The Framingham Heart Study has been a leader in the development and dissemination of multivariable statistical models to estimate the risk of coronary heart disease. These models quantify the impact of measurable and modifiable risk factors on the development of coronary heart disease and can be used to generate estimates of risk of coronary heart disease over a predetermined period, for example the next 10 years. We developed a system, which we call a points system, for making these complex statistical models useful to practitioners. The system is easy to use, it does not require a calculator or computer and it simplifies the estimation of risk based on complex statistical models. This system represents an effort to make available a tool for clinicians to aid in their decision-making process regarding treatment and to assist them in motivating patients toward healthy behaviours. The system is also readily available to patients who can easily estimate their own coronary heart disease risk and monitor this risk over time.

Likelihood Modelling: Presentation of Multivariate Data for Clinical Use: The Framingham Study Risk Score Functions

Telemedicine is the use of telecommunications technology to support health care at a distance. Technological advances have progressively increased the ability of clinicians to care for diverse patient populations in need of skin expertise. Dermatology relies on visual cues that are easily captured by imaging technologies, making it ideally suited for this care model. Moreover, there is a shortage of medical dermatologists in the United States, where skin disorders account for 1 in 8 primary care visits and specialists tend to congregate in urban areas. Even in regions where dermatologic expertise is readily accessible, teledermatology may serve as an alternative that streamlines health care delivery by triaging chief complaints and reducing unnecessary in-person visits. In addition, many patients in the developing world have no access to dermatologic expertise, rendering it possible for teledermatologists to make a significant contribution to patient health outcomes. Teledermatology also affords educational benefits to primary care providers and dermatologists, and enables patients to play a more active role in the health care process by promoting direct communication with dermatologists.

Teledermatology: from historical perspective to emerging techniques of the modern era: part I: History, rationale, and current practice.

Microneedling (MN) is a novel therapeutic modality in dermatology. Through physical trauma from needle penetration, MN induces a wound healing cascade with minimal damage to the epidermis. This allows for enhancement in the absorption of mainstay topical therapies across the thick stratum corneum. MN has become increasingly utilized over the last several years as it is a relatively simple procedure that is cost-effective, well tolerated, and offers both cosmetic and therapeutic benefits. The ability to treat localized areas of disease has led to numerous studies gauging its potential in focal diseases of inflammation, dyschromia, and photodamage. This review discusses the principles and evidence behind the expanding applications of MN. It has shown promising results as an adjuvant therapy for enhanced drug delivery in the treatment of atrophic scars, alopecia, actinic keratoses, and disorders of pigmentation such as melasma. The efficacy in treatment of vitiligo remains limited. Overall, the procedure has few adverse sequelae compared to other therapies, is highly efficacious, and is a viable resurfacing option for skin of color. Future research is needed to determine the frequency, interval, and specific device settings that foster optimal results. Additionally, large controlled trials are needed to shed light on the utility of MN as an evidence-based regimen for the treatment of various dermatologic conditions.

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Review of applications of microneedling in dermatology.

Background:The purpose of this article is to provide a comprehensive review based on images and discussion of the current understanding of the arterial supply of the face to facilitate safe minimally invasive antiaging procedures.Methods:Contrast-enhanced computed tomographic scans of 40 fresh froze

Arteries of the Face and Their Relevance for Minimally Invasive Facial Procedures: An Anatomical Review.

Background:Injection of soft-tissue fillers into the facial fat compartments is frequently performed to ameliorate the signs of facial aging. This study was designed to investigate the functional anatomy of the deep facial fat compartments and to provide information on the effects of injected materi

The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation.

Mesotherapy, Microneedling, and Chemical Peels.

Background: Anatomical knowledge of the facial vasculature is crucial for successful plastic, reconstructive, and minimally invasive procedures of the face Whereas the majority of previous investigations focused on facial arteries, the precise course, variability, and relationship with adjacent structures of the facial vein have been widely neglected Methods: Seventy-two fresh frozen human cephalic cadavers (32 male and 40 female cadavers;mean age, 752 +/- 109 years;mean body mass index, 242 +/- 66 kg/m(2);99 percent Caucasian ethnicity) were investigated by means of layer-by-layer anatomical dissection In addition, 10 cephalic specimens were investigated using contrast agent-enhanced computed tomographic imaging Results: The facial vein displayed a constant course in relation to the adjacent anatomical structures The vein was identified posterior to the facial artery, anterior to the parotid duct, and deep to the zygomaticus major muscle The angular vein formed the lateral boundary of the deep medial cheek fat and the premaxillary space, and the medial boundary of the deep lateral cheek fat and the suborbicularis oculi fat The mean distance of the inferior and superior labial veins, of the deep facial vein, and of the angular vein from the inferior orbital margin was 516 +/- 31, 426 +/- 23, 274 +/- 30, and 42 +/- 07 mm, respectively Conclusions: This work provides detailed information on the course of the facial vein in relation to neighboring structures The presented clinically relevant anatomical observations and descriptions of landmarks will serve as helpful information for plastic, reconstructive, and aesthetic surgeons

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The Anatomy of the Facial Vein: Implications for Plastic, Reconstructive, and Aesthetic Procedures.

Summary Background The buccal space is an integral deep facial space which is involved in a variety of intra- and extra-oral pathologies and provides a good location for the harvest of the facial artery. The age-related anatomy of this space was investigated and compared to previous reports. Methods We conducted anatomic dissections in 102 fresh frozen human cephalic specimens (45 males, 57 females; age range 50–100 years) and performed additional computed tomographic, magnetic resonance and 3-D surface volumetric imaging studies to visualize the boundaries and the contents of the buccal space after injection of contrast enhancing material. Results The mean vertical extent of contrast agent injected into the buccal space was 25.2 ± 4.3 mm and did not significantly differ between individuals of different age (p = 0.77) or gender (p = 0.13). The maximal injected volume was 10.02 cc [range: 3.09–10.02] without significant influence of age (p = 0.13) or gender (p = 0.81). The change in surface volume was 3.64 ± 1.04 cc resulting in a mean surface-volume-coefficient of 0.87 ± 0.12 without being statistically significant influenced by age (p = 0.53) or gender (p = 0.78). Conclusions The facial artery was constantly identified within the buccal space whereas the facial vein was found to course within its posterior boundary. The buccal space did not undergo age-related changes in volume or size which highlights this space is a reliable and predictable landmark for various plastic, reconstructive and aesthetic procedures.

Updated anatomy of the buccal space and its implications for plastic, reconstructive and aesthetic procedures

BACKGROUND Breast reduction remains associated with significantly higher rates of overall morbidity, superficial surgical-site infections, and wound disruptions. The authors developed a validated risk model to identify patients at higher risk for postoperative surgical-site morbidity after breast reduction. METHODS A retrospective review was performed of all women undergoing breast reduction from the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2012 data. Surgical-site morbidity included surgical-site infection and wound disruption events. Stepwise multivariable logistic regression identified risk factors associated with surgical-site morbidity. The model was validated using bootstrap replications (n = 100) and the Hosmer-Lemeshow test, and converted into the Baltodano breast reduction score, a clinical risk tool predictive of surgical-site morbidity. RESULTS The authors identified 7068 breast reductions. Rate of 30-day surgical-site morbidity was 3.98 percent. Independent risk factors included resident participation (OR, 1.5; 95 percent CI, 1.1 to 2.0; p = 0.004), body mass index (for every 5-unit increase: OR, 1.3; 95 percent CI, 1.1 to 1.4; p < 0.001), smoking (OR, 1.6; 95 percent CI, 1.1 to 2.4; p = 0.014), steroid use (OR, 3.5; 95 percent CI, 1.4 to 8.4; p = 0.006), and operation in the third quarter of the year (OR, 1.5; 95 percent CI, 1.1 to 1.9; p = 0.014). The factors were integrated into the Baltodano score, ranging from 0 to 16. The predicted probability of surgical-site morbidity associated with each risk score was estimated. Predicted and observed risks of surgical-site morbidity were highly comparable. CONCLUSIONS The authors present the Baltodano breast reduction score, a validated risk-stratification tool for predicting 30-day surgical-site morbidity following breast reduction using data that are readily available to the clinician. This may allow targeted screening and intervention in high-risk patients, better counseling, selective resident participation, and ultimately a decrease in overall health care costs. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

The Baltodano Breast Reduction Score: A Nationwide, Multi-Institutional, Validated Approach to Reducing Surgical-Site Morbidity.

Harlequin ichthyosis (HI) is a rare autosomal recessive disorder of cornification in which children are born with an extremely thick stratum corneum that becomes a restrictive circumferential encasement around the orifices, limbs, chest, and abdomen, resulting in limb contractures. We present a neonate diagnosed in utero with HI. The infant was born with encasing bands of thickened skin creating strictures that were causing digital and limb cyanosis (compartment syndrome). We treated the child using a new technique of lysis of the encasing bands that we call linear band incision, using a new escharotomy-like procedure while the infant was undergoing a 3-week course oral acitretin therapy. The technique involved linear incision and lysis of encasements that resulted in reperfusion of the injured limbs and prevention of further digital necrosis. The child is currently a healthy 8-year-old boy with skin manifestations resembling congenital ichthyosiform erythroderma. He has use of all of the limbs that were released in the procedures and is maintained on frequent application of bland emollients. Linear band incision is a potentially life- and limb-saving technique in children with HI.

Malcolm Z. Roth

Papers

Mesotherapy, Microneedling, and Chemical Peels.

The Anatomy of the Facial Vein: Implications for Plastic, Reconstructive, and Aesthetic Procedures.

Updated anatomy of the buccal space and its implications for plastic, reconstructive and aesthetic procedures

The Baltodano Breast Reduction Score: A Nationwide, Multi-Institutional, Validated Approach to Reducing Surgical-Site Morbidity.

Techniques for Toddlers: Linear Band Incision for Harlequin Ichthyosis with Associated Compartment Syndrome