchasing.
Figure 48.9  This office emergency kit is the bare minimum for
offices that do not use conscious sedation or general
anesthesia.

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Chapter 48  Design of the Surgical Suite, Including Large Equipment and Monitoring Devices
better – the generally accepted minimum size is 12 × 12 feet
(3.7 × 3.7 m) – to accommodate cabinets, table, and equip-
ment. All walls and floors should be washable, and all equip-
ment should be mobile or portable. The facility and staff
should be prepared for emergencies. It is important to under-
stand reimbursement, accreditation, licensing, and certifica-
tion issues.
 REFERENCES
1. Hancox JG, Venkat AP, Hill A, et al. Why are there differences in the
perceived safety of office-based surgery? Dermatol Surg 2004;30:1377–
1379.
2. Lapetina EM, Armstrong EM. Preventing errors in the outpatient setting:
a tale of three states. Health Aff (Millwood) 2002;21:26–39.
3. Sterling JB, Hanke CW. Office accreditation in dermatology. Semin
Cutan Med Surg 2005;24:128–132.
4. Becker S, Biala M. Ambulatory surgery centers – current business and
legal issues. J Health Care Finance 2000;27:1–7.
5. Small NC, Bert JM. Office ambulatory surgery centers: creation and
management. J Am Acad Orthop Surg 2003;11:157–162.
6. Rutala WA, Weber DJ. Surface disinfection: should we do it? J Hosp
Infect 2001;48(Suppl A):S64–S68.
7. Skoutelis AT, Westenfelder GO, Beckerdite M, et al. Hospital carpeting
and epidemiology of Clostridium difficile. Am J Infect Control 1994;
22:212–217.
8. Maloney M. The surgical suite. In: Grekin RC, ed. The dermatologic
surgical suite, design and materials, 1st edn. New York: Churchill Living-
stone; 1991.
9. Wilson WC, Shapiro B. Perioperative hypoxia, the clinical spectrum and
current oxygen monitoring methodology. Anesth Clin North Am
2001;19:769–812.
10. American Red Cross. First aid/CPR/AED program. 2001:52.
11. Smith JJ, Maida A, Henderson JA. Hospital outpatient prospective
payment under Medicare: understanding the system and its implications.
Radiology 2002;225:13–19.
12. Ownings MF, Kozak LJ. Ambulatory and inpatient procedures in the
United States. Vital Health Stat 13 1998;139:67–70.
When designing a surgical facility, and in particular an ASC,
cost analysis should be performed to determine if the increase
in reimbursement from a facility fee covers the increased
overhead. Since reimbursement is not a fixed entity, this can
prove difficult. Patients should be notified up front that they
will receive separate bills for technical and professional fees.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Failure to plan adequately in advance for the design and type
of surgical suite that will meet one’s needs both in the short
term and allow for future growth.
 Failure to determine if accreditation is worth pursuing during
the planning stages.
 Not compiling a budget and/or obtaining adequate financing.
 Overpaying for equipment or consultants.
 Not performing a cost analysis to determine if an ASC is
appropriate for one’s practice.
 SUMMARY
When developing a surgical suite, it is wise to plan far in
advance. Decide which type of surgical facility is right for
your practice. Expert advice on space planning, architecture,
and internal design should be obtained. Correcting a problem
later can be far more expensive than approaching the issue
directly from the start. Larger surgery rooms are usually

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49
Dermatology Office Accreditation
Emily Tierney MD and C William Hanke MD MPH FACP
Summary box
 Accreditation focuses on the quality of patient care provided
while Medicare standards tend to focus on the physical
aspects of the healthcare facility and environment.
 Accreditation surveys review every aspect of a healthcare
facility and confirm that the facility does what it says it is
doing.
 A year-long preparation for an accreditation survey is usually
necessary.
 A consultant can provide helpful guidance regarding state
licensure and certificate of need.
 Healthcare legislation and regulation for ambulatory surgery
centers vary significantly between states.
 Pitfalls in achieving accreditation include outdated and
irrelevant policies and procedures, inaccurate and incomplete
patient care documentation, credentialing and privileging,
and inadequate quality improvement and risk management
activities.
 Patient safety in office-based facilities is enhanced by
accreditation.
 INTRODUCTION
The concept of accreditation began in hospitals and has now
moved into the outpatient arena. The process is designed to
assess the quality of patient care provided by the organization.
The process verifies that the organization meets specific cri-
teria indicative of quality of care and helps the organization
ensure continued maintenance of a high level of standards
and delivery of high-quality care. Accreditation is the highest
form of public recognition a healthcare organization can
receive. Achieving accreditation also helps an organization to
improve the care and services offered, increase efficiency and
reduce costs, develop better risk management programs,
lower liability insurance premiums, motivate staff by instilling
pride and loyalty, strengthen public relations and marketing
efforts, and to recruit and retain the best professional staff
members. The accreditation process involves self-assessment
by the organization, as well as a thorough review by the
accreditation association’s expert surveyors, who themselves
have extensive experience in the ambulatory healthcare envi-
ronment. The organizations which provide accreditation for
dermatology offices include the Accreditation Association for
Ambulatory Health Care (AAAHC) (see Boxes 49.1 and
49.2),1 the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO),2 and the American Association for
Accreditation of Ambulatory Surgical Facilities (AAAASF).3
Accreditation through these non-governmental organizations
is viewed by state regulatory agencies as a private means to
provide quality oversight. The private accrediting organiza-
tions enforce minimal standards and improve patient safety,
thereby reducing the burden of government bodies with
respect to regulation of the quality of patient care.
 TECHNICAL ASPECTS
The accreditation survey process
Preparation
The surveyed organization should prepare 1 year in advance
for an accreditation survey. Items reviewed during an accred-
itation survey must be provided in advance of the survey (Box
49.3). Information is reviewed about patients including:
patient services, satisfaction, clinical records, patient hand-
outs, marketing materials, and statements of patients’ rights
and responsibilities. Items needed about physicians and other
staff members include: personnel records, board certification,
and continuing education schedules. Other logistical details
must be supplied including emergency drills, maintenance,
lab statistics, committee and governing body meetings, cre-
dentialing and privileging policies, audit and balance sheets,
Medicare reports, and quality improvement.
A mock survey can be incredibly helpful to organize an
office for the items which need attention prior to the accred-
itation survey. Assistance from consultants can be particularly
helpful in preparing for a survey. In recognition of the need
for quality consultative guidance, The AAAHC1 established
Healthcare Consultants International to provide office-based
policy and procedure manuals, telephone consults, and on-site
training.
Accreditation survey
An accreditation survey reviews every aspect of the practice,
not just the physical environment, and surveyors will take
time to check a number of policies and procedures. Docu-
ments reviewed during an accreditation survey should be
prepared in advance (see Box 49.3). The purpose of this
review is to make sure the surveyed organization is doing
what it says it is doing. Similar to the clinical record, if it is
not written down, it did not happen.

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Part 5  Office-based Surgery: Physical and Regulatory
tions. A surgical procedure will be observed to ensure that
proper sterile technique is followed, to assess surgical skill,
and to follow postoperative recovery.
The accreditation survey is usually performed by one to
two surveyors over a day to a day and a half, depending on
the size and scope of the organization. During this time, the
surveyors may directly ask questions to the staff informally
or during formal interviews.
Sample questions may include:
• What do you think is good about the organization and
what should be changed?
• Would you bring your family members to be seen as
patients here?
• Are you happy with your employment?
• Are you aware of a policy or procedure for a particular
activity?
• Are you involved in quality improvement?
• How is information shared within the organization?
• What are you most proud of in the organization?
Personnel should answer these questions honestly and should
avoid fabricating their answers. If they are unable to answer
a particular question, they should say ‘I do not know the
answer but I know where I can find the answer.’ The person-
nel should be reassured by the surveyed organization that
their comments will not be the cause of a failure to achieve
accreditation nor will their responses result in punitive
treatment.
Documented policies, procedures, credentialing, privileg-
ing, quality improvement, and risk management activities are
points of emphasis by the surveyors.
Summation conference
The surveyors will report the findings to the healthcare organ-
ization at a summation conference, which involves dialogue
between the surveyors and the principals of the organization.
For accreditation organizations other than Medicare, it will
take several months for a decision to be announced.
Survey report and accreditation decision
After the summation conference, a survey report is submitted
to an accreditation committee, which decides whether or not
accreditation is granted. The process takes a number of
months to be completed. The AAAHC1 has a range of accred-
itation terms depending upon the findings in the survey,
including:
• 3-year, 1-year, or 6-month accreditation terms
• a deferred accreditation decision
• a denial of accreditation.
The healthcare organization always has the right to appeal the
decision.
Recent changes in accreditation process
for office-based surgery
As a result of the exponential growth in office-based surgery,
in 2006 it was estimated that 82% of surgical cases were
performed in an outpatient setting. These figures have dra-
matically influenced private accreditation organizations and
government. In September 2001, the AAAHC established an
office-based surgery accreditation program in an attempt to
streamline the accreditation process.1 This program uses a
single surveyor for a 1-day survey, using a special AAAHC
The accreditation surveyor inspects the facilities and envi-
ronment during an initial orientation tour and observes a
typical surgical procedure. Medical equipment must have
completed, dated maintenance tags to show that it is in
proper working order. All medications and materials in the
surgical area and crash cart must be up to date. There should
be a stipulated safe handling procedure for narcotic medica-
Box 49.1  AAAHC member organizations
Ambulatory Surgery Foundation (ASF)
American Academy of Cosmetic Surgery (AACS)
American Academy of Dental Group Practice (AADGP)
American Academy of Dermatology (AAD)
American Academy of Facial Plastic and Reconstructive Surgery
(AAFPRS)
American Academy of Oral and Maxillofacial Surgery (AAOMS)
American College of Gastroenterlogy (ACG)
American College Health Association (ACHA)
American College of Mohs Surgery (ACMS)
American College of Obstetricians and Gynecologists (ACOG)
American Gastroenterological Association (AGA)
American Society of Anesthesiologists (ASA)
American Society for Dermatologic Surgery (ASDS)
American Society of Gastrointestinal Endoscopy (ASGE)
Medical Group Management Association (MGMA)
Society for Ambulatory Anesthesia (SAMBA)
Box 49.2  Healthcare organizations
with AAAHC accreditation
(in descending frequency)
Ambulatory surgery centers
Office-based surgery organizations
Student or Indian health centers
Endoscopy centers
Group practices or health maintenance organizations
Box 49.3  Items reviewed during an
accreditation survey
 Statement of patient rights and responsibilities.
 Governing body and committee meeting minutes.
 Personnel records for physician and non-physician staff.
 Credentialing and privileging policies.
 Patient satisfaction surveys.
 Clinical records.
 Recent audit and balance sheets.
 Emergency drill records.
 Patient handouts and marketing materials.
 Laboratory statistical reports.
 Maintenance logs.
 Reports of Medicare, local or state surveys.
 Continuing education schedules for physicians and
non-physicians.
 Peer-based quality improvement program.
 Risk management program.

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Chapter 49  Dermatology Office Accreditation
improve performance. During an accreditation survey, the
JCAHO evaluates an organization’s performance of functions
and processes aimed at continuously improving patient out-
comes. This assessment is accomplished through evaluating
an organization’s compliance with the applicable standards in
the manual, based on the following:
• Tracing the care delivered to patients.
• Verbal and written information provided to the
JCAHO.
• On-site observations and interviews by JCAHO
surveyors.
• Documents provided by the organization.
JCAHO surveys are unannounced, with a few exceptions,
such as with the Bureau of Prisons or Department of Defense
facilities. An organization can have an unannounced survey
between 18 and 39 months after its previous full survey. For
example, an organization that is due to have its next unan-
nounced survey in January 2010 could have its survey as early
as July 2008 or as late as April 2010 (18 to 39 months). Data
from the Priority Focus Process will determine the timing of
an organization’s survey within the 18- and 39-month time
frame.
Accreditation decisions
The accreditation decision process focuses on how critical an
issue is to patient care or safety.2 Compliance with the stand-
ards is scored by determining compliance with elements of
performance, which are specific performance expectations
that must be in place for an organization to provide safe,
high-quality care, treatment, and services. At the organization
exit conference, the survey team presents a written summary
of the survey findings. In this summary, organizations will not
receive an accreditation decision or any scores. The final
accreditation decision will be made after the JCAHO receives
and approves an organization’s Evidence of Standards Com-
pliance submission.2 As of January 1, 2009, the accreditation
decision categories are accreditation, provisional accredita-
tion, conditional accreditation, preliminary denial of accredi-
tation, denial of accreditation, and preliminary accreditation.2
An organization’s accreditation cycle is continuous, as long
as the organization has a full, unannounced survey within 39
months of its last survey, and continues to meet all accredi-
tation-related requirements, including, but not limited to,
submission of an annual periodic performance review (PPR),
and an annual subscription payment. The annual PPR is an
additional requirement of the accreditation process in which
an organization reviews its compliance with all applicable
Joint Commission standards and completes and submits to
the Joint Commission a plan of action for any standard not
in full compliance. The plan of action also includes specific
‘measures of success.’ The PPR facilitates a continuous
accreditation process by incorporating an additional form of
evaluation.2
Office-based surgery accreditation
by the JCAHO
Office practices that perform invasive procedures are eligible
for accreditation under the Joint Commission’s Office-based
Surgery (OBS) accreditation program.2 Since beginning the
OBS accreditation program in 2001, the Joint Commission
has completed surveys of many different surgical specialties,
handbook1 which emphasizes the standards specifically
required for small offices consisting of no more than four
surgeons and two operating rooms.
Accreditation Association for Ambulatory
Health Care
The AAAHC currently accredits over 3800 organizations in
a wide variety of ambulatory healthcare settings, including
ambulatory and office-based surgery centers, managed care
organizations, as well as Indian and student health centers,
among others.1
Survey process
Following the receipt of a completed application from an
organization, the AAAHC starts the scheduling process for
the survey:1
• The size and range of services being offered by the
organization seeking accreditation are what determine
the length of the on-site visit, the number of surveyors
needed, and the survey fee.
• Survey dates are determined by the accreditation
association’s scheduling office, in cooperation with the
organization being surveyed.
• The expertise of the survey team members is matched
as closely as possible to the practice specialty of the
organization being surveyed.
• The on-site survey includes a comprehensive assessment
of compliance of the entire organization with the
accreditation association standards, including any
separate entities that have a close interrelationship with
the organization seeking accreditation.
• At the conclusion of the on-site survey, surveyors hold a
summation conference at which they present their
findings to the organization’s representatives. The
organization will have the opportunity to comment on
the findings, as well as the entire survey process.
Codes of standards applying to all
organizations in AAAHC accreditation1
• Rights of patients.
• Governance.
• Administration.
• Quality of care provided.
• Quality management and improvement.
• Clinical records and health information.
• Facilities and environment.
The Joint Commission on Accreditation
of Healthcare Organizations
Accreditation process overview
The JCAHO accreditation process seeks to help organizations
identify and correct problems and to improve the safety and
quality of care and services provided. The process focuses on
systems critical to the safety and the quality of care, treat-
ment, and services.2
Survey process
A survey is designed to be individualized to each organization,
to be consistent, and to support the organization’s efforts to

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Part 5  Office-based Surgery: Physical and Regulatory
ment, policy and procedures, recovery room environment,
general safety in the facility, blood and medications, medical
records, quality assessment/quality improvement, personnel,
governance, and anesthesia.3
Basic mandates
Surgical procedures should be of a duration and degree to
permit safe recovery and discharge from the facility. Changes
in facility ownership must be reported to the AAAASF office
within 30 days. Any death occurring in an accredited facility,
or any death occurring within 30 days of a surgical procedure
performed in an accredited facility, must be reported to the
AAAASF office within 5 business days after the facility is
notified or otherwise becomes aware of that death.3
All individuals using the facility must meet one of the fol-
lowing criteria:3
• A Doctor of Medicine certified or eligible for
certification by one of the member boards of the
American Board of Medical Specialties (ABMS medical
or surgical specialty).
• A Doctor of Osteopathy certified or eligible for
certification by the American Osteopathic Association
Bureau of Osteopathic Specialists (AOABS).
• A podiatrist certified or eligible for certification by the
American Board of Podiatric Surgery (ABPS).
• An oral and maxillofacial surgeon certified or eligible for
certification by the American Board of Oral and
Maxillofacial Surgery (ABOMS).
In addition, every physician, podiatrist, and oral and maxil-
lofacial surgeon operating in an AAAASF-accredited facility,
must hold, or must demonstrate that they have held, unre-
stricted hospital privileges in their specialty at an accredited
and/or licensed acute care hospital within 30 minutes of the
accredited facility for all operations that they perform within
the facility.3
Inspection and self-evaluation
A facility is inspected every 3 years. The facility inspector
will review any deficiencies with the facility director and
forward the Standards and Checklist answer sheet to the
AAAASF central office.3
A facility is also evaluated by the facility director each year
between inspections and the Standards and Checklist answer
sheet is sent to the AAAASF Office.
Denial or loss of accreditation
The AAAASF may deny or revoke accreditation of a facility
if the facility fails to satisfy every standard for its class (A, B,
C-M, or C), or if any surgeon operating at the facility:3
• has had their privileges to perform surgery restricted or
limited by any hospital at which the surgeon has
privileges, related to lack of clinical competence, ethical
issues, or professional problems other than economic
competition
• has been found to be in violation of the code of ethics
of any professional medical, podiatric, or oral and
maxillofacial surgical society or association of which
they are a member
• has had their right to practice medicine, podiatry or oral
and maxillofacial surgery limited, suspended, terminated,
including plastic surgery, dermatologic surgery, oral surgery,
podiatric surgery, endoscopy, and orthopedics. Practices
must meet all of the following criteria to be eligible for
accreditation under the OBS program:2
• The practice is composed of four or fewer surgeons
(physician, dentist, or podiatrist) performing operative
or invasive procedures. OBS practices, including
multisite practices, are limited to four or fewer licensed
independent practitioners.
• The practice must be surgeon owned or operated, for
example a professional services corporation, private
physician office, or small group practice.
• Invasive procedures are provided to patients. (Practices
only providing procedures such as excisions of skin
lesions, moles, warts, and abscess drainage limited to
the skin and subcutaneous tissue are not typically
surveyed under OBS standards.)
• Local anesthesia, minimal sedation, conscious sedation,
or general anesthesia are administered.
• Office-based practices that render four or more patients
incapable of self-preservation at the same time are
required to meet the provisions of the Life Safety
Code® (National Fire Protection Association).
A typical on-site survey lasts 1 day. Practices that have more
than one office, and still meet all of the above criteria, require
a multiple-day survey.
American Association for Accreditation of
Ambulatory Surgical Facilities
Organizational goals
The goal of the AAAASF is to develop and implement stand-
ards of excellence to ensure the highest quality of patient care
through an accreditation program that serves both the medical
community and the public interest. The AAAASF accredita-
tion process is a means for measuring medical competence
and providing an external source for evaluating patient safety
in the ambulatory surgery setting.3
The AAAASF was established to provide the medical com-
munity and the public interest with a means of standardizing
and improving the quality of medical and surgical care in the
ambulatory environment.3
Goals of AAAASF accreditation
• To encourage the highest level of competence for
medical and surgical care of patients in the ambulatory
setting.
• To provide a forum for the discussion of new concepts
in ambulatory surgery care and a repository of
information that can be disseminated to the public and
medical community.
• To encourage constant improvement in the quality of
care provided to patients in the ambulatory surgery
setting.
• To provide a means of measuring both medical and
surgical competence, and ethical conduct, by providing
an external source for the evaluation of professional
credentialing, patient safety, and quality of care.3
Designed to ensure verifiable quality care with specific
requirements, the AAAASF standards that every facility must
meet include: general environment, operating room environ-

809
Chapter 49  Dermatology Office Accreditation
tory, or administrative requirements mandating that derma-
tologists obtain hospital credentialing and privileging to
perform outpatient procedures will limit patient choice and
increase the cost of care. The standards of the AAAASF
require a physician to have hospital privileges in order to
perform procedures in the outpatient setting, and the JCAHO
has established a standard whereby physicians must perform
a minimum number of procedures in the hospital each year
to retain privileges in the outpatient setting.
Several states are developing alternative credentialing and
privileging programs for outpatient surgical procedures. These
are usually administered through the state licensing board.
Dermatologists need to be involved in the development of
these legislative, regulatory, and administrative requirements.
Quality assurance and improvement
To obtain accreditation, a healthcare organization must
develop a quality assurance and improvement program which
links quality improvement activities, peer review, and risk
management in an organized and systematic fashion. The
organization under investigation should be able to create a
document which outlines the structure and design of the
quality assurance and improvement program. The plan should
be simple and understandable and must be accomplished in
the office setting. Samples of such plans have been published
in the medical literature.5,6
Quality assurance and improvement studies should be
carried out using the scientific method, whereby a question
should clearly be identified, data are collected, a hypothesis
is developed and tested, and a theory is established. This
method relies on logic, data, and common sense.
Quality improvement techniques
Quality improvement techniques analyze processes that
increase efficiency and productivity. We know that 85% of
medical errors result from faults in a process whereas only
15% result from human error.
The process to be improved – the problem – must be iden-
tified. The process must be relevant to the physician’s office.
Suitable targets for analysis may include clinical problems,
administrative functions, cost of care issues, and ultimately
patient outcomes.3,7 Remember that problems which have
occurred only once should have been fixed and should not,
therefore, be made the subject of a quality assurance and
improvement study. Patient satisfaction surveys can indicate
problem areas and can be a starting point for a quality assur-
ance and improvement study.
One or more methods to improve the process are selected.
The new process is then tested and improvement is verified
over time, following the Deming circle, which summarizes
the problem analysis process in terms of planning, doing,
checking, and acting. On completion of the quality assurance
and improvement study, the results are reported to the gov-
erning body.
Another way to look at improving quality is by ‘closing the
loop,’ as advocated by the AAAHC. In this scheme, a process
is evaluated, a corrective action(s) is implemented, the
process is re-evaluated, and the results are reported to the
governing body. To provide peer-based review, at least two
physicians in an office should be actively involved in quality
improvement activities. In solo dermatology practices, peer
review can be obtained by exchanging patient charts, pathol-
or otherwise affected by any state, province, or country,
or if they have been disciplined by any medical licensing
authority
• has failed to report any of the above to the AAAASF.
Important points of emphasis
for AAAASF accreditation
The AAAASF accreditation program requires 100% compli-
ance with each standard for an organization to become and
remain accredited. There are no exceptions. However, when
a standard refers to ‘appropriate’ or ‘proper’ or ‘adequate,’
reasonable flexibility and room for individual consideration
by the inspector is permitted as long as patient and staff
safety remains uncompromised.3
Credentialing and privileging
Both credentialing and privileging are time-limited, and they
must be renewed every 2–3 years. As regards the survey, both
processes consist of three stages, and they all must be com-
pleted for accreditation.
Credentialing involves reviewing documentation that
shows an individual meets specific criteria for working within
an organization. These documents include diplomas, current
licenses, board certification, and the Drug Enforcement
Administration (DEA) certifications.
The three stages of credentialing are:
1. To establish that minimum training, experience, and
other requirements are appropriate.
2. To establish a process to review, assess, and validate an
individual’s qualifications.
3. To carry out the review, assessment, and validation
independently.4
It should be noted that an organization cannot rely upon
another entity, such as a hospital, to verify credentials. Priv-
ileging determines the specific procedures and treatments
that a healthcare professional can perform. For example, a
physician might be able to carry out specific activities, such
as admitting a patient or performing surgery.
The three stages of privileging are:
1. To determine which clinical procedures and treatments
are offered to patients.
2. To determine the qualifications related to training and
experience required to obtain each privilege.
3. To establish a process to evaluate the applicant’s
qualifications.
National standards do not exist for credentialing and privileg-
ing, so each organization must have in place its own processes
and standards. The credentials and privileges of the individual
practitioners are reviewed by the appropriate medical staff
committee and the governing body.
A dermatologist who provides satisfactory evidence of com-
pletion of an appropriate training course of specific surgical
procedures should be credentialed and privileged to perform
those procedures. Dermatology organizations should carry
out an independent evaluation process to confirm clinical
competency.
It is rare that dermatologists are represented on hospital
medical staff credentialing committees, because they work
primarily in the outpatient setting. Hospitals compete eco-
nomically with ambulatory surgery centers (ASCs) and
office-based facilities, meaning that any legislative, regula-

810
Part 5  Office-based Surgery: Physical and Regulatory
deficiencies in the Medicare Conditions of Coverage as docu-
mented by the OIG.
State licensing and certificate of need
Early in the development of the ASC, two questions need to
be answered:
1. Is licensure of ASCs required in your state?
2. Is certificate of need (CON) required?
State licensing requirements vary from those that are non-
existent to those involving many pages of specifications. Pro-
cedures that may be performed can be limited by state
regulations. Some states offer exemptions from all or some
of the requirements for ASCs in physicians’ offices, smaller
facilities, and single specialty facilities. Exemptions can be
obtained on an individual basis.
In more than half of the states, CON laws regulate the
building, opening, expansion, services provided, and sales of
ASCs (Boxes 49.4–49.6). Exemptions may be obtained for
office-based surgery, for new projects costing less than a
specific dollar amount, for relocations, expansions or renova-
tions, and for change of ownership.
ogy slides, or Mohs sections with another dermatologist. All
quality improvement activities should be documented in
writing, just like the medical records of patients which reflect
all activities involved in patient care. All quality improvement
activities need to be reported to the governing body as well
as to other personnel in the practice during routine staff
meetings.
Accrediting bodies, such as the AAAHC and JCAHO,
require benchmarking, a process whereby healthcare organi-
zations compare themselves to similar organizations. Health-
care organizations can benchmark themselves against another
organization, the medical literature, or a national study.
National studies regarding quality among various healthcare
organizations are conducted by:
• the Institute for Quality Improvement (IQI), a non-
profit subsidiary of AAAHC
• the Federated Ambulatory Surgery Association (FASA).
Medicare certification and reimbursement
Medicare certification must be obtained in order to receive a
facility fee from Medicare. The surgeons fees are usually
reduced when billed with a facility fee; however, the net
effect is an increased reimbursement when both fees are
billed together. Payers may refuse to pay facility fees by
arguing that the facility is a physician practice and not an
ASC.
Achieving Medicare certification involves three steps:
1. Operate according to the Medicare Conditions of
Coverage standards.
2. Obtain a Medicare survey.
3. Obtain a Medicare provider number.
Medicare standards focus on the healthcare facility and envi-
ronment, rather than the quality of care. There are nine
national standards for Medicare and state-specific Medicare
standards.
Medicare surveys may be carried out by a state agency or
accreditation body with deemed status. Three national
accreditation bodies (AAAHC, JCAHO, and AAAASF) have
been deemed by the Centers for Medicare and Medicaid
Services (CMS) to determine whether a healthcare facility
meets the Medicare Conditions of Coverage. During a status
survey, the additional Medicare standards are applied. Medi-
care surveys are always carried out on an unannounced basis.
Office of Inspector General
The Office of Inspector General (OIG) enforces the Medi-
care certification process through announced inspections. The
mission of the OIG is ‘to protect the integrity of the Depart-
ment of Health and Human Services programs as well as
the health and welfare of beneficiaries served by them.’ The
statutory mission is carried out through a nationwide program
of audits, investigations, inspections, sanctions, and fraud
alerts.8
The challenge of the OIG to the practitioner is that the
OIG has no accountability and interprets the Medicare Con-
ditions of Coverage according to their own interpretation of
their mission, which is usually to find fault with an ASC.
After an OIG inspection, the ASC must offer a Plan of
Correction, usually within 10 days, or else they risk losing
Medicare certification and the resulting facility fees. The Plan
of Correction is the detailed point-by-point response to the
Box 49.4  States with CON laws applying
to ASCs
Alabama
Alaska
Connecticut
Delaware
District of Columbia
Georgia
Hawaii
Illinois
Iowa
Kentucky
Maine
Maryland
Massachusetts
Michigan
Mississippi
Missouri
Montana
Nevada
New Hampshire
New York
North Carolina
Rhode Island
South Carolina
Tennessee
Vermont
Virginia
Washington
West Virginia
Box 49.5  States with CON laws that do not
apply to ASCs
Arkansas
Florida
Louisiana
Nebraska
New Jersey
Ohio
Oklahoma
Oregon
Wisconsin
Box 49.6  States with no CON laws
Arizona
California
Colorado
Idaho
Indiana
Kansas
Minnesota
New Mexico
North Dakota
Pennsylvania
South Dakota
Texas
Utah
Wyoming

811
Chapter 49  Dermatology Office Accreditation
2. A few states have voluntary guidelines or position
statements, which may be used to establish standards in
cases of medical malpractice.
Typically, the requirements address the duration of surgery,
the level of anesthesia, emergency protocols, the training and
qualifications of the surgeon and other personnel, the neces-
sary equipment, and the reporting of adverse events.
The regulatory process begins with passing a law (statute)
which is enforced through regulations developed by the
appropriate state agency. Many states have regulated office-
based surgery through state boards of medicine. The follow-
ing examples illustrate the varied approaches taken by the
states.
The political climate changed in September 1994 with the
regulation of office-based medicine by California legislation
under AB 595.9 These regulations apply to facilities using
anesthesia (excluding local anesthesia and nerve blocks). The
current California definition includes conscious sedation. This
legislation requires offices to obtain:
• a state license
• Medicare certification or accreditation by an approved
organization
• a written transfer agreement with a hospital, physician
staff privileges at a hospital, or a plan for handling
medical emergencies.
This law was revised in 1999 to require a minimum level of
liability insurance coverage, the reporting of complications,
and prominent display of the accreditation certificate.
In Florida, from 1999 to 2000, the Board of Medicine
adopted a set of rules which require that the following are
mandatory:
• Hospital privileges for offices using ‘level 3’ anesthesia
(general anesthesia, spinal anesthesia, major intravenous
anesthesia).
• Hospital transfer agreements.
• Reporting of adverse incidents in medical offices.
State societies representing dermatology, plastic surgery, and
cosmetic surgery sued for injunctive relief and won in a lower
court only to have it reversed by the Court of Appeals. The
New York State Department of Health developed guidelines
in consultation with dermatologic surgeons. These guidelines
were overturned by the New York Supreme Court, which
said that the department did not have the authority to prom-
ulgate guidelines or regulations. Several bills to require regu-
lations have been defeated in the New York State Legislature.
The state of New Jersey developed regulations in 1999 that
required hospital privileges for ‘surgery’ in medical offices or
‘alternative’ credentialing by the Board of Medicine.
In a process which began in 2001, the Ohio Board of
Medicine deliberated for over 2 years about regulations for
office-based surgery. The very restrictive language used in the
initial regulations proposed by the board was modified fol-
lowing aggressive lobbying by the state dermatology society.
In Texas, the state dermatology society has been very active
and effective in lobbying the Board of Medicine to develop
fair, appropriate, and reasonable regulations.
These examples show that laws and regulations can be
modified at many points in the process including the legisla-
ture where the law is passed, the state agency or board of
medicine where the regulations are formulated, and in the courts
where the whole process can be overturned. It is extremely
ASCs in office-based practices may be exempt from the
CON regulations in many states if certain conditions are met.
Such factors include the following
• The ASC will not be Medicare certified.
• Only physicians in the practice will use the facility.
• The number of operating rooms does not exceed a
specified number.
• The dollar amount spent on the facility and equipment
does not exceed a specified amount.
Most states require a letter of intent be filed before a CON
application. This letter may need to provide detailed informa-
tion about the location, the number of operating rooms, the
area served, the types of services provided, and the source of
financing. It informs not only the respective state agency
about the intent to file a CON but also any group that may
oppose the development of an ASC. Typically the opponents
will be hospitals or other ASCs that do not want competition.
The CON may be contested by hospitals or other ASCs
through an administrative appeal or by legal action.
States may use objective numeric criteria or subjective
criteria to judge whether or not to approve a CON. The
objective criteria may be based upon population per operating
room, number of cases per operating room, or similar factors,
in the area served by the CON applicant. Throughout the
CON application and the hearing process, three or four key
arguments in favor of granting the CON should be developed.
For example, one argument is that the ASC can provide lower
costs for patients and payers than local hospitals. This can be
demonstrated when comparing the explanation of benefits
and co-payments for Medicare patients from local hospitals
against those for an ASC. Letters from prominent individuals,
payers, and community groups should confirm that the ASC
should result in a higher quality of patient care and lower
costs relative to hospital-based surgery.
A second argument might be developed if it can be shown
that patients have to wait for surgery because community
operating rooms are busy. This is an easy argument if 950 or
1000 cases per year are carried out in each operating room.
If the operating rooms are being used for less than 700 or
800 cases per year, it is difficult to demonstrate overuse.
Alternatively, operating room capacity can be estimated by
dividing the total number of hours that an operating room is
open by the average number of hours spent on each case. As
inpatient cases generally take longer than outpatient cases, it
is important to distinguish between inpatient and outpatient
operating rooms.
A third argument may focus on the preferred way for the
community to expand services. Factors to take into account
include the cost of reconfiguring a hospital, and the relative
cost of outpatient surgery in a hospital, in an ASC, and in an
office.
Of essential importance is to define the CON planning area
in a way that is favorable to the project.
State legislation and regulation
Office-based surgery has been regulated primarily by one of
two methods:
1. Individual states have laws and regulations and the
penalty for non-compliance is a disciplinary proceeding
against the physician’s or dentist’s licenses, or a fine
(Table 49.1).

812
Part 5  Office-based Surgery: Physical and Regulatory
Table 49.1  Office-based surgery statute or rule (revised April 21, 2009)
STATE STATUTE
OR RULE
ENTITY
AGENCY
DESCRIPTION
Arizona
Az. Rev. Stat., Sec.
36-424 (C).
Proposed Rule
Article 7,
R4-16-701-709
Physician
offices
Dept of Health
Services,
Division of
Assurance and
Licensure
Services
Physician offices and clinics are exempt from the licensing requirements
applicable to healthcare institutions unless patients are kept overnight as bed
patients or treated otherwise under general anesthesia, except where treatment
by general anesthesia is regulated under the dentistry statutes.
Arizona Medical
Board
Legislation was enacted in 2004 providing the board with specific authority to
develop rules. Proposed regulations include anesthesia, administration,
procedure and patient selection, equipment, and emergency and transfer
provisions. The proposed rules were published in the Arizona Administrative
Register and a hearing was held on September 17 to address comments. One
amendment was made to the proposed rules which were adopted at the Dec
13–14, 2007 meeting. The rules have been submitted to the Governor’s
Rulewriting Review Council for approval.
California
Health Safety Code,
Ch. A.3, Sec. 1248;
Bus. & Prof. Code,
Secs. 2216.1,
2216.2, 2240
Outpatient
facilities
Medical Board
of California
Licensure, Medicare certification, or accreditation is required for all outpatient
settings where anesthesia is used (excluding local or peripheral nerve blocks).
The Division of Licensing has approved the AAAHC, among others, as
state-recognized accreditation agencies. The legislation also contains a
number of other requirements such as those relating to liability insurance
coverage, reporting complications, adequate personnel, and written discharge
criteria. Facilities must be state licensed, Medicare-certified or accredited by an
accrediting agency approved by the medical board in order to charge and
collect a facility fee for use of the emergency room or operating room of the
facility for services provided to injured employees under the state’s workers’
compensation laws. Liposuction extraction and postoperative care standards
for outpatient settings went in effect on Feb 20, 2003. Procedures performed
under general anesthesia or intravenous sedation, or that result in the extraction
of 5000 or more cubic centimeters of total aspirate, must be performed in a
hospital or an outpatient setting that is licensed, or accredited by one of the
approved entities listed above.
Colorado
Policy Statement
40-12
Office-based
surgery and
anesthesia
Board of
Medical
Examiners
In Nov 2001, the board adopted a policy statement regarding the provision of
surgical and anesthesia services in office settings. Overnight patient stays are
not recommended unless the facility is accredited as a ‘Class B or C facility’ by
the AAAHC or other named accrediting organization, or Colorado Department
of Public Health and the Environment.
Connecticut
Conn. Gen. Stats
Sec. 19a-691; HB
5531 (signed into
law on June 3, 2004)
Offices where
certain types
of anesthesia
are
administered
Office of Health
Care Access
(OHCA),
Department of
Public Health
Any office or unlicensed facility at which moderate sedation/analgesia, deep
sedation/analgesia, or general anesthesia is administered must be accredited
by the AAAHC, among other accrediting organizations, or be Medicare
certified, within 18 months of administering such sedation or anesthesia. A law,
effective Jul 1, 2004, requires a license and a CON for non-hospital outpatient
surgical facilities that use moderate sedation, deep sedation, or general
anesthesia. Medical offices are exempt if they do not administer deep sedation
or general anesthesia and meet certain other conditions. Facilities that
operated before Jul 1, 2003, or received an OHCA determination that a CON
was not required, may operate until Mar 30, 2007 without a license. A law,
effective Jul 1, 2005, requires a CON approval, regardless of cost, for any
healthcare facility that purchases, acquires, or accepts the donation of imaging
and scanning equipment. The CON requirement will be waived if the equipment
was acquired prior to Jul 1, 2005, or a CON or determination that a CON was
not required was obtained from the OHCA before Jul 2005.
District of Columbia
DC Code Secs.
32-1301 to 32-1309.
Office-based
surgery
Department of
Health
Accreditation by a private accrediting body or certification to participate in a
federal health program may be accepted in lieu of relicensing inspection.
Office-based facilities are subject to the same licensing requirements as health
facilities if complex procedures are performed.
Board of
Medicine
The board issued an advisory in 2000 that it will follow ASA guidelines in
determining the acceptable standard of care in cases involving office-based
anesthesia.

813
Chapter 49  Dermatology Office Accreditation
STATE STATUTE
OR RULE
ENTITY
AGENCY
DESCRIPTION
Florida
Fla. Stats. Chapter
395; Fla. Admin.
Code Sec.
59A-5.004
Fla. Stats. Sect.
458.309(1), (3);
458.351(6); 455.681
Fla. Admin. Code
Rules 64B-9.009,
9.0091, 9.0092
Office surgery
performed in
facility not
regulated by
Agency for
Health Care
Administration
(AHCA) or the
Department of
Health
AHCA
Ambulatory surgical centers not accredited by AAAHC or another approved
accrediting organization are subject to an annual licensure inspection survey.
The agency accepts the survey report of an accrediting organization as
substantial compliance.
Board of
Medicine,
Department of
Health
Florida law requires Department of Health inspections for physician office
facilities where certain levels of surgery are performed, unless a nationally
recognized accrediting agency or another accrediting organization
subsequently approved by the Board of Medicine accredits the offices.
Physicians performing certain levels of surgery in an office are required to
register with the board and indicate whether their office is accredited or subject
to a state inspection. The rules recognize AAAHC as an approved accrediting
agency. The rules also require compliance with a number of state standards for
office-based surgery. The board imposed an emergency rule moratorium from
Feb 11 to May 10, 2004, on performing liposuction and abdominoplasty
procedures within 14 days of each other on the same patient in an office
setting. In 2004, the District Court of Appeal invalidated the rule requiring an
MD or DO anesthesiologist to supervise administration of anesthesia in level III
surgeries. The board has amended the rule by deleting this requirement.
AHCA’s Bureau
of Managed
Health Care
HMOs and prepaid health plans are required to undergo an external quality
assurance review by an approved accreditation organization, which includes
the AAAHC.
Illinois
Rules for the
Administration of the
Medical Practice Act
of 1987, Sec.
1285.340
Office-based
anesthesia
Department of
Professional
Regulation
The department has established minimum CME and ACLS certification
requirements for operating physicians and anesthesiologists who administer
certain levels of anesthesia in physician offices. In 2004, a court invalidated the
rule requiring surgeons to have certain training and experience in anesthesia in
order for a CRNA to provide anesthesia.
Kansas
Kan. Rev. Stats.
Sec. 65-429
K.A.R.
100-25-1-100-25
Kan. Rev. Stats.
Sec. 40-3211 (b)
Office-based
surgery
Department of
Health and the
Environment
The department recognizes accreditation by entities defined in the state statute
in lieu of its own licensing and risk management surveys.
Kansas State
Board of
Healing Arts
Regulations which set forth requirements for all office-based surgery and
procedures became effective Jan 1, 2006. In addition, effective Jul 1, 2006, any
physician who performs any office-based surgery or procedure using general
anesthesia or a spinal or epidural block must operate in an office that meets the
standards of approved accrediting organizations, including the AAAHC.
Insurance
Department
A quality of care assessment by an independent organization is required for
licensure of HMOs. AAAHC accreditation is recognized as meeting this
requirement.
Massachusetts
Massachusetts
Medical Society
Guidelines for
Office-based
Surgery; S. 639
(introduced in 2003)
Office-based
surgery
Mass. Medical
Society Board of
Registration in
Medicine
The board endorsed the medical society’s guidelines, which are based on the
level of anesthesia and the complexity of the procedures performed. In addition
to other requirements, the recommendations provide that offices where surgery
other than minor procedures are performed should be accredited by an
accrediting organization, including the AAAHC or AAOMS Office Anesthesia
Evaluation program, or any other agency approved by the board.
Mississippi
Mississippi State
Board of Medical
Licensure, Rules
and Regulations,
Article XXIV
Office-based
surgery
State Board of
Medical
Licensure
Depending on the level of surgery performed, the board’s requirements
address surgeon registration, surgical logs and records, reporting of adverse
incidents, equipment, supplies, and training of surgeons. The board provides
an alternative credentialing mechanism for procedures outside a physician’s
core curriculum. Strong recommendations are included for amount of fat to be
removed using tumescent liposuction.
Table 49.1  Office-based surgery statute or rule (revised April 21, 2009)—cont’d

814
Part 5  Office-based Surgery: Physical and Regulatory
STATE STATUTE
OR RULE
ENTITY
AGENCY
DESCRIPTION
New Jersey
NJAC 8:43A-
3.12 (b)
NJAC 13:35-4A.12;
17; N.J.A.C.
13:35-6.7
Office-based
surgery and
anesthesia
Department of
Health and
Senior Services
After licensure, ASCs must submit annually the report of a survey by an
independent accreditation organization whose standards meet or exceed
Medicare conditions of coverage.
Board of
Medical
Examiners
Regulations govern the administration of office-based anesthesia, including
standards for training, credentialing, staffing, equipment, and reporting. In Dec
2002, the board issued the final rule detailing the alternative privileging
mechanism for office-based physicians who do not hold hospital privileges.
Certain documentation of competence, training, and clinical experience are
required to obtain privileges for performing surgery or special procedures,
performing or supervising general and regional anesthesia or conscious
sedation, or utilizing lasers. The privileging requirement is not imposed for
‘minor surgery’ although certain procedures such as liposuction and breast
augmentation are not considered minor. Privileges are granted for 2 years.
Initial applications must have been submitted by Dec 16, 2003. Physicians who
submit an application for alternative privileging may continue to provide
services until the board acts on their application. The board developed a list of
acceptable in-office procedures and alternative privileging application forms,
and selected an entity to review the documentation submitted along with
application. Effective Nov 7, 2005, physicians who perform ‘new or novel
procedures in an office setting’ must establish procedural protocol that
provides for the protection of patients consistent with settings under the
jurisdiction of an Institutional Review Board which complies with the
requirements of the Food and Drug Administration. In Jun 2005, the New
Jersey Supreme Court upheld the Superior Court’s ruling that the Board of
Medical Examiners has the legal authority to impose supervision requirements
on CRNAs working in physician’s offices. A supervising physician without
concurrent responsibilities must be present in the room when a CRNA administers
general or regional anesthesia. These rules are the most restrictive of any state.
New York
NYCRR Title 10,
Sec. 755.2
S.6052
Office-based
surgery
State
Department of
Health
ASCs must obtain accreditation from AAAHC or other named accrediting
organizations within 2 full years of operation. After an initial licensing inspection,
the Department accepts accreditation surveys in lieu of its own relicensing
inspections. On Jul 18, 2007, the Governor signed into law legislation (S.6052)
requiring that office-based surgeries be performed by physicians in settings
that have obtained and maintained accreditation. Under the law, performing
surgery in an unaccredited setting would constitute professional medical
misconduct. In addition, the new law requires physicians in these practices to
report adverse events, including patients who die within 30 days of a
procedure, unplanned transfers to hospitals, or other ‘serious or life-
threatening’ events, to the state Health Department’s Patient Safety Center
within 24 hours. Data from these reports are protected under the new legislation
and will not be subject to public disclosure under state ‘freedom of information’
act requests but can be included in reports that aggregate such outcome data.
The law takes effect 6 months from its enactment; however, the accreditation
requirement will become effective 2 years after enactment. The AAAHC has
been recognized by the Department of Health as an approved accrediting
organization. For more information, check the New York State Department of
Health website at:
based_surgery/
North Carolina
10 NC Admin. Code
03R.2116; 03R Sec.
2100; 03Q.0202(a)
Position Statement
on Office-based
Procedures
Office-based
surgery
Division of
Facility Services,
Department of
Health and
Human
Resources
ASFs are required to obtain accreditation from the AAAHC or a comparable
accreditation authority within 2 years of completion of the facility. ASFs
accredited by the AAAHC or other accrediting organizations are deemed as
meeting licensure requirements.
North Carolina
Medical Board
On Jan 23, 2003, the board approved a position statement of standards of
practice. By Jan 2004, any physician performing level II or III procedures in an
office should be able to demonstrate substantial compliance with the guidelines,
or obtain accreditation by a nationally recognized agency such as the AAAHC, or
other board-approved agency. Other guidelines address physician credentialing,
including an alternative privileging option, emergencies, performance
improvement, medical records, patient selection, equipment and supplies, and
personnel. Failure to comply creates the risk of disciplinary action by the board.
Table 49.1  Office-based surgery statute or rule (revised April 21, 2009)—cont’d

815
Chapter 49  Dermatology Office Accreditation
STATE STATUTE
OR RULE
ENTITY
AGENCY
DESCRIPTION
Ohio
Ohio Code Sec.
3702-30; Admin.
Code Sec. 3701-83
Administrative Code
Secs. 4731-25-01 to
07
Office-based
surgery
State of Ohio
Medical Board
The department accepts accreditation reports of ASFs in lieu of compliance
with health facility regulations and an on-site state survey. The department is
authorized to renew a license without a state survey if the facility is accredited
by the AAAHC or other named accrediting organizations, and is deemed to be
in compliance with the Medicare Conditions of Coverage. Compliance may also
be demonstrated by an ASF that has achieved Medicare certification through a
state survey that was conducted within 90 days of the licensure renewal date.
Effective Jun 1, 2006, the department adopted rules which, among other
changes, increase penalties for operating without a license and failing to obtain
informed consent from patients. The extent of the fine depends on factors,
including whether there has been ‘harm’ to the patient. The Medical Board
approved regulations requiring accreditation of offices where physicians or
podiatrists perform surgery using moderate sedation or higher anesthesia. The
rule took effect on Jan 1, 2004. Application is required within 18 months of that
date and accreditation must be obtained within 3 years after that date. The
AAAHC, other named accrediting organizations, and any other board-approved
agencies are recognized. The rules also contain education, training, and
experience requirements for surgery and anesthesia, and limits on liposuction.
Oklahoma
Okl. Admin. Code
Sec. 310:655-17-11
Office-based
surgery
State Board of
Medicine
The board adopted guidelines for physicians who perform procedures that
require anesthesia or sedation in an office setting.
Department of
Health
The department examines the quality of healthcare services offered by HMOs
and prepaid health plans, and has approved the AAAHC as an independent
quality examiner.
Oregon
ORS Sec. 441.055
(2); OAR Sec.
333-076-0114 (2);
Oregon Admin.
Rules Sec.
847-017-0000 to 006
Office-based
surgery
Oregon Board
of Medical
Examiners
Regulations were adopted at the Oct 13, 2006, meeting of the board which
require that every physician performing procedures or surgery using conscious
sedation or anesthesia services must perform them in a facility that is
accredited by an agency approved by the Board. The AAAHC is included as an
approved accrediting agency.
Department of
Human
Services,
Oregon Health
Division
The division may accept certificates by accreditation entities listed in the statute
as evidence of compliance with acceptable standards in lieu of state
inspections.
Pennsylvania
Pa. Rules and
Regulations, Title
28, Part IV, Subpart
F, Ch. 551-571
Pa. Rules and
Regulations, Title
28, Part I, Ch. 9
ASFs (includes
physician
offices with a
distinct part
used solely for
surgery on a
regular and
organized
basis), HMOs
Department of
Health
For class A, limited to local or topical anesthesia, ASFs must register and
obtain accreditation from a named accreditation organization, including the
AAAHC. For higher classes B and C, licensure is required, although the rules
allow the department to delegate the survey function to nationally recognized
accreditation agencies. At this time, the department is not recognizing
accreditation for class B or C licensure but conducts its own licensure surveys.
Rhode Island
RI Stats., Ch. 23-17
Dept of Health Rules
and Regulations,
R23-17-POSPST
Office-based
surgery
Department of
Health
The department issued regulations requiring licensure for offices in which
surgery other than minor procedures is performed, along with other
requirements. Physicians who provide such services must be licensed.
Application for accreditation by the AAAHC, JCAHO, or AAAASF is required
within 9 months from initial licensure, with accreditation required within 2 years
after licensure. Accreditation must be maintained as a condition of licensure
thereafter. In Jun 2002, the enabling law was amended to specifically include
office-based podiatry. External quality review is required for licensure of HMOs.
AAAHC accreditation has been recognized as meeting this requirement. The
department revised its regulations and is expected to issue RFPs to approve
external quality reviews of organizations.
Table 49.1  Office-based surgery statute or rule (revised April 21, 2009)—cont’d

816
Part 5  Office-based Surgery: Physical and Regulatory
Table 49.1  Office-based surgery statute or rule (revised April 21, 2009)—cont’d
STATE STATUTE
OR RULE
ENTITY
AGENCY
DESCRIPTION
South Carolina
Regulation 61-91,
Sec. 202
Regulation 81-96
Office-based
surgery
Department of
Health and
Environmental
Control
The department may consider accreditation surveys in determining the
appropriateness of conducting its own inspections.
Board of
Medical
Examiners
The General Assembly ratified Regulation 81–96, which requires accreditation
of certain office-based surgery practices, on Jun 7, 2007. The regulations
define three levels of practice and requirements are based on the level of
practice. While the regulation’s effective date was in June, the board will be
issuing specific guidelines clarifying the requirements of the regulations,
including the time-frame for compliance.
Texas
25 Texas Admin.
Code Sec. 135.20;
135.22
Tex. Civ. Stats.
Article 4495b,
Subch, G, Secs.
7.01-7.07; Article
4427e 22 TAC Secs.
192.1-192.6; 22 TAC
Sec. 221.1-221.17
Outpatient
surgical
settings that
are not part of
a licensed
hospital or
ASC
Department of
State Health
Services
Effective Apr 4, 2004, an initial or renewal state licensing survey may be waived
if the ASC provides documented evidence of accreditation by the AAAHC or
another accrediting organization and Medicare deemed status. The Executive
Commissioner of the Health and Human Services Commission has adopted
amendments to the regulations governing ASCs that include new requirements
for the governing body to adopt policies relating to accurate billing, evaluation
of nutritional needs of patients staying for over 8 hours, and establishment of an
emergency call system. In addition, the regulations amend requirements for
anesthesia, surgical and nursing services, and reporting requirements.
State Board of
Medical
Examiners;
State Board of
Nursing
Examiners
The two boards adopted regulations governing physicians and CRNAs
providing or administering general or regional anesthesia, or monitored
anesthesia, in outpatient settings. The regulations exempt licensed ASCs and
outpatient settings accredited by accreditation organizations, including the
AAAHC.
Virginia
18 VAC 85-20-310
to 390 (Emergency
Regulations effective
until November 17,
2003)
ASCs and
office-based
surgery
Board of
Medicine
The board issued emergency regulations governing office-based anesthesia to
be effective from Nov 18, 2002 to Nov 17, 2003. The regulations cover
non-hospital settins where moderate sedation or higher levels are administered,
and include reporting and other requirements. Legislation required the board to
adopt regulations by Jan 7, 2003, but it could not complete the regulatory
process by that date, thus necessitating emergency regulations until the
adoption of a final rule.
Washington
Office-based
surgery
Washington
State Medical
Association
The state medical association adopted guidelines for office-based anesthesia
that include accreditation by the AAAHC, JCAHO, AAAASF, or Medicare of
offices that conduct conscious or deep sedation, or general anesthesia. The
Medical Quality Assurance Commission has begun a process to draft
regulations for oversight of office-based surgery. Four public workshops were
held in 2003.
For office-based surgery procedures meeting certain thresholds, Connecticut, Ohio, Pennsylvania, and Rhode Island require accreditation. California and Florida require state
certification or accreditation. North Carolina and Texas exempt accredited settings from surgery/anesthesia standards. Illinois, Mississippi, New Jersey, and Virginia adopted
office anesthesia or surgery regulations. Colorado, District of Columbia, Kansas, Massachusetts, New York, North Carolina, Oklahoma, and South Carolina adopted voluntary
guidelines or policy statements. Oregon and Washington adopted guidelines through their state medical association. Arizona prohibits treatment under general anesthesia
in unlicensed physician offices.
This information was compiled from a variety of sources, including the NCSL, AMA, medical specialty societies, regulators, and accreditation organizations. The AAAHC can-
not guarantee its complete accuracy, and continues to research state statutes and rules governing ambulatory health care.
AAAASF, American Association for Accreditation of Ambulatory Surgical Facilities; AAAHC, Accreditation Association for Ambulatory Health Care; AMA, American Medical As-
sociation; AOA, American Osteopathic Association; ASC, ambulatory surgical center; ASF, ambulatory surgery facility; CME, continuing medical education; CON, certificate of
need; CRNA, Certified Registered Nurse Anesthetist; HFAP, Healthcare Facilities Accreditation Program; HMO, health maintenance organization; JCAHO, Joint Commission
on Accreditation of Healthcare Organizations; NCSL, National Conference of State Legislatures; OIG, Office of Inspector General; RFP, request for proposal.
important to have an active state dermatology society, working
in the legislative, executive, and judicial branches.
In a position statement on office-based medicine posted on
its website (see Box 49.7), the American Academy of Der-
matology (AAD) supported the following:
• Mandatory reporting of adverse incidents in a non-
judgmental manner to the appropriate state agency. The
manner of reporting the basic information and its
availability to appropriate researchers may subject the
practitioner to malpractice challenges.

817
Chapter 49  Dermatology Office Accreditation
oped by the staff that follow them. If an organization uses a
consultant’s manual, or hospital or ASC policies and proce-
dures as a model, it needs to modify them to fit its practice.
Simply filling in the blanks and replacing the hospital’s name
is not appropriate.
Inaccurate and incomplete credentialing
and privileging
Incomplete or illegible medical charts can lead to failure of
an accreditation survey. Common problems include failure to
document the presence or absence of allergies, incomplete
forms, or missing signatures. Medical charts need to be able
to be read by the office staff.
A healthcare organization may fail an accreditation survey
if credentialing is not completed, or if the information pro-
vided on, for example, diplomas, current licenses, board cer-
tification, and DEA certificates is not independently verified.
The organization should go directly to the source, whether it
is the medical school, medical subspecialty board, or state or
federal government to verify the information. It is not suffi-
cient to rely upon the hospital or ASC for credentialing. A
credentials verification organization (CVO) can perform this
task for a nominal fee.
Another problem is that of privileging. Privileges need to
be site specific, reflecting the competence of the surgeon in
that setting. For example, a surgeon may be able to perform
cardiac transplantation in a hospital but not in an office-based
facility.
Inadequate quality improvement program
and safety plans
The organizations should have a peer-based quality improve-
ment program, which includes risk management. Organiza-
tions may also make mistakes in executing the program. The
quality improvement studies should be simple, with a one-
page summary being adequate. It should address such topics
as clinical issues, administrative problems, cost of care, and
patient outcomes.
A one-time audit of charts is not a study. For example,
finding operative reports are missing in 20% of audited patient
charts is not a quality improvement program. Changes in
processes need to be made and followed over time, perhaps
over 1, 3, 6, 9, or even 12 months. Safety plans should be
active, with at least four or five fire and emergency drills per
year. These drills should include response to a fire in the
facility, and patient evacuation in response to a bomb threat
or tornado, earthquake, or other natural disaster. Documen-
tation should cover procedures that are carried out correctly
and things that go wrong.
Inadequate government inspections
In March 2000, the OIG released a comprehensive evaluation
of the accreditation survey process. It found that while
private accreditation organizations were providing a good
service, government inspections were inadequate. In their
report, Quality Oversight of ASCs: a System in Neglect, the
OIG assessed how state agencies and accreditation organiza-
tions oversee ASCs and their accountability to the CMS. The
evaluation was carried out by OIG personnel trained as sur-
veyors who accompanied state agency and other surveyors on
ASC surveys.
• The use of general anesthesia only in accredited
facilities.
• ‘Reasonable, appropriate, and fair’ physician
credentialing by state medical boards.
• Emergency transfer protocols for medical offices where
surgical procedures are performed.
The AAD opposed the requirement for mandatory hospital
staff privileges, hospital admitting privileges, and hospital
transfer agreements for office-based surgery.
 OPTIMIZING OUTCOMES
Box 49.7  Useful website addresses
American Academy of Dermatology (AAD)

Accreditation Association for Ambulatory Health Care (AAAHC)

American Association for Accreditation of Ambulatory Surgical
Facilities (AAASF)

Centers for Medicare and Medicaid Services (CMS)

Ambulatory Surgery Center Association (ASCA)

Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)

Office of Inspector General (OIG)

Optimizing outcomes
 Expect preparation to take 1 year – a mock survey is
invaluable, and a consultant can help in preparation.
 Update all documented policies and procedures.
 Make sure that all patient documentation is accurate and
complete.
 Make sure that all credentialing and privileging is in order.
 Review and improve if necessary quality assurance/
improvement and risk management activities.
 Check that all medications and materials in the crash cart
and surgical areas are up to date.
 Check that there is a safe procedure for handling narcotics.
 Check that all medical equipment has maintenance tags and
is in excellent working condition.
 Ensure that all surgical procedures are carried out with
proper sterile technique, appropriate surgical skill, and
postoperative recovery.
 PITFALLS AND THEIR MANAGEMENT
Outdated and irrelevant policies
and procedures
Dermatology offices may have problems obtaining accredita-
tion if they present outdated, irrelevant policies and proce-
dures that were developed for another healthcare organization
or written for the surveyor of another facility.10 The policies
and procedures must match what is really occurring in the
office. Ideally the policies and procedures should be devel-

818
Part 5  Office-based Surgery: Physical and Regulatory
sedation. A questionnaire study by Morello et al.12 covering
400 675 operative procedures in 418 accredited office surgi-
cal facilities over a 5-year period demonstrated a death rate
of 1 in 57 000 (0.000017%) and the rate for significant com-
plications was 1 in 213 cases. These rates are comparable to
those of hospitals and ASCs.
One study demonstrated no difference in patient deaths
between accredited and non-accredited facilities, but it did
not state the total number of surgical procedures reviewed.13
Patient deaths seem to be associated with general anesthesia
and with prolonged combinations of procedures, such as lipo-
suction and abdominoplasty or face lift.
Using information collected by state agencies on the safety
of office-based surgery, it has been concluded that mandatory
reporting of adverse events from office-based surgery is war-
ranted to identify modifiable risk factors and reduce the risk
of adverse outcomes. More comprehensive studies of patients
receiving surgery in office-based surgical centers in dermatol-
ogy and across all specialties are highly needed.
 SUMMARY
Dermatology office accreditation is essential to improve the
quality of medical, surgical, and cosmetic dermatologic care
provided. Patient safety has been demonstrated in national
studies across multiple institutions to be improved by accred-
itation. Accreditation also offers specialists, such as dermato-
logic surgeons, an opportunity to serve on accreditation
boards and to play roles as survey monitors to ensure that
high standards of care are maintained both within and across
medical specialties.
 REFERENCES
1. Accreditation Association for Ambulatory Health Care. Accreditation
Handbook for Ambulatory Health Care. 2008.
2. Joint Commission on Accreditation of Healthcare Organizations. http://
Accessed December 2008.
3. American Association for Accreditation of Ambulatory Surgical Facilities.
Accessed December 2008.
4. Balkrishnan R. No smoking gun: findings from a national survey of office-
based cosmetic surgery adverse event reporting. Dermatol Surg
2003;29:1093–1099.
5. Davey WP. Quality improvement and management in a dermatology
office. Arch Dermatol 1997;133:1385–1387.
6. Kesheimer K, Davey WP. Continuous quality improvement in a derma-
tology surgery office. Arch Dermatol 2000;136:1400–1403.
7. American Academy of Dermatology Quality of Care Committee. Quality
Assurance/Quality Improvement Self-Assessment Program. Schaumberg,
IL: American Academy of Dermatology; 2001.
8. Office of Inspector General. Quality oversight of ASCs: a system in
neglect. OE1-01-00-00450. Boston: OEI.
9. Lanier L. American Academy of Dermatology. Private communication.
10. Taylor D, Iqbal Y. How to clear accreditation. Outpatient Surg Mag
2001:22:32–39.
11. Bitar G, Mullis W, Jacobs W, et al. Safety and efficacy of office-based
surgery with monitored anesthesia care/sedation in 4778 consecutive
plastic surgery procedures. Plast Reconstr Surg 2003;111:150–156.
12. Morello DC, Colon GA, Fredericks S, et al. Patient safety in accredited
office surgical facilities. Plast Reconstr Surg 1997;99:1496–1500.
13. Coldiron B. Office surgical incidents: 19 months of Florida data. Derma-
tol Surg 2002;28:710–712.
The OIG report found the following:
• Regulation of ASCs has become increasingly important
because the number of Medicare ASCs doubled
between 1999 and 2000 and the number of major
procedures in ASCs increased from 12 000 to 101 000
per year.
• Almost one-third of ASCs certified by state agencies
have not been recertified in 5 years or more, whereas
the private accreditation organizations survey every 3
years.
• The approach of private accreditation organizations is
more consultative and educational, rather than just a
check on compliance.
• The CMS does not hold the state agencies accountable
to Medicare or the public.
The OIG report recommends the following:
• The CMS should determine a minimum cycle for
surveying ASCs certified by state agencies.
• The Medicare Conditions of Coverage used to
determine compliance with Medicare standards should
add sections on patients’ rights and continuous quality
improvement and should be adjusted to reflect the level
of surgery (local to general anesthesia) carried out by
different ASCs.
• The CMS should ensure that state agency certification
and accreditation have the appropriate balance between
compliance and continuous quality improvement.
• The state agencies should be accountable to the
Medicare program and the public for their performance
in regulating ASCs.
 PRACTICAL APPLICATIONS
Practical benefits of accreditation
for the dermatology office
The process of obtaining accreditation helps a dermatologic
office to:
• improve the care and services offered
• increase efficiency and reduce costs
• develop better risk management programs
• lower liability insurance premiums
• motivate personnel by instilling pride and loyalty
• strengthen public relations and marketing efforts
• recruit and retain qualified professional personnel.
Importance of enhanced patient safety
Patient safety is a prime concern for all medical personnel,
and in office-based facilities can be enhanced by accredita-
tion, as documented in chart reviews11 and surveys with ques-
tionnaires.12 A chart review study by Bitar et al.11 of 3615
patient charts with a 30-day follow-up period revealed deaths,
ventilator requirements, deep vein thromboses, or pulmonary
emboli among those who had multiple procedures in an
office-based surgery setting with monitored anesthesia care/

819
Index
Abbreviations:
KTP – potassium titanyl phosphate laser
Nd:YAG – neodymium:yttrium aluminium
garnet laser
SMAS – superficial musculoaponeurotic
system
UPCO2 – Ultrapulse CO2 laser
A
Abbe cross-lip flap, 303–304, 303f
postoperative care, 305
revisions, 305
ABCD mnemonic, 693, 43e9
abdomen, liposuction, 459–460, 460f–461f
ablative fractional resurfacing, 551–552
ablative lasers
scar revision, 334, 335b
skin resurfacing see ablative laser skin
resurfacing
ablative laser skin resurfacing, 549–554
ablative fractional resurfacing, 551–552
benefits, 550
carbon dioxide laser, 550, 551f
contraindications, 550
erbium:yttrium-aluminium-garnet laser,
550–551
objectives, 550
optimizing outcomes, 552–553
pitfalls and their management, 553–554
postoperative care, 553
preoperative preparation, 549
side effects and complications, 552–553,
552t
technical aspects, 550–552
abscesses
after chin implants, 427
drainage, 184–187, 184b, 184f
field block, 61
inflamed and infected, 184–187, 184b,
184f
absorbable sutures, 68–69, 69t, 191–193, 192t
incompletely dissolved, 250
absorptive dressings, 117
accreditation see dermatology office
accreditation
Accreditation Association for Ambulatory
Health Care (AAAHC), 807
codes of standards, 807
healthcare organizations with accreditation
from, 806b
member organization, 806b
survey process, 807
Achilles tendon, 25f
acne
and ablative laser skin resurfacing, 554
after hyaluronic acid injections, 380–381
after microdermabrasion/dermabrasion,
535
cryosurgery, 157t, 158
keloids, 159
scars see acne scars
acne scars
dermabrasion, 530
non-ablative fractional resurfacing, 556f
acral areas, vitiligo surgery, 690
actinic cheilitis, cryosurgery, 157t
actinic keratosis
chemical peels for, 402, 402f–403f, 406f
cryosurgery, 156, 161, 161f
photodynamic therapy, 558–559
squamous cell carcinoma arising from,
726
ActiveFX, 551–552
Adaptic, 116–117
adipocytes, 481
adipose tissue, head/face, 6–7, 6f
adjuvant therapy, melanomas, 704
adolescents and cosmetic surgery, 348
adrenaline see epinephrine
Adson forceps, 67, 422
advanced cardiac life support, 801–802
advancement flaps
bilateral, 255–256, 256f
bipedicle, 261, 261f
Burow’s type, 257, 258f
cheek, 220, 220f–221f
circumoral axial, 304, 304f
mucosal, 260–261
random pattern cutaneous flaps, 254–257,
255f
unilateral, 255–256, 255f, 257f
V to Y, 257–258
Advanta, 365, 369t–374t, 375f
aesthetics
composite grafts, 320
facial, 616–617
follicular unit hair transplantation, 501
random pattern cutaneous flaps, 277, 285
skin grafting, 323
aethoxysklerol, 583
Affirm, 556
age/aging
bone reabsorption, 9
face see facial aging
gravitational, 354
and keloids, 669
muscular repercussions, 434
and skin elasticity, 5
surgical site infection risk, 86
Aggrenox, 79
agitation, follicular unit hair transplantation,
509t
AIDS
surgical site infection risk, 87
see also HIV infection
airborne transmission, 30
air driven dermatomes, 315
ala nasi, 8f
composite grafts, 318, 319f, 322f
alar defects, lower cheek skin for, 292, 294f
alar groove, 8f
alar rim, 8f
alcohol
after follicular unit hair transplantation, 508b
anticoagulant effect, 79
alcohol as an antiseptic, 31t
hand scrub, 29–30, 32, 32f
pitfalls and their management, 39b
surgical site preparation, 35, 39b
alexandrite lasers
combined with chemical peels, 402
hair removal, 520–521, 522t
melanocytic lesions, 540–541
pigmented lesions, 537–538
epidermal, 540
port-wine stain, 569–570
Q-switched, 402
tattoo removal, 545
vascular lesions, 566
alginates, 117t, 120, 120f
leg ulcers, 745t
performance, 132t
technique, 120–121
allergic contact dermatitis, ear piercing, 788
allergic reactions
to antibiotics, 81
effect on surgery, 81
to latex, 81
to local anesthetics, 56–58, 56b, 81, 176b
in Mohs micrographic surgery, 722
in sclerotherapy, 586
to sutures, 190
Page references followed by a f, t or b indicate figures, tables or boxes respectively. Entries preceded by
can be found online.

820
Index
Alloderm, 123, 365, 369t–374t
leg ulcers, 749t
allografts, 121
cultured epidermal, 123–125
alopecia
androgenic see androgenic alopecia
diffuse, 488
female pattern, 488t
senile, 488t
alopecia areata, cryosurgery, 157t
α-hydroxy acids (AHAs)
as a chemical peel agent, 396b, 398–399,
399b, 399f
chemical peel pretreatment, 395
α-tocopherol, anticoagulant effect, 79
alternating current, 138–139
aluminium chloride, 229, 232t
aluminium oxide crystals, microdermabrasion,
532
aluminium oxide exposure, 532
ambulatory phlebectomy, 589, 593
ambulatory surgery centre (ASC), 795–797
American Association for Accreditation of
Ambulatory Surgical Facilities, 808–809
basic mandates, 808
denial or loss of accreditation, 808–809
goals of accreditation, 808
important points of emphasis, 809
inspection and self-evaluation, 808
organizational goals, 808
American Heart Association (AHA),
endocarditis prophylaxis guidelines,
90–91
American Joint Committee on Cancer
(AJCC), melanoma staging, 701, 702t,
726–727
American Society of Anesthesiologists’
Physical Status Classification System,
447–451, 451t
amethocaine, 48
aminocaproic acid, 232t
aminolevulinic acid (ALA), 557–559
hair removal, 518
amrinone, 59–60
Amstat, 232t
anaerobic diphtheroids, 30
analgesia, 43–63
anaphylaxis
to anesthetic agents, 722
in Mohs micrographic surgery, 722
topical antibiotics-associated, 89
androgenic alopecia
diagnosis and classification, 487–489
diffuse, 488t
hair-bearing grafts, 314
anesthesia/anesthetics, 43–63
chin implants, 421–422
elliptical excision, 240–241
follicular unit hair transplantation,
494–495, 495t
hemostatic, 228–229
infiltrative techniques, 49–51
laser and light treatment of vascular
lesions, 575
laser treatment of pigmented lesions, 540
local see local anesthesia/anesthetics; nerve
blocks
lower eyelid blepharoplasty, 643, 645
mechanism of action, 44–45
nail surgery, 757, 758f
nerve blocks see local anesthesia/
anesthetics; nerve blocks
optimizing outcomes, 55–56
photodynamic therapy, 559
pitfalls and their management, 56–60
local adverse effects, 56–57
systemic adverse effects, 57–60
practical applications, 60–61
preoperative and postoperative, 60
random pattern cutaneous flaps, 278–279
skin biopsies, 170–171, 171b
soft tissue augmentation, 368
structure and physiology of, 43–44
synthetic implants, 368
technical aspects, 46–55
topical see topical anesthesia/anesthetics
tumescent see tumescent anaesthesia
upper eyelid blepharoplasty, 640–641
vitiligo surgery, 685
angioedema, follicular unit hair transplantation,
509t
angiogenesis, 106–107, 106f
stimulation, dressings, 115
angiogenic growth factors, 106–107
angiopoietin (Ang), 106–107, 107t
angiosarcoma, 730
angry patients, 341
angular artery, 14, 16f–17f
inadvertent injection of, 380
animal derived fillers, 366t
ankle, superficial anatomy of the, 25f
ankle blocks, 26b, 54–55, 58f
ankle-brachial index (ABI), 739, 740f
anterior button keloids, 672, 675, 675f
anterior labial commissure, 26f
anterior mandibular groove, 417
antiandrogenic medications, 516
antibiotics, 85–93
allergic reactions, 81
incisional, 89
leg ulcers, 743
ointments, 282
optimizing outcomes, 92
pitfalls and their management, 92
postoperative care, 92
potential development of wound infection,
85–87
practical applications, 87–92
laser resurfacing, 89
postoperative surgical site infection, 90
tumescent liposuction, 89–90
wound classification, 87–88
in pregnancy, 74
preoperative preparation, 87
prophylactic, 78
ablative laser skin resurfacing, 549,
552–553
autologous fat transfer, 470–471
and cytotoxic drugs, 87
elliptical excision, 239
endocarditis, 90–92
follicular unit hair transplantation, 493
indwelling devices, 91–92
liposuction, 454
nail surgery, 757
skin biopsies, 170
skin grafting, 323
timing and dosing, 88–89
topical and incisional antibiotics, 89
wound classification, 87–92, 88t
wound infection, 88–89
resistance, 85, 743
topical, 89
anticoagulants, effect on surgery, 79–81
antimicrobials
in dressings, 125
for leg ulcers, 742–743
see also specific classes
antiseptic agents, 31t, 32f
hand scrub solutions, 31–33
leg ulcers, 743
new, 32–33
antitragus, 23f
anti-tumor necrosis factor (TNF), surgical site
infection risk, 87
antiviral prophylaxis
ablative laser skin resurfacing, 549
chemical peel pretreatment, 395
non-ablative laser skin remodeling, 554
anus, 26f
anxiety
follicular unit hair transplantation, 509t
and hemostasis, 233
in Mohs micrographic surgery, 722–723
Apligraf, 124–125, 124f, 320–321
leg ulcers, 749t, 45e5
apocrine hidrocystoma, 183–184, 183f, 184b
appearance, patient, 339–340
aprotinin, 232t
ardeparin sodium, 79
areola, vitiligo surgery, 690
arms
liposuction, 343–346
skin tension lines, 10f
Artecoll, 364–365, 369t–374t, 387
ArteFill, 386–387
arterial bleeding, 27b
see also hemorrhage
arterial ulcers, 129
etiology, 735–736, 737f
physical findings in, 740t
prevention, 45e3
arteriosclerotic occlusion, 735–736
aseptic technique, 29–41
normal flora, 30
pitfalls and their management, 39, 39b
preoperative preparation, 31–37
of environment, 36
of patient, 34–35
of surgical instruments, 36–37
of surgical personnel, 31–34, 32f
surgical site infection, 30–31
techniques and optimizing outcomes,
37–39
draping, 37–38
environmental cleaning, 38
face masks, 37
hair removal, 37
instrument cleaning and sterilization, 38
instrument packaging and quality
assurance, 38
maintaining a sterile field, 38–39
surgical gloves, 37
surgical hand scrub, 37
surgical site preparation, 37
surgical technique, 39
wound dressings, 39
aspirin, 79
autologous fat transfer, 470–471
effect on hemostasis, 227t
liposuction risk, 451
random pattern cutaneous flaps, 253
and skin biopsies, 170
asymmetry
botulinum toxin injections complications,
445

821
Index
chin implants, 427–428
facial, botulinum toxin injections, 442,
442f
A-T flap, 256–257, 256f
atrophic scars
cryosurgery, 157t
revision, fractional laser resurfacing, 329
atrophy
aging face, 354–356, 356f
steroid injection side effects, 674
attire, surgical, 33–34
atypical keratinocytes, 400–401
atypical moles
clinical features and presentation, 693–696,
694f–697f, 694t
dermoscopy, 698–700, 701f, 43e5, 43e8f,
43e7f
early detection and prevention, 698–701,
701f
chemoprevention, 43e10
examination and biopsy of lesions,
43e10
ophthalmologic examination, 43e9
routine dermatologic examinations,
43e9f
screening, 43e9
self-examination, 43e9
sun protection, 43e10
melanoma risk, 43e2–43e3, 432e–433e,
698
natural history and progression, 43e1,
696–698, 699f
observation techniques, 435e–436e, 698,
700t
phenotypic expressions, 693, 696–697,
696f
pitfalls and their management, 705
prevention, 43e4
prophylactic excision, 435e–436e, 698,
700f
short-term mole monitoring (STMM),
435e–436e
technical aspects, 698–704
visual aids for physician surveillance, 43e9,
701f
atypical mole syndrome, 693–696, 698t
Aufricht retractor, 422
auricle, 22
auriculotemporal nerve block, 51t, 52
autoclave sterilization, 36, 71
autografts, 121
cultured epidermal, 122
definition, 309
autoimmune disease and ablative laser skin
resurfacing, 554
Autologen, 369t–374t
autologous collagen, 388
autologous fat transfer, 469–483
controversies, 470, 471b
facial rebalancing, 474, 474f
fat autograft muscle injection see fat
autograft muscle injection (FAMI)
frontiers, 481
harvesting, 471
donor site, 471
technique, 471, 471f
use of lidocaine, 471
historical vignette, 469
indications, 473–474
injection techniques, 472–473, 473f
Lipostructure™, 469–470, 474
lower eyelids, 646
new trends, 469–470
optimizing outcomes, 476–479
longevity, 476–478
touch-up procedures, 478–479
use of frozen fat, 479
overcorrection, 480
pitfalls and their management, 479–481
preoperative preparation, 470–471
processing the fat, 471–472, 472f–473f
technical aspects, 471–475
autologous fillers, 366t, 369t–374t
autologous non-cultured epidermal cell
suspension, 42e3
vitiligo, 689t
autolytic debridement, 116, 125, 746
automatic external defibrillator (AED), 802
automatic internal cardiac defibrillators
(AICDs), effect on surgery, 78
automation, follicular unit hair transplantation,
507
avastin, angiosarcoma, 730
Avitene, 232t
avoidance behaviors, keloid management, 679
axial arteries, 20
axial pattern flaps, 289–308, 290f–291f
Abbe cross-lip flap, 303–305
blood supply, 289–290
circumoral axial advancement flaps, 304,
304f
cutaneous, 289–291
dorsal nasal flap, 299–303, 307b
historical vignette, 294–295
lip flaps, 303–305, 307b
for nasal reconstruction, 291–292,
292f–294f
optimizing outcomes, 307
paramedian forehead flap repair, 295–299,
304–305, 307b
pitfalls and their management, 307
postoperative care, 304–305
preoperative preparation, 295, 295f
versus random pattern flaps, 291
technical aspects, 295–304
axilla
hyperhidrosis, 346–347 (see also
hyperhidrosis)
liposuction, 462–463
azithromycin in pregnancy, 74
Azzalure see Dysport/Azzalure
B
bacitracin, topical, 89
bacteremia, 90
bacteria, removal in leg ulcers, 45e4
bacterial infection
chemical peel complications, 410–411,
411f
in leg ulcers, 742–743
Baker/Gordon phenol formulation, 407, 407b
banner transposition flap, 272, 275f–276f
glabellar, 272, 278f
helical rim advancement flap, 272, 276f
nasal, 272, 277f
Bard-Parker scalpel handle and blades, 65, 66f
basal cell carcinoma
clinical features, 725
cryosurgery, 157t, 161–162, 162f, 724
cytology, 169
electrodesiccation and curettage, 146,
146f
elliptical excision, 241
histological forms of, 724–725
imiquimod, 724
interferon-α (IFN-α), 724
locations, 724
margins, 241
metastatic, 725
Mohs micrographic surgery, 714, 724–725
non-surgical treatment, 724
radiation therapy, 724
recurrence, 725
basal cell layer see stratum germinativum
basement membrane zone (BMZ)
restoration of, 103–104
structure, 104f
basophils, 97–100, 100t
basosquamous carcinomas, 725
basting sutures, full-thickness skin grafts,
312–313
beard area, vitiligo surgery, 690
Beaver scalpel handle and blades, 65, 66f,
333
Beer’s law, 801
behavior modification, body dysmorphic
disorder, 346
benoxinate, 49
benzocaine, 44t
adverse effects, 60
topical anesthesia, 47, 47t
benzodiazepines, anxiolytic effect, 60, 295
benzyl alcohol, 58–59
β-blockers
drug interactions, 58
effect on surgery, 81
non-selective, 81
betacaine, topical anesthesia, 47t
bichloroacetic acid, medium-depth chemical
peels, 402–403, 404f
Bier’s block, 228–229
bilateral advancement flaps, 255–256, 256f
T-plasty, 256–257, 256f
bilateral corrugator supercilii muscles, 16, 17t,
18f
bilayered cellular matrix (BCM), 125
bilberry, 80t
effect on hemostasis, 227t
bilobed transposition flap, 270–272, 273f
advantages, 270–272
nasal reconstruction, 292
undermining, 272, 274f
uses, 270, 272, 274f
Biobrane, 123
biocatalyst fillers, 366t
biofilms, 45e4
biopsy
nail see nail surgery, biopsies
sentinel lymph node see sentinel lymph
node biopsy
skin see skin biopsy
biosurgery, 125
biosurgical debridement, 746
Biosyn, 192t, 193
bipedicle advancement flap, 261, 261f
Bishop-Harmon forceps, 67
blackcurrant, 80t
bladderwrack, 80t
bleaching, excess hair, 515
bleeding see hemorrhage
bleeding disorders, 226
effect on surgery, 78–79
inherited, 78–79
liposuction, 451
bleomycin, keloid management, 679

822
Index
blepharoplasty, 627–649
examination, 635f–636f
historical vignette, 627–628
initial consultation, 628–632, 633f–634f
key anatomic considerations, 628
laboratory evaluation before, 630–631
lower eyelid, 643–647
advanced considerations, 646–647
transconjunctival, 643–645, 643f–644f
anesthesia, 643
draping, 643
incision, 643–644
skin marking, 643
skin preparation, 643
UPCO2 laser in, 645, 645f
transcutaneous, 645–646, 646f
anesthesia, 645
draping, 645
fat pad extraction, 646
incision, 646
skin and muscle excision, 646
skin closure, 646
skin marking, 645
skin preparation, 645
patient questionnaire, 633f–634f
patient selection, 628–632, 635f–636f
pitfalls and their management, 647–648
technique, 640–647
upper eyelid, 640–643
anesthesia, 640–641
draping, 640–641
fat pad extraction, 641, 641f
skin and muscle excision, 641–643,
642f
skin closure, 643
skin marking, 640, 640f
skin preparation, 640–641
UPCO2 laser, 642–643, 642f
blindness
after autologous fat transfer, 481
after blepharoplasty, 648
blistering after laser hair removal, 524–525
blood pressure
automatic cuffs, 801
effect on surgery, 74
minimum incision face lift, 605
blood supply
axial pattern flaps, 289–290
eyelids, 631f
forehead, 294
lower face, 616
random pattern cutaneous flaps, 254
scalp, 491
body dysmorphic disorder, 341–347
clinical features, 343
clinical vignette, 341–342, 341f
common complaints in patients with,
342t
complications and psychiatric comorbidity,
343–346
criteria, 341–342, 342b, 456t
epidemiology, 342
etiology and pathophysiology, 342–343
evaluation, 343, 344f–345f
information resources, 345b
liposuction, 456
questionnaire, 343, 344f–345f
treatment options, 346–347
appropriate referrals, 346–347
behavior modification, 346
education, 346
body fat mirroring facial fat, 354, 355f
body image, 348
see also body dysmorphic disorder
body-image inventory (BII), 456
body mass index (BMI), 454–455, 455t
body peels, 408–409
bolsters, full-thickness skin grafts, 313
bone
chisels, 68
head/face, 6–7, 6f
resorption, chin implants, 426
Botox, 434
comparison chart, 435t
dose, 437
bunny lines, 438t
dimpled chin, 438t
forehead lines, 438t
gingival smile, 438t
glabellar frown lines, 437–439, 438t
hyperhidrosis, 438t
marionettes lines, 438t
nasal tip droop, 438t
neck and chest, 438t
perioral wrinkles, 438t
periorbicular wrinkles, 438t
repeated nasal flare, 438t
reconstitution, 437, 437t
see also botulinum toxins
Botox sign, 438t, 439, 445
botulinum toxins, 433–446
adjunctive treatments, 443–444
different surgical modalities, 444
fillers, 443
lasers and light sources, 443–444
before chemical peels, 405, 407f
commercially available preparations,
433–434, 435t
glabellar lines, 379
hyperhidrosis treatment, 444
immunogenicity, 436
injection techniques and cosmetic
considerations, 437–443
facial asymmetry and facial palsy, 442,
442f
leg contour, 443
masseteric hypertrophy, 442
mid and lower face, 439–442
bunny lines, 439
dimpled chin, 441, 441f
face lift, 441–442
gingival smile, 440, 440f
marionette lines, 441
nasal tip droop, 440
perioral wrinkles, 440–441, 441f
repeated nasal flare, 440
neck and chest, 442, 443f
upper face, 437–439
forehead lines, 439, 440f
glabellar frown lines, 437–438,
438f–439f
periorbicular wrinkles, 438–439, 439f
muscular repercussions in the aging
process, 434
pharmacology and mechanism of action,
434
pitfalls and their management, 444–445,
444b–445b
pretreatment preparation, 436–437
contraindications and precautions, 436
patient preparation, education and
recommendations, 436–437
short-, mid-, and long-term effects,
434–436
storage and reconstitution, 436
technical aspects, 437–444
type A (BT-A) see botulinum toxin type A
(BT-A)
type B (BT-B), 433–434
botulinum toxin type A (BT-A), 433–434
bunny lines, 439
crow’s feet, 438–439, 439f
with different surgical modalities, 444
dose, 437
facial asymmetry, 442, 442f
and fillers, 443
gastrocnemius muscle hypertrophy, 443
gingival smile, 440
glabellar frown lines, 437–438, 439f
hyperhidrosis, 444
and lasers and light sources, 443–444
marionette lines, 441
neck rejuvenation, 442, 443f, 651
perioral wrinkles, 440–441
pharmacology and mechanism of action,
434
reconstitution, 436
safety, 445
side effects, 445
storage, 436
topical, 434
see also Botox; Dysport/Azzalure
botulism, 433
bovine collagen, 365f
contraindications, 368
history, 364
hypersensitivity, 368
technical aspects, 368
Bowenoid papulosis, 726
Bowen’s disease
cryosurgery, 157t
ungual, 773, 774f
bradycardia, follicular unit hair transplantation,
509t
breastfeeding, breast liposuction and, 342
breasts
autologous fat transfer, 473–474
cancer, liposuction contraindications,
342
liposuction
female, 346
men, 346
Breslow level, 241
bromhidrosis, liposuction, 346–347
brow
ideal, 12–13
lifting see brow lifting
ptosis, botulinum toxin injections
complications, 445
brow lifting, 627–649
consultation, 631–632
coronal forehead lifting, 639–640
direct, 637, 638f
endoscopic forehead lifting, 640
fillers for, 366
forehead lifting, 639
historical vignette, 627–628
initial consultation, 628–632
key anatomic considerations, 628
mid-forehead lifting, 637–638, 639f
patient evaluation, 631–632
patient selection, 628–632
pitfalls and their management, 647–648
pretrichal forehead lifting, 638–639
suspension sutures, 217
technique, 632–640, 637f

823
Index
temporal, 638, 639f–640f
transblepharoplasty/internal brow
suspension, 632–637, 637f
Brown-Adson forceps, 67
browplasty, 632–637
bruising
after calcium hydroxylapatite injections,
382
hyaluronic acid injections, 380
BTX-A see botulinum toxins
buccinator muscle, 17t, 18, 18f–19f
fat autograft muscle injection, 476f–477f
Buck’s fascia, 24
bulbar conjunctiva, 8f
bullae
formation after cryosurgery, 164
skin grafting of leg ulcers, 749
bunny lines, 438t, 439, 445
bupivacaine, 44t–45t
local anesthesia, 60–61
toxicity, 59
buried stitches
butterfly suture, 205, 205f
pulley stitch, 206f
random pattern cutaneous flaps, 282
traditional, 204–205, 205f
vertical mattress suture, 205, 205f, 282
burns
electrical see electrical burns
honey and, 110–111
Burow’s grafts, 313–314
Burow’s type advancement flap, 257, 258f
butterfly suture, buried, 205, 205f
buttocks, 345
button keloids, 672, 675, 675f
C
cabinets, surgical suite, 799–800, 800f
cadexomer iodine, 125
café-au-lait macules, laser treatment, 540,
541f, 544
calcaneus, 25f
calcitonin gene-related peptide, 742
calcium hydroxylapatite, 381–382
injection technique, 382
key publications, 381–382
safety, 382
side effects, 381
camouflage, follicular unit hair transplantation,
506, 506f
candida infection
chemical peel complications, 411, 411f
surgical site infections, 85–86
cannulae
autologous fat transfer, 473
fat autograft muscle injection (FAMI), 475,
475f
liposuction, 341, 344f–345f
canthal tendons, 631f
capillary malformations, 567b
capilliarity, sutures, 190
carbolic acid, 29
carbon dioxide, solid, 154, 396b, 400
carbon dioxide lasers
continuous-wave, hemostasis, 229–230
hemangiomas, 572
matricectomy, 761–762
neck rejuvenation, 662–663
nevus of Ota-like macules, 540–541
pigmented lesions, 539
preoperative preparation, 549
scar revision, 328–329, 334
skin resurfacing, 550, 551f
UPCO2 see Ultrapulse CO2 laser
carcinoembryonic antigen (CEA) rapid
staining, 718
carcinoma cuniculatum, 773
cardiac pacemakers see pacemakers
cardiopulmonary resuscitation (CPR),
801–802
cardiotoxicity
local anesthesia, 59
phenol, 407
cardiovascular disease, effect on surgery,
74–78
cartilage, 316
grafts, 316–320 (see also composite grafts)
head/face, 6–7, 6f
caruncula lacrimalis, 8f
Castroviejo needle holder, 67–68
cayenne fruit, 80t
CD-34 immunostain, 718
cefalexin in pregnancy, 74
celery plant, 80t
cellular grafts, vitiligo, 42e3–42e5
cellular response to injury, 99–101
cellulite, liposuction, 341
cellulitis after chin implants, 427
Center for Disease Control and Prevention
(CDC), surgical site infection definition,
30
central nervous system, local anesthesia
toxicity, 59
centrifugation, autologous fat transfer, 472,
472f–473f
cervical nerves, 20–21
cervicofacial head wrap, 611, 612f
cervicofacial rotation flap, 214–215, 214f
chamber cryosurgery technique, 155, 155f,
163
chamomile, 80t
cheek advancement flap, 220, 220f–221f
cheek melolabial interpolation flap, 292
cheek(s)
bones, 11, 11f
cosmetic unit of, 8f
flap elevation plane, 280
sensory nerves, 607f
structure, 217–218
undermining plane, 280t
cheetah phenotype, 693, 696f
chemabrasion, vitiligo, 42e7
chemical burns, local anesthesia-associated, 57
chemical debridement, 746, 747f
chemical depilatories, 515
chemical immersion sterilization, 36, 71
chemical peels, 393–413
agents, 393, 398–400, 403b (see also
specific agents)
classification, 394f, 394t
deep (phenol peels), 394f, 394t, 405–408
history, 393
postoperative care, 408
preoperative preparation, 407
technical aspects, 408
history, 393
medium-depth, 394f, 394t, 402–405, 405f
agents, 403b
indications, 403b
optimizing outcomes, 405
postoperative care, 404–405
technical aspects, 403–404
non-facial, 408–409, 408f–409f
pitfalls and their management, 409–411
infection, 410–411
milia, 410
pigmentation, 410
prolonged erythema, 410
scarring, 411
systemic complications, 411
preoperative preparation, 393–396
consent, 395
consultation, 395–396
deep (phenol peels), 407
photography, 395
skin preparation, 393–395
α-hydroxy acids, 395
antiviral prophylaxis, 395
hydroquinone, 395
pretreatment with tretinoin,
394–395
role of sun damage, 394
sunscreens, 395
superficial peels, 396–397
superficial, 394f, 394t, 396–402
advantages, 396b
agents, 398–400
α-hydroxy acids, 396b, 398–399,
399b, 399f
Jessner’s solution, 396b, 398, 398b
modified Unna’s resorcinol paste,
396b
salicylic acid, 396b, 399–400
solid CO2 slush, 396b, 400
tretinoin, 396b, 400
trichloroacetic acid, 396b, 398
limitations, 396b
novel approaches for melasma, 401
optimizing outcomes, 401–402
postoperative care, 401
preoperative preparation, 396–397
technical aspects, 397–401
treatment of atypical keratinocytes,
400–401
variables, 397b
chemoprevention, atypical moles, 43e10
chemosurgery, 711b–712b, 712f
see also Mohs micrographic surgery
chemotactic factors, 99–100
chemotherapy, melanoma metastases, 43e15
cherry angiomas, 567b
chest
botulinum toxin injections, 438t, 442
male, liposuction, 346
children
ingrown toenails see ingrown toenails, in
infancy; ingrown toenails, juvenile
local anesthesia in, 60
chin
anatomy, 417–418, 418f
deficiency, 418–419
dimpled/cellulitic, botulinum toxin
injections, 438t, 441, 441f
fillers for, 367
implants see chin implants
muscles, 7, 417, 418f
chin implants, 415–431
before and after photos, 428f–430f
anatomy, 417–418, 418f
anesthesia, 421–422
extended, 421, 421f
historical vignette, 415b
ideal materials, 420–421, 420b
ideal profile, 415–417, 416f, 416t
incision, 422

824
Index
in minimum incision face lift, 611
modification of, 421
optimizing outcomes, 423–424
pitfalls and their management, 424–428,
428b
asymmetry, 427–428
bone resorption, 426
changes in pre-existing characteristics,
428
effect on dentures, 428
extrusion, 427
hematoma, 427
infection, 426–427, 427f
marginal mandibular nerve injury, 424,
425f
mental nerve injury, 425
migration/malposition, 426
necrosis, 427
overcorrection, 425
removal of implants, 425
speech and smile alterations, 428
undercorrection, 425
visible or palpable projections, 425–426,
426f
postoperative care, 424
preoperative preparation, 418–421
evaluation and exam, 418–420, 419f
implant selection, 420–421, 421f
removal, 425
sizers, 422, 424f
surgical technique, 421–423
intraoral approach, 421
submental approach, 421–423,
422f–424f
sutures/suturing, 423, 423f
technical aspects, 421–423
chlorhexidine gluconate, 31t
hand scrub, 32
surgical site preparation, 35, 37, 39b
chloroprocaine, 44t
chloroxylenol see parachlorometaxylenol
(PCMX)
chondritis after Mohs micrographic surgery,
723
chondrodermatitis nodularis helicis chronica,
157t
chondroitin sulfate, 108
chondroitin supplements, effect on hemostasis,
227t
chromic surgical gut, 191, 192t
chromomycosis, 157t
chromophores, 537
absorption Spectra, 564–565, 564f
hair removal, 517–518, 517b
cigarette smoking see smoking
circumoral axial advancement flaps, 304, 304f
cleaning
environmental, 36, 38
instruments, 71
operating theatre, 36, 38, 802
see also sterilization, instrument
Clinical picture, Etiologic, Anatomic
distribution and Pathophysiologic
(CEAP) classification, 585, 591–593,
591t, 750t, 45e6
clitoris, 24–26, 25f–26f
clonidine, anxiolytic effect, 233
clopidogrel, 79, 227t
closed cryosurgery technique, 155, 155f
Clostridium, 433
Clostridium botulinum, 433
Clostridium tetani, 433
ClosureFAST catheter, 591, 592f
coagulase-negative staphylococci, 30
antibiotic resistance, 85
surgical site infections, 85–86
coagulation, 98–99, 99t, 225
disorders affecting, 226t
coagulation factors, 225
cobblestoning, minipunch grafting, 686, 686f
coblation, 137
cocaine, 44t
history, 43
topical anesthesia, 46–47, 47t
cocaine hydrochloride, 232t
cognitive behavioural therapy, body
dysmorphic disorder, 346
CO2 lasers see carbon dioxide lasers
cold tolerance, cryosurgery, 156
collagen, 103
as an injectable filler, 364 (see also specific
types)
biosynthesis, 108, 109f
and botulinum toxin injections, 443
composition, 4–5
dermis, 4–5
remodeling phase of wound healing, 108
collagenases, 109t
debridement, 746
fat processing in autologous fat transfer,
472
collagen dressings, 121
colony stimulating factor (CSF), 738t
columnella, nasal, 8f
Combes formula see Jessner’s solution
compartment syndrome, 462–463
complement system, 102
complete lymph node dissection (CLND),
43e13
complex layered facial closures, 211–223
facial anatomy, 212
functional skin biomechanics, 212–214
historical vignette, 211
objectives of wound closure, 211–212
optimizing outcomes, 220
pitfalls and their management, 222
postoperative care, 220
preoperative preparation, 211–214
suspension sutures, 216–220, 216f
technical aspects, 214–220
composite grafts, 309, 316–320, 319f, 322f
definition, 316–318
dressings, 320
leg ulcers, 749t
revascularization, 316–318
reverse tongue-in-groove technique,
318–320
survival, 318
sutures, 318–320
undermining, 320
use of, 318
composite skin substitutes, 124–125, 124f
compound hemangiomas, 571–572
comprehension level, psychiatric exam, 340
compression, hemostasis, 229, 229f
compression bandages, 235–236
compression stockings
leg ulcers, 742, 742t
venous ulcers, 128
compression therapy
after neck rejuvenation, 663
keloid management, 677
leg ulcers, 741–742, 742t, 45e3
minimum incision face lift, 611, 612f
types of, 128t
venous ulcers, 128
bandages, 128
compression bandages, 128
elastic bandages, 128
four-layer bandage, 129
orthotic device, 129
pneumatic compression, 129
stockings, 128
Unna boot, 128, 129f
vertical vector face lift, 622–623
concha, 23f
as a donor site for grafts, 318
condylomata, cryosurgery, 156–157, 157t
confusion, follicular unit hair transplantation,
509t
CON laws, 810–811, 810b
consent see informed consent
consultants, hiring, 797
consultation
blepharoplasty, 628–632
brow lifting, 628–632
chemical peels, 395–396
components, 73–74
liposuction, 447, 448f–450f, 452f
Mohs micrographic surgery, 714–715
vertical vector face lift, 617–618
consultation area, 73
contact dermatitis
after skin biopsies, 176b
ear piercing, 788
topical antibiotics-associated, 89
contact transmission, 30
continuous-wave lasers, 229–230
Cook total body peel, 408, 409f
cooling
laser hair removal, 519–520, 520f
laser-tissue interaction principles, 565,
565f–566f
pulsed-dye laser treatment, 568
corona, 26f
coronal forehead lifting, 639–640
coronary artery stenting, 74–78
corpus cavernosa, 24, 25f
corpus spongiosum, 24, 25f
corrugator supercilii muscles, 16, 17t, 18f
fat autograft muscle injection, 476f–477f
corset platysma repair, 656t, 657–658,
657f–658f
corticosteroids
action, 101–102
intralesional see intralesional steroids
keloid management, 673–674
polytherapy for keloid prevention, 674
side effects, 674
solo therapy for existing keloids,
673–674
solo therapy for keloid prevention,
674
leg ulcers, 742
Corynebacterium diphtheriae, 433
cosmetic surgery
and adolescents, 348
aging face, 357–358
increase in, 339
pitfalls and their management, 347–348
psychosocial issues see psychosocial issues
see also specific procedures
Cosmoderm, 364, 368–375, 369t–374t
Cosmoplast, 364, 368–375, 369t–374t
costs, dressings, 132
Coumadin, 79

825
Index
counseling see patient counseling
cover gowns, 33
cranial nerves see specific nerves
craniofacial skeletal aging, 352, 352f
crash cart, 801–802
credentialing, 809, 817
creep, 5, 212
crescent excision, 243, 244f
Crile-Wood needle holders, 67–68
cross-cultural patients, 348
cross-lip flaps, 303–304, 303f
Abbe see Abbe cross-lip flap
crow’s feet
botulinum toxin injections, 438–439, 438t
fillers for, 366
crus of helix, 23f
as a donor site for grafts, 318
crust, 167–168, 168f
cryoanesthesia, 49, 49t
microdermabrasion/dermabrasion, 531
cryogens, 154
cryogen spray, pulsed-dye laser treatment, 568
cryosurgery, 153–166
basal cell carcinoma, 724
basic principles, 153–154
equipment, 154–155, 154f–155f
fractional, 163, 163f
general principles, 156
historical vignette, 154
keloid management, 678–679
pitfalls and their management, 164–165
postoperative care, 163–164
practical applications, 156–163, 157t
acne, 158
actinic keratosis, 156, 161
basal cell carcinoma, 161–162, 162f
cutaneous larva migrans, 157–158
hemangiomas, 160
human papillomavirus infection,
156–157
hypertrophic scars and keloids,
158–160, 159f, 159t
Kaposi’s sarcoma, 162–163
lentigo maligna, 163
molluscum contagiosum, 157
palliative treatment, 163, 163f
pyogenic granulomas, 160, 160f
seborrheic keratosis, 158, 158f
solar lentigo, 158
squamous cell carcinoma, 162, 162f
vascular malformations, 160–161, 161f
preoperative preparation, 155–156
segmental, 163, 163f
side-effects, 678
techniques, 155
chamber technique, 155, 155f, 163
closed technique, 155, 155f
intralesional technique, 155
open technique, 155, 163
cultured epidermal allografts, 123–125, 749t
cultured epidermal autografts, 122, 749t
cultured epidermal grafts, 122
cultured melanocyte-epidermal grafting, 42e5
cultured melanocyte grafting, 42e3–42e5,
689t
cultures, skin biopsies, 169
Cupid’s bow, 9f
curette biopsy, 167–168, 172, 173f
curettes, 65, 68, 68f, 172
current, 138–139
current channeling, 149, 149f
curved needles, 195
cutaneous flaps
advantages in facial reconstruction, 252
axial pattern flaps, 289–291
blood supply, 289–290
disadvantages in facial reconstruction,
252–253
random pattern see random pattern
cutaneous flaps
cutaneous oncology, 724–730
see also specific tumors
cutaneous venous system, 582f
cyanoacrylate tissue glue, 92
Cymetra, 365, 369t–374t
cyst excision, 184–186, 184b, 184f
field block, 50, 61
pitfalls and their management, 186b, 187
cystic acne, cryosurgery, 157t
cysts
after follicular unit hair transplantation, 509t
drainage, 185–186
epidermal see epidermal cysts
excision see cyst excision
inflamed and infected, 184–187, 184b,
184f
pilar, 182, 183f
removal, 177
scarred, 187
scrotal, 186–187
cytochrome p450-3A4, 59, 59b
cytokeratin marker, 718
cytokines, 99–100, 738t
cytology, 169
cytotoxic drugs and antibiotic prophylaxis, 87
D
dacarbazine, melanoma metastases, 43e15
Dacron, 70, 193, 194t
da huang, 80t
dalteparin sodium, 79
danaparoid sodium, 79
danshen, 80t
Darwinian tubercle, 23f
Davis and Geck, 70
debridement, 125, 745f
autolytic, 116, 125, 746
biosurgical, 125, 746
chemical, 746, 747f
enzymatic, 125, 746
leg ulcers, 743–744, 45e4
maggot therapy, 125, 746
mechanical, 125, 746, 746f
surgical/sharp, 125, 131f, 745–746, 745f
types of, 744–746
Debut Prestige ear-piercing kit, 787
décolleté wrinkles, 442, 443f
deep-brain stimulators
effect on surgery, 79
malfunction due to electrosurgery,
150–151
deep fibular nerve, 58f
DeepFX, 551–552
deep hemangiomas, 571–572
deep peroneal nerve, 54–55, 58f
deep venous system, 582f
defatting
flaps, 335b
full-thickness skin grafts, 311–312, 311f
defibrillators
antibiotic prophylaxis, 91–92
effect on surgery, 78
malfunction due to electrosurgery, 150–151
dehiscence
after skin biopsies, 176b
random pattern cutaneous flaps, 284
DeJardin forceps, 67
delayed grafts, 320
delta-aminolevulinic acid, 726
densitometers, hair, 485, 486f, 487
dentures, chin implants, 428
depigmentation, therapeutic in vitiligo,
42e8
depilatories, chemical, 515
depression
body dysmorphic disorder, 345
cosmetic surgery and, 348
psychiatric exam, 340
depressor anguli oris, 17t, 18, 18f–19f, 417,
418f
fat autograft muscle injection, 476f–477f
depressor labii inferioris, 17t, 18, 18f–19f,
417, 418f
fat autograft muscle injection, 476f–477f
depressor septi nasi, 18f
Dermabond, 197
dermabrasion, 530
hand engines, 532–533, 532f–533f
historical vignette, 530
indications, 530
optimizing outcomes, 535
pitfalls and their management, 535
postoperative care, 533–535
preoperative preparation, 530–531
scar revision, 334, 335b, 335f
skin grafts, 323
technical aspects, 532–533
test spot, 531
vitiligo, 42e7
see also microdermabrasion
Dermagraft, 123–124, 124f
leg ulcers, 749t
dermal aging, 351
dermal fillers see fillers; specific fillers
dermal grafts, 321
Dermalive, 369t–374t
dermal matrix, 4–5
Dermalon, 69–70, 194t
dermal pigmented lesions, laser treatment,
540–542, 544–545
dermal replacements, 123–124, 124f
leg ulcers, 749t
see also fillers; specific products
dermatitis
contact see contact dermatitis
radiation, 572, 572f
dermatofibroma, 157t
dermatofibrosarcoma protuberans, 729
dermatologic disease and ablative laser skin
resurfacing, 554
dermatology office accreditation, 795–796,
805–818
Accreditation Association for Ambulatory
Health Care, 807
codes of standards, 807
survey process, 807
accreditation survey process, 805–807
accreditation survey, 805–806,
806b
preparation, 805
recent changes in, for office-based
surgery, 806–807
summation conference, 806
survey report and accreditation decision,
806

826
Index
American Association for Accreditation of
Ambulatory Surgical Facilities,
808–809
basic mandates, 808
denial or loss of accreditation, 808–809
goals of accreditation, 808
important points of emphasis, 809
inspection and self-evaluation, 808
organizational goals, 808
CON laws, 810–811, 810b
credentialing and privileging, 809
importance of enhanced patient safety,
818
Joint Commission on Accreditation of
Healthcare Organizations, 807–808
accreditation decisions, 807
accreditation process overview, 807
office-based surgery accreditation,
807–808
survey process, 807
Medicare certification and reimbursement,
810
Office of Inspector General, 810
optimizing outcomes, 817
pitfalls and their management, 817–818
inaccurate and incomplete credentialing
and privileging, 817
inadequate government inspections,
817–818
inadequate quality improvement
programme and safety plans,
817
outdated and development policies and
procedures, 817
practical applications, 818
practical benefits, 818
quality assurance and improvement,
809–810
quality improvement techniques, 809–810
state legislation and regulation, 811–817,
812t–816t
state licensing and certificate need,
810–811
dermatomes, electric/air driven, 315, 315f
Dermicol-P35, 382–383
dermis
as an injectable filler, 364
composition, 123
head/face, 6f
reconstitution, wound healing, 104
structure and functional biomechanics, 4–5,
4f
dermoscopy, melanomas/atypical moles,
698–700, 701f, 43e5, 43e8f, 43e7f
devil’s claw, 80t
Dexon, 69
Dexon II, 191, 192t
Dexon Plus, 69
Dexon S, 69, 191, 192t
diabetes mellitus
foot ulcers see diabetic foot ulcers
incidence, 736
surgical site infection risk, 86
diabetic foot ulcers, 129–130
etiology, 736, 737f
ischemic, 736
neuropathic, 736, 740t
physical findings in, 740t
prevention, 45e3
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), 341–342, 456t
diathermy, 137–138, 138f
diazepam
anxiolytic effect, 60
microdermabrasion/dermabrasion, 531
dietary supplements, 714–715
diet history, liposuction, 454–456, 455t
diffuse patterned alopecia (DPA), 488, 488t
diffuse unpatterned alopecia (DUPA), 488,
488t
digital blocks, 26b, 53–54, 55f
complications, 53–54
injury prevention, 56b
technique, 53
digits
anatomy, 755
ischaemia, 56–57
tumors, 714
diode lasers
hair removal, 521, 522t
hemangiomas, 571–572
1450-nm, 555
skin remodeling, 555
vascular lesions, 566
diphenhydramine, 58–59
diplopia
after blepharoplasty, 648
botulinum toxin injections complications,
445
dipyridamole, 79, 227t
direct brow lifting, 637, 638f
direct current, 138
discoid lupus erythematosus, 157t
dissecting stereomicroscopes, 494, 494f
distal flap tissue necrosis
axial pattern flaps, 290–291
random pattern cutaneous flaps, 284–285
distal interphalangeal crease, 24f
distal interphalangeal joint, 755, 779
distal palmar crease, 24f
distal phalanx
anatomy, 755, 756f
traumatic shortening, 777, 779f
distant focus of infection, 86
distraction test, 629, 632f
dog-ear repairs, 244–247, 247f–248f
dong quai, 80t, 227t
door knob probe, 160
Doppler ultrasound
endovenous ablation for varicose veins, 590
before sclerotherapy, 583, 583f
dorsal finger cysts, 773, 773f
dorsal nasal arteries, 294
dorsal nasal flap, 292, 299–303, 302f
backcut, 300–302
design, 300–302
optimizing outcomes, 307b
pitfalls and their management, 307b
secondary procedures, 302–303
technique, 302
undermining, 302, 302f
uses, 299–300
dorsal nasal rotation flap, 262–264, 265f
double syringe system (DSS) sclerotherapy, 584
drainage, 177–188
cysts, 185
history, 177
optimizing outcomes, 185–186
postoperative care, 186
preoperative preparation, 177
draping, 35, 37–38
elliptical excision, 241
lower eyelid blepharoplasty, 643, 645
upper eyelid blepharoplasty, 640–641
dressings, 115–134
asepsis, 39
composite grafts, 320
definition, 115
foam see foam dressings
full-thickness skin grafts, 313
functions of, 115–116, 116t
hemostasis, 235–236
historical perspectives, 115
hydrocolloid see hydrocolloid dressings
laser treatment of pigmented lesions, 546
leakage, 130b, 130f
leg ulcers, 743, 745t
lower eyelid blepharoplasty, 645
materials and relative performance, 132t
microdermabrasion/dermabrasion, 533–534
occlusive see occlusive/moisture retentive
dressings
optimizing outcomes, 130
practical applications, 131–132
random pattern cutaneous flaps, 282
split-thickness skin grafts, 316
surgical site infection prevention, 92
types of, 116–125, 116b (see also specific
types)
absorptive, 117
alginates, 120
antimicrobial, 125
biologic, 121 (see also skin grafting)
biosynthetic, 122
collagen, 121
film see film dressings
foam see foam dressings
hyaluronic acid, 121
hydrocolloid see hydrocolloid dressings
hydrofibers, 121
hydrogels, 119
non-adherent, 116–117
occlusive/moisture retentive, 117–125
venous ulcers, 129
vertical vector face lift, 622–623
dry eyes after blepharoplasty, 648
dry heat sterilization, 36, 71
dry technique liposuction, 447
ductility, needle, 195
dumbbell keloids, 672, 675–676, 676f
duplex ultrasound
endovenous ablation for varicose veins,
590, 590f, 593–595
foam sclerotherapy, 584–585
liquid sclerotherapy, 584
Dynamic Cooling Device (DCD), 566f, 569
dyschromia, 357–358
dysphagia, botulinum toxin injections
complications, 445
dysplastic nevi see atypical moles
Dysport/Azzalure, 434
comparison chart, 435t
dose, 437
bunny lines, 438t
dimpled chin, 438t
forehead lines, 438t
gingival smile, 438t
glabellar frown lines, 437–439, 438t
hyperhidrosis, 438t
marionettes lines, 438t
nasal tip droop, 438t
neck and chest, 438t
perioral wrinkles, 438t
periorbicular wrinkles, 438t, 439f
repeated nasal flare, 438t
reconstitution, 437, 437t

827
Index
E
earlobe reduction, 788–790
elliptical excision, 788–790, 788f–790f
optimizing outcomes, 790
pitfalls and their management, 790
postoperative care, 790
preoperative preparation, 788
technical aspects, 788
earlobes
keloids, 670, 672, 675–676, 675f–676f,
678
reduction see earlobe reduction
split see split earlobes
ear piercing, 786–788
and keloids, 670
kits, 787
modifications, 787
needle techniques, 786–787
one-needle technique, 786–787, 786f
two-needle technique, 787, 787f
optimizing outcomes, 787
pitfalls and their management, 787–788
elongation of ear-piercing tract, 788
embedded earrings, 787
hypersensitivity and allergic contact
dermatitis, 788
hypertrophic scars or keloid formation,
788
infections, 787–788
split earlobes, 788 (see also split
earlobes)
postoperative care, 787
preoperative preparation, 786
technical aspects, 786–787
earrings, embedded, 787
ear(s)
flap elevation plane, 281f
lymphatic drainage, 21–22
muscles, 20
size of, 22
skin, 6f
topographic landmarks, 22, 23f
tumours, 714
undermining plane, 280t
eccrine adenocarcinoma, 730
ectropion
after ablative laser skin resurfacing, 553
after blepharoplasty, 646, 648
after botulinum toxin injections, 445
after Mohs micrographic surgery, 723
repair, 333–334, 334f, 335b
edema
after ablative laser skin resurfacing, 552
after cryosurgery, 164
after fat autograft muscle injection,
478f
after follicular unit hair transplantation,
509t
after medium-depth chemical peels,
404–405
after vertical vector face lift, 622–623
education
body dysmorphic disorder, 346
botulinum toxins, 436–437
effect, psychiatric exam, 340
Effient, 227t
eflornithine hydrochloride, 516
elastic bandages
leg ulcers, 741–742, 742t
venous ulcers, 128
elastic fibers, 4–5, 109
elasticity see skin, elasticity
elastin, 4–5, 109
elective lymph node biopsy, 43e12
electrical burns, electrosurgery-induced,
148–149, 149f
electric dermatomes, 315, 315f
electric shocks, 149
electrocautery, 142t, 230
definition, 137
elliptical excision, 241–242
technique, 144
electrochemotherapy, 147–148
electrocoagulation, 142t, 230
bipolar, 230
with biterminal forceps, 144
indications, 145t
optimizing outcomes, 146–147
technique, 143–144, 144f
electrocution, 149
electrodesiccation, 142t, 230
and curettage see electrodesiccation and
curettage (ED&C)
indications, 145t
technique, 143, 143f
electrodesiccation and curettage (ED&C)
basal cell carcinoma, 146, 146f
indications, 145–146
optimizing outcomes, 145–146
electrofulguration, 142t, 230
indications, 145t
technique, 143, 143f
electrolysis, 137, 516
electromagnetic radiation, 563
electron microscopy, skin biopsies, 169
electroporation, 147
electroradiosurgery, matricectomy, 761
electrosection, 142t
with coagulation, 142t
indications, 145t
optimizing outcomes, 147
technique, 144, 145f
electrosurgery, 137–152
bipolar, 144
biterminal, 230
definition, 137, 137b
hemostasis, 230–233
hi-frequency, 137
indications, 145t
monopolar versus bipolar, 141–142
monoterminal, 230
monoterminal versus biterminal, 142
optimizing outcomes, 144–148
pitfalls and their management, 148–151
cardiac pacemaker/defibrillator/
deep-brain stimulator
malfunction, 150–151, 150t
electrical burns, 148–149, 149f
electrocution and electric shocks, 149
eye injury, 149
infection transmission, 149
postoperative care, 148
preoperative preparation, 141
principles of electricity, 137–139
techniques and practical applications,
141–144
types, 142–144, 142t (see also specific
types)
units and waveforms, 139–141, 140f–141f
electrosurgical units, 139–141, 140f
elliptical excision, 239–250
anesthesia, 240–241
earlobe reduction, 788–790, 788f–790f
evaluation, 239–240
history, 239
informed consent, 240
optimizing outcomes, 248, 248b
pitfalls and their management, 249–250,
249b
postoperative care, 247–248
preoperative preparation, 239–241
prepping and draping, 241
scar revision, 329, 329f–330f
technical aspects, 241–247, 241f–242f
crescent excision, 243, 244f
dog-ear repairs, 244–247, 247f
M-plasty, 243–244, 245f
partial closure, 244, 246f
S-plasty, 244, 246f
undermining, 242–243
wound closure, 243
embedded earrings, 787
embolia cutis medicamentosa, 586
emergency equipment, 801–802
emissary vessels, scalp, 6–7
EMLA
adverse effects, 57
laser hair removal, 521–523
recommended use of, 60t
skin biopsies, 170
topical anesthesia, 47–48, 47t
endocarditis
antibiotic prophylaxis, 90–92, 91t
infective, 90
prosthetic valve, 90
risk following surgery, 74–78
endocrine factors associated with keloids,
670–671
endoscopic forehead lifting, 640
endoscopic transthoracic sympathectomy
(ETS), 465
endovenous ablation for varicose veins,
589–600
endovenous laser ablation, 589, 595–
599
consent form, 594f
neodynium:yttrium aluminium garnet
(Nd:YAG) lasers, 597–598
postoperative care, 597f
technique, 598–599
historical vignette, 589b
pitfalls on their management, 599
preoperative preparation, 590
Doppler ultrasound, 590
duplex ultrasound, 590, 590f
radiofrequency closure, 590–595,
592f–593f
with ambulatory phlebectomy, 593
CEAP classification for symptoms,
591–593, 591t
follow-up care, 593–595
single puncture under duplex guidance,
593–595
standard technique, 591–593
reflux diagnosis, 590, 590f
techniques, 590–599
endovenous laser ablation (EVLA), 589,
595–599
consent form, 594f
neodynium:yttrium aluminium garnet
(Nd:YAG) lasers, 597–598
postoperative care, 597f
technique, 598–599
enoxaparin sodium, 79
Enterococcus spp., 30, 85–86

828
Index
entropion, botulinum toxin injections
complications, 445
environmental cleaning, 36, 38
enzymatic debridement, 125, 746
eosinophils, 97–98, 100t
ephelides
cryosurgery, 158
laser treatment, 540
epidermal aging, 351
epidermal cultured allografts, 123–125
epidermal cultured autografts, 122
epidermal cysts
definition, 180
incisional surgery, 180–182, 181f–182f,
182b
presentation, 180
epidermal growth factor (EGF), 105,
115–116, 738t
epidermal lesions
laser treatment, 540, 543–544
squamous cell carcinoma arising from, 726
epidermis
head/face, 6f
injury involving only the, 95
protection, laser-tissue interaction
principles, 565
structure and functional biomechanics,
3–4, 4f
epidermoid carcinoma, 773, 774f
epidermoid cyst, 175
epidermolysis bullosa (EB), 103, 320–321
epilation, paramedian forehead flap, 304
epinephrine
addition to local anesthetics, 45t, 46
adverse effects, 56–58
in cardiovascular disease, 74
in children, 60
contraindications, 53–54
drug interactions, 58
and flap death, 278–279
hemostatic anesthesia, 228
liposuction, 451–454
nerve blocks, 51
in pregnancy, 74
random pattern cutaneous flaps, 278–279
skin biopsies, 170–171
tumescent anaesthesia, 50–51, 50t
epithelial cells, 3–4
epithelial migration enhancement, 115
equipment
maintenance, 802
surgical suite, 798–802
see also instruments; specific items
erbium:glass lasers
1540-nm, 555
skin remodeling, 555
erbium:yttrium aluminium garnet (Er:YAG)
lasers
café-au-lait macules, 544
hemangiomas, 572
indications, 551
pigmented lesions, 539
preoperative preparation, 549
scar revision, 328–329, 334
skin resurfacing, 550–551
Erb’s point, 20, 23, 23f, 616
erosion, 96, 96f
Er:YAG lasers see erbium:yttrium aluminium
garnet (Er:YAG) lasers
erythema
ablative laser skin resurfacing, 552
calcium hydroxylapatite injections, 382
chemical peel complications, 410, 410f
cryosurgery, 164
elliptical excision, 250
facial, 567b, 573
hyaluronic acid injections, 380
laser hair removal, 524
microdermabrasion, 532
microdermabrasion/dermabrasion, 534
erythematous scars, laser treatment, 574
erythrocyte sedimentation rate (ESR), leg
ulcers, 741t
erythromycin esolate in pregnancy, 74
erythromycin in pregnancy, 74
erythroplasia of Queyrat, 726
Escherichia coli, 30, 85–86
estrogen, liposuction risk, 451
Ethibond, 70
Ethibond Excel, 193, 194t
Ethicon, 70, 195, 196t
Ethilon, 194t
ethnicity and keloids, 669
ethyl chloride, 49t
ethylenediaminetetraacetic acid (EDTA),
32
ethylene oxide, 36, 71
etidocaine, 45t, 60–61
eumelanin, 514–515
evening primrose oil, 80t
Evolence, 382–383
excimer lasers, 687–688
excisional biopsy, 167
excision and closure, vitiligo, 42e7
excision tray, 71, 71f
exercise
after follicular unit hair transplantation,
508b
history, liposuction, 454–456, 455t
expanded polytetrafluoroethylene (e-PTFE),
365, 366t, 375f
exsanguinating tourniquet, 231f
exteriorization, 177–188
history, 177
optimizing outcomes, 185–186
postoperative care, 186
preoperative preparation, 177
external carotid artery, 16f
external nasal nerve block, 51t, 52
extracellular matrix
degradation products, 100
remodeling phase of wound healing, 108
in wound angiogenesis, 107
extramammary Paget’s disease, 730
extraocular muscles, injury during
blepharoplasty, 648
extremities
nerve blocks, 53–55, 55f, 57f
see also foot; hand(s)
exudation after cryosurgery, 164
eyebrows, 8f
lift see brow lifting
transplantation, 506
vitiligo surgery, 690
eyelash transplantation, 506
eyelid ptosis
after blepharoplasty, 647
assessment, 629–630
botulinum toxin injections complications,
445
measurement, 629
eyelid(s)
bloody supply, 631f
cross-sectional anatomy, 630f
facial expression muscles, 17t
fat pads, 628, 630f–631f
lower see lower eyelid
malposition after blepharoplasty, 646
margins, 7
muscles, 628, 629f
ptosis see eyelid ptosis
retraction after blepharoplasty, 646, 648
skin see eyelid skin
tendons, 631f
tumours, 714
undermining plane, 280t
upper see upper eyelid
vitiligo surgery, 690
eyelid skin
thickness, 4
vascular supply, 7
eye(s)
examination, melanoma risk, 43e9
injury from electrosurgery, 149
lateral angle of, 8f
medial angle of, 8f
surface anatomy, 628, 628f
EZ Derm, 123
F
face
aesthetics, 616–617
aging see facial aging
analysis, 615
anatomy
functional, 212
landmarks, 13–20, 13f–19f
relevant to face lift surgery, 601–602
anthropometric landmarks, 12–13, 12f
arterial supply, 16f
balance, 615, 616f
bones, 352 (see also specific bones)
bony structures of, 11–12, 11f
central facial relationships, 12, 13f
complex layered closures see complex
layered facial closures
cosmetic units of the, 7–9, 7f, 328
layers, 212
lifts see face lift
lymphatic drainage, 21–22
muscles, 14–20, 213f (see also facial
expression muscles)
nerve blocks, 51–53, 51t, 52f–54f
rebalancing, autologous fat transfer, 474,
474f
reconstruction, 252 (see also specific
techniques)
rejuvenation see specific procedures
skin see facial skin
skin resurfacing see ablative laser skin
resurfacing; non-ablative laser skin
remodeling
structural rejuvenation, 358
surgery, optimizing, 24b
topography, 11–12
visible veins, 572–573
see also specific areas
face lift
botulinum toxin injections, 441–442
minimum incision see minimum incision
face lift
suspension sutures, 218, 218f–219f
vertical vector see vertical vector face
lift
face masks, 33–34, 37

829
Index
facial aging, 351–361, 601
craniofacial skeletal aging, 352, 352f
epidermal and dermal aging, 351
evaluation, 351–361
external, 351
facial fat mirroring body fat, 354–356,
355f–357f
factors contributing to, 616
internal, 351
life as art, 353–354, 355f
mimetic muscle aging, 351
myths of gravitational aging, 354
optimizing outcomes, 357, 358f
pitfalls and their management, 354b
practical applications, 357–358
cosmetic management, 357–358, 359f
structural facial rejuvenation, 358,
359f–361f
skin/muscle interaction, 351–352, 352f
structural fat remodeling with age,
352–353, 353f–354f
technical aspects, 351–357
facial artery, 14, 16f–17f
facial expression muscles, 14–15, 17t, 18f–19f
see also specific muscles
facial fat mirroring body fat, 354, 355f
facial nerve
anatomy, 616
blocks, 26b, 278
branches, 603f, 616
buccal branches, 13f, 15f, 19f, 20
cervical branch, 13f, 15f, 20
damage during rhytidectomy, 602
danger zone, 20
injury, 27b
in vertical vector face lift, 624
marginal mandibular branch, 13f, 14, 15f,
20–21, 21f, 27b
mastoid bone protection of, 11
palsy, botulinum toxin injections, 442
relationship with parotid gland, 13f
temporal branches, 13f–15f, 15–16, 19f,
20–21, 21f, 27b
trauma vulnerability, 20
zygomatic branches, 13f, 15–16, 15f, 19f,
20, 27b
facial plane, 416–417, 416t
facial profile, ideal, 415–417, 416f, 416t
facial retaining ligaments, 602, 602f
facial skin, 6f
functional biomechanics, 212–214
tension lines, 10f (see also wrinkles)
thickness, 4
facial vein, 16f
FAMI see fat autograft muscle injection
(FAMI)
Fascian, 369t–374t
fat
as an injectable filler, 364
autologous transfer see autologous fat
transfer
facial fat mirroring body fat, 354–356,
355f
frozen, 479, 479f
hypertrophy after fat augmentation,
480–481, 480f
necrosis after fat augmentation, 480–481
structural remodeling with age, 352–353,
353f–354f
survival, 469–470
fat augmentation, autologous see autologous fat
transfer
fat autograft muscle injection (FAMI),
474–475
before and after photographs, 475f, 478f
cannulae, 475, 475f
facial muscles commonly injected, 475,
475t, 476f–477f
fat harvesting, 475
fat processing, 475
indications, 474–475
postoperative course, 475, 478f
protocol, 479, 480b
symmetry, 480–481, 480f
fat embolism, ocular, 481
female breast liposuction, 346
female pattern alopecia, 488t
female urogenital triangle, 24–26, 25f–26f
femoral nerve, 54–55
ferric sulfate, 229, 232t
feverfew, 80t, 227t
Fibrel, 364
fibrin clot, 98–99, 99t, 225–226
fibrin foam, 364
fibrin sealant, 229, 232t
fibroblast growth factor (FGF), 106–107,
107t, 115–116
wound healing, 738t
fibroblasts, 4–5, 100–101, 104–105
and keloids, 671
fibronectin, 4–5, 103, 105
fibroplasia, 104–105
fibrosis, subcutaneous
after minimum incision face lift, 612
after vertical vector face lift, 622–623
fibroxanthoma, atypical, 729
field block, 50, 50f, 61
figure-of-eight suture, 235f
fillers
available worldwide, 369t–374t
with botulinum toxin injections, 443
commercially available, 366t
deep dermal, 369t–374t
historical aspects, 363–366
mid-dermal, 369t–374t
most commonly used, 367t
neck rejuvenation, 651
new products, 364
stimulatory, 366
subdermal, 369t–374t
superficial, 369t–374t
variable dermal, 369t–374t
see also soft tissue augmentation; specific
fillers
film dressings, 117t, 118, 118f
leg ulcers, 745t
performance, 132t
technique, 118–119
film-forming iodophor preparations, 35
finasteride, 489, 492
fine needle aspiration (FNA) cytology, 169
Fischer’s technique, 447
fish oil, 227t
fistulas after chin implants, 427
Fitzpatrick skin phototype classification
laser hair removal, 516, 516t
microdermabrasion/dermabrasion, 531
flanks, liposuction, 460, 460f
flaps
classification, 251
complications, 327–328
definition, 251
failure, random pattern cutaneous flaps,
284–285
perfusion, 254
refinements, 327–328
surgical site infection risk, 86
using multiple, 215
see also specific flaps
flashlamp-pumped pulsed-dye laser
keloid management, 676
scar revision, 328
flexor digitorum longus tendon, 25f
flexor hallucis longus tendon, 25f
flexor retinaculum, 25f
flora, normal, 30
Flowers Mandibular Glove, 421
fluence
laser hair removal, 519, 519t
laser-tissue interaction principles, 565
fluorescent pulsed light, hair removal, 522t
Fluor-Hydroxy Pulse Peel, 401
Fluori-Methane, 49t
Fluoro Ethyl, 49t
5-fluorouracil
actinic keratosis, 161, 726
atypical keratinocytes treatment, 400–401
atypical moles prevention, 43e10
cryosurgery of actinic keratosis, 156
keloid management, 679
flurazepam, 531
foam dressings, 117–118, 117t, 118f
leg ulcers, 745t
performance, 132t
technique, 118
wound healing, 110
foam sclerotherapy, 584–585
assessment of treatment outcomes, 586t
duplex ultrasound in, 584–585
foam generation, concentrations and
volumes, 584, 585t
puncture and injection, 584
safety measures for, 585
follicular cell implantation (FCI), 507
follicular unit extraction, 486, 499
advances, 499
advantages, 499
donor area, 499f
indications, 499
limitations, 499
pros and cons, 500t
follicular unit hair transplantation, 485–512
aesthetics, 501
anesthesia, 494–495, 495t
assessing donor supply, 490–491
density, 490
donor dimensions, 491
scalp laxity, 490–491
contraindications, 490
follicular unit extraction see follicular unit
extraction
graft handling, 494
graft storage, 494
historical vignette, 486–487
incisions, 510
instruments, 500
medications, 503t
operating room, 494–495, 494f
optimizing outcomes, 502–507
automation, 507
creating camouflage, 506
eyebrow transplantation, 506
eyelash transplants, 506
forelock integration, 504–505
hair cloning, 507
hair direction, 504

830
Index
hairline placement, 504
long hair transplants, 506–507
optimizing density, 505
transition zones, 502–503
trichophytic donor closure, 507
visibility, 503, 503f
patient evaluation and surgical planning,
487–490
diagnosis and classification of
androgenetic alopecia, 487–489,
488f, 488t
suitable candidates, 489–490, 489b
patient preparation, 492–494
pitfalls and their management, 507–511,
509t
broad hairline, 489
covering too large an area, 489
dry grafts, 489
forward frontal hairline, 489
graft crushing during insertion, 489
low donor density identification failure,
507–508
low donor incision, 489
multibladed knives, 489
surgery before medical therapy, 507
tight scalp identification failure,
508–510
wide donor strip, 489
wrongly angled hair, 489
young patients, 507
planning the first session, 491
planning the second session, 491–492
planning the subsequent sessions, 492
postoperative care, 502, 507, 508b
preoperative preparation, 487–494, 493b
techniques, 495–502
donor closure, 496–497, 497f
donor harvest, 495
follicular unit extraction, 499, 499f, 500t
graft dissection, 497–499, 498f
local anesthesia, 495–496
patient disposition, 502
recipient sites, 499–502
density, 500–501
graft distribution, 501–502,
501f–502f
hair direction, 500, 500f
sizes and orientation, 500
strip excision, 496, 496f
in younger people, 489
follicular units, 485
discovery, 487
transplant see follicular unit hair
transplantation
folliculitis
after follicular unit hair transplantation, 509t
bacterial, 509t
sterile, 509t
foot
diabetic ulcers see diabetic foot ulcers
incisions, 24
sensory innervation, 54–55, 58f
superficial anatomy of the, 23–24, 25f
footwear
leg ulcers, 45e3
surgical, 34
forceps, 65, 67, 67f
forehead
autologous fat transfer, 478
complex closures, 215
cosmetic unit of, 8f
facial expression muscles, 17t
flap elevation plane, 280–281, 281f
flaps see forehead flaps
lifting see forehead lifting
lines, botulinum toxin injections, 438t,
439, 440f
lipoma, 179, 179f, 180b
skin thickness, 4
suspension sutures, 216–217
undermining plane, 280t
vascular supply, 294
forehead flaps
Indian forehead flap technique, 251–252
paramedian forehead flap see paramedian
forehead flap
forehead lifting, 639
coronal, 639–640
endoscopic, 640
mid-, 638
pretrichal, 638–639
foreign bodies, nails, 762, 763f
forelock integration, follicular unit hair
transplantation, 504–505, 505f
foreskin, 24, 26f
formaldehyde, 36
formalin, skin biopsies, 168
for recognition of adult immobilized for life
(FRAIL), 45e2
forward weighting, follicular unit hair
transplantation, 501, 501f
four-layer bandage, 129
fractional cryosurgery, 163, 163f
fractional lasers
pigmented lesions, 539
resurfacing see fractional resurfacing lasers
fractional photothermolysis, 556
fractional resurfacing lasers
in lower eyelid blepharoplasty, 645
neck rejuvenation, 662–663
scar revision, 328–329
Fragmin, 79
FRAIL (for recognition of adult immobilized
for life), 45e2
Frankfort horizontal plane, 415, 416t, 419
Fraxel repair system, 551–552
Fraxel SR, 556
freckles, laser hair removal, 516–517
Frigiderm, 49t
frontal bone, 11, 11f
frontal eminences, 11
frontalis-associated the lipoma of the forehead,
179, 179f, 180b
frontalis muscle, 15, 15f, 17t, 19f, 179
fat autograft muscle injection, 476f–477f
frown lines see glabellar frown lines
frozen fat, 479, 479f
full-thickness skin grafts, 121, 310–314
bolsters, 313
Burow’s grafts, 313–314
defatting, 311–312, 311f
definition, 309
donor site
harvesting, 311, 311f
selection, 310–311
dressings, 313
ectropion repair, 333–334, 334f
equipment, 310
failure, 322
hair-bearing grafts, 314
leg ulcers, 747–749
optimizing outcomes, 748–749
performance of, 310–313, 311f–312f
pitfalls and their management, 323, 749
postoperative care, 322
preoperative preparation, 747–748
sutures/suturing, 312–313, 313f
techniques, 748
vs. split-thickness skin grafts, 121t
fusiform excision see elliptical excision
G
galea aponeurotica, 7, 18f–19f
galeotomy, 7
galvanic electrolysis, 516
garlic, 80t, 227t
gas bubbles, after laser treatment, 543–544,
543f
gas sterilization, 36, 71
gastrocnemius muscle hypertrophy, 443
gauze, 117
gauze ribbon, 186
gelatin, 232t
gelatinases, 109t
Gelfoam, 232t
genetic predisposition
to atypical moles, 696–697
to keloids, 671
genital area
biopsies, 175
superficial anatomy of the, 24–26, 25f–26f
tumors, 714
vitiligo surgery, 690
gentian violet, 530–531
Genzyme Tissue Repair, 749t
geometric broken-line closure, 330, 331f
German chamomile, 80t
ginger, 227t
gingival smile, botulinum toxin injections,
438t, 440, 440f
ginkgo, 80t, 227t
ginseng, 227t
glabella, 11–12, 12f
autologous fat transfer longevity, 478
glabellar banner flaps, 272, 278f
glabellar fold, calcium hydroxylapatite
injections, 382
glabellar frown lines
botulinum toxin injections, 379, 437–438,
438t, 439f
fillers for, 378–379
glans penis, 26f
Glogau’s classification of photoaging groups,
397t
glomus tumor, subungual, 772–773, 772f
gloves, surgical, 34, 37, 38f
Glu-stitch, 197, 243
glutaraldehyde, 36
glycolic acid, 398–399, 399f
glycomer 631, 192t, 193
glycoproteins, 4–5
glycosaminoglycans, 4–5, 108
Glymatrix technology, 382–383
GM2-KLH21 vaccine, melanomas, 43e14
gnathion, 12f
gonion, 12f
Gore-Tex, 369t–374t
gowns, 33–34
Gradle scissors, 66
Graefe forceps, 67
grafts see skin grafting
Gram-negative bacteria, 30
granulation tissue, 104–105
granulocyte macrophage-colony stimulating
factor (GM-CSF), 742

831
Index
granulocytes, 102
granuloma annulare, 157t
granuloma faciale, 157t
granulomas
after polymethylmethacrylate injections,
387
pyogenic, 160, 160f
gravimetry, 444
gravitational aging, 354, 601
greater auricular nerve, 20
block, 51t, 53, 54f
damage in vertical vector face lift, 624
greater vestibular gland duct, 26f
great saphenous vein see long saphenous vein
ground substance, 4–5, 108
growth factors, 98–100, 102, 102t
angiogenic, 106–107, 107t
effect of stimulation in leg ulcers, 45e4
retention, dressings, 115–116
wound healing, 110
wounding, 97–98
see also specific growth factors
gut, surgical see surgical gut
gutter treatment, ingrown toenails, 766, 766f
H
Hageman factor XII, 99
hair
anatomy, 513, 514f
characteristics, follicular unit hair
transplantation, 503–504, 506f
cloning, 507
color, 514–515
densitometers, 485, 486f, 487
excess, classification, 515
growth see hair growth
loss see hair loss
removal, 35, 35f, 37, 39b (see also laser
hair removal)
surgical site infection risk, 87
texture changes after follicular unit hair
transplantation, 509t
thinning after laser hair removal, 525
transplantation see follicular unit hair
transplantation
types, 514
hair bearing grafts, 314
hair bulb, 513
hair covers, 34
hair follicles, 513–514
hair growth, 513–514
direction, 500, 500f, 504, 504f
phases, 513–514, 514t, 515f
hairline placement, follicular unit hair
transplantation, 504, 505f, 510–511
hair loss, 487
after follicular unit hair transplantation, 509t
medications, 508b
see also alopecia
half-buried horizontal mattress (tip) stitch,
201–202, 202f
Halsted clamps, 233
hand(s)
autologous fat transfer, 473–474, 473f
autologous fat transfer longevity, 478
sensory innervation, 54, 55f–56f
superficial anatomy of the, 23–24, 24f
hand scrub, 31–33, 32f
duration and method, 33
surgical site infection risk, 87
technique, 37
head
lymphatics, 21–22, 22f, 26b
nerve supply, 20–21
sensory nerves see sensory innervation of
the head and neck
soft tissue anatomy, 6–7
headache after cryosurgery, 164
health questionnaire, 76f–77f
heated chemical vapor sterilization, 36
helical rim advancement flap, 272, 276f
hemangiomas, 567b
classification, 570
compound/deep, 571–572
cryosurgery, 157t, 160
infantile, 570–571
involuting, 572
laser treatment, 570–572
natural history, 570
proliferating, 571, 571f
ulcerated, 571
hematogenous total joint infection prophylaxis,
91t
hematomas, 92
after chin implants, 427
after endovenous ablation for varicose
veins, 599
after minimum incision face lift, 612
after vertical vector face lift, 624
elliptical excision, 249
evolution, 237
prevention, 110
random pattern cutaneous flaps, 284
retrobulbar, 648
subungual, 762, 762f
hematoxylin, 718
hemoglobin, 564–565
hemophilia, 226
hemorrhage
cryosurgery, 164
elliptical excision, 249
follicular unit hair transplantation, 508b, 509t
herbs causing, 453t–454t
minimum incision face lift, 612
Mohs micrographic surgery, 723
nail surgery, 757, 777
neck rejuvenation, 663
paramedian forehead flap, 304–305
random pattern cutaneous flaps, 284
skin biopsies, 169–170, 176b
soft tissue augmentation, 375–376
hemostasis, 98–99, 99t, 225–238
amplification (platelet aggregation and
activation), 225
anatomic location and, 233–234
anesthesia, 228–229
common disorders affecting, 226t
compression, 229, 229f
electrocoagulation, 146–147
electrosurgery, 230–233
elliptical excision, 241–242
evaluation, 226
general approach to intraoperative bleeding,
228
hematoma evolution, 237
hypertension and anxiety, 233
initiation (thrombin formation), 225
interview questions for bleeding history,
226, 226t
laser surgery, 229–230
optimizing outcomes, 233–235
oral medications and supplements affecting,
227–228, 227t
pitfalls and their management, 236–237
postoperative care, 235–236, 236b
preoperative preparation, 225–228
procedural, 234–235
propagation (fibrin formation and
stabilization of the platelet clot),
225–226
random pattern cutaneous flaps, 253,
281–282, 284
surgical field preparation, 228
suture ligation, 233, 233f
technical aspects, 228–233
topical hemostatics, 229, 232t
tourniquets, 230f–231f
hemostatics
physical, 229, 232t
physiologic, 229–230, 232t
topical, 229, 232t
hemostats, 65, 67
heparin, 79
hepatitis, effect on surgery, 78
herbs causing bleeding/thrombosis, 453t–454t
herpes labialis, postoperative
ablative laser skin resurfacing, 549,
552–554
hyaluronic acid injections, 380–381
non-ablative laser skin remodeling, 554,
557
herpes simplex virus infection
after ablative laser skin resurfacing,
552–553
after chemical peels, 411, 411f
effect on surgery, 78
prophylaxis prior to chemical peels, 395
herpes virus infection after
microdermabrasion/dermabrasion, 533
hiccups after follicular unit hair
transplantation, 509t
hidradenitis suppurativa, 185, 185f
hidrocystomas, 186
hips, liposuction, 345
hirsutism, 515
histamine, 98–101
histiocytoma, malignant fibrous, 729
Histoacryl, 197
histology
laser hair removal, 520
microdermabrasion, 527–528, 529f
history taking
chemical peels, 396
elliptical excision, 239
laser hair removal, 516
laser treatment of pigmented lesions, 539
leg ulcer management, 737–739
liposuction, 447–451
medical history, 74
medications, 79–81
Mohs micrographic surgery, 714–715
social history, 82
soft tissue augmentation, 367–368
surgical history, 81–82
HIV infection
autologous fat transfer, 476–478
effect on surgery, 78
follicular unit hair transplantation, 493
lipodystrophy/lipoatrophy, 383–385,
383f–384f
surgical site infection risk, 87
HMB-45 staining, 718, 728
homografts, 309
honey and wound healing, 110–111
Hooke’s law, 5