MOHS FELLOWSHIP

2008-2009 Mohs and Advanced Dermatologic Surgery Fellowship at CSI

This California Skin Institute fellowship in Advanced Dermatologic Surgery is designed to provide a comprehensive exposure to cutaneous oncology, Mohs Micrographic Surgery, reconstructive surgery, general dermatologic surgery, and a broad range of advanced dermatologic cosmetic surgery with local anesthesia. An excellent multidisciplinary faculty has been assembled to provide training in applicable techniques in facial plastic surgery and ophthalmic plastic surgery. An association with Stanford ENT/Facial Plastic Surgery and Dermatology, the Mittelman Facial Plastic Surgery Fellowship Training Program, the University of California-San Francisco Oculoplastic Surgery Fellowship Training Progam, and the University of California-San Francisco Dermatology provides close interaction with five other surgical fellows (two Stanford-affiliated facial plastic surgery fellows, the UCSF oculoplastic surgery fellow, and the two UCSF dermatologic surgery fellows) as well as didactic education, expanded clinical exposure, and research and publication opportunities. An additional benefit of this program for both the academic and private practice dermatologic surgeon is exposure to the business and marketing practices of a dermatologic surgery practice that opened its doors almost 12 years ago in one of the most competitive markets in the country.

The California Skin Intitute consists of two offices spanning Silicon Valley and is the largest private practice of dermatology in Northern California consisting of 9 dermatology providers. The Mountain View office consists of a 5000 square foot of space, including a 1000 square foot Medicare-approved surgery center, staffed by 23 employees. We have a Fraxel laser, Intense Pulsed Light device, Diode hair laser, Versapulse 532nm vascular laser, Q-switched Alexandrite, Q-switched Nd:YAG, and an Ultrapulse carbon dioxide laser. The San Jose consists of a 6000 square foot office that is staffed by 27 employees and has additional lasers.

The main Mohs lab consists of 2 cryostats with 2 full-time histotechnicians and the satellite lab has one cryostat staffed by one histotechnician. In 2006-2007, over 1500 Mohs cases were performed. This case volume represents one of the largest Mohs practices in Northern California.

Additional Clinical Faculty:

1. Richard Goode, MD, Professor and Former Acting Chairman, Department of Otolaryngology and Head and Neck Surgery, and Director of the Stanford Facial Plastic Surgery Fellowship Training Program. Dr. Goode’s fellow trains with Dr. Morganroth in facial reconstruction techniques and dermatologic cosmetic surgery up to 1 day/week. The Mohs fellow will be able to work directly with Dr. Goode and observe advanced reconstruction cases and more advanced facial rejuvenation procedures.

2. Peter Levin, MD, Co-Director of Oculoplastic Surgery at Stanford University Medical Center (SUMC). Dr. Levin has a private practice within the same building as the Mohs program. The Fellow will be able to work directly with Dr. Levin in advanced periorbital reconstructions cases, periorbital cosmetic surgery, and non-cosmetic services such as ptosis repair and lid tightening procedures.

3. James Newman, MD, Clinical Instructor, Department of Otolaryngology and Head and Neck Surgery, Stanford University and Fellowship-Trained Facial Plastic Surgeon (former fellow of Dr. Goode) currently in private practice and teaching at the Stanford VA Hospital one day/week. The Fellow will participate with Dr. Newman in more advanced cosmetic procedures including endoscopic browlift and mid-facelift procedures, advanced facial rejuvenation, and radiofrequency rejuvenation.

4. Stanford University Medical Center Facial Plastic Surgery Fellows. The Fellow will interact regularly with the facial plastic fellows from the Stanford program and the Stanford-affiliated Mittelman Facial Plastic Surgery Fellowship training program. Dr. Mittelman’s fellow visits the practice on Wednesdays.

5. Hayes Gladstone, MD, Director of Dermatologic Surgery, Stanford University Department of Dermatology. The Fellow will have ample opportunity to interact with Dr. Gladstone in a number of ways including clinical observation of procedures and basic science and clinical research.

Current Schedule for the Mohs Fellowship:

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
Early A.M.		Derm GR
A.M.	Mohs	Mohs	Mohs	Mohs/Cosm	Cons/Cosm
P.M.	Cons/Cosm	Mohs	Cons/Cosm	Cons/Cosm	Cons/Cosm
Late P.M.	Journal Club			Ent/GR

* MOHS surgery is performed up to 4 days per week.
** Cos/Cons segments include consultations for surgery, follow-ups, and all cosmetic procedures.

The Mohs practice continues to grow and is expected in have significant growth with the recent practice expansion. Most Mohs referrals come from outside the practice and have the same complexity and histologic variation as the cases referred to local academic centers including melanoma, melanoma in situ, Merkel cell carcinoma, Paget’s disease, sebaceous carcinoma, microcystic adnexal carcinoma, dermatofibromasarcoma protuberans, apocrine carcinoma, atypical fibroxanthoma, and eccrine carcinoma.

All reconstructions are done under local anesthesia immediately following extirpation of the skin cancers. The full range of reconstructive techniques are utilized including two-stage pedicle flaps, cartilage grafts, and advanced flap and graft combinations. Many patients with large tumors are referred to us by local plastic surgeons for Mohs and to have us do the complex repairs including nasal cartilage framework restoration and forehead flaps or for larger periorbital tumors. Some defects are allowed to heal by granulation to provide the fellow with exposure to the advantages of granulation in many anatomic regions and practice the art of second intention wound management. It is extremely rare that a Mohs defect is sent out for reconstruction unless the Mohs case is referred by another surgical specialist who plans to do the repair or defects that involve >50% of eyelid loss. In early 2006, there were two separate Mohs days where two patients had heminasal loss. On both of these days, the Mohs fellow performed two forehead flaps (total of 4) solo. See www.mohsdoctor.com for reconstruction examples.

The 2006-2007 fellow performed over 1000 Mohs procedures as primary surgeon and hundreds of flaps and grafts including flap and graft combinations, pedicle flaps including forehead flaps, and cartilage grafts.

For fellows interested in general dermatologic surgery, we frequently see patients in consultation for revision of surgical scars, excision of benign and malignant tumors, keloid excision, laser surgery for syringomata and sebaceous hyperplasia, and congenital nevi, hemangiomata, and port wine stains.

Advanced Cosmetic Dermatologic Surgery

The focus of this fellowship is cutaneous oncology, Mohs surgery, dermatologic surgery, and reconstruction. An additional benefit of the fellowship is the unique opportunity to participate on the leading edge of cosmetic dermatologic surgery. The fellowship offers a unique experience in providing local anesthesia rejuvenation procedures to patients that expect a similar outcome to traditional techniques performed with general anesthesia.

The monthly cosmetic caseload typically consists of 10-26 major procedures. Examples of major procedures include: upper and lower blepharoplasty, periorbital laser, and full face TCA peel; 3 to 5 area tumescent liposuction; neck liposuction and chin-jowl implant; mini-facelift combined with a number of procedures. Minor procedures examples include: neck liposuction and submentoplasty; TCA chemical peel; upper blepharoplasty; and liposuction of the arms. A unique feature of this practice is the complexity of the cosmetic cases. For example, it is common that patients undergo a facelift, necklift, submentoplasty, upper blepharoplasty, lower blepharoplasty, chin implant, laser resurfacing of the perirorbital and perioral area, and TCA peeling of the balance of the face completely under local anesthesia in one sitting.

Some weeks are very busy. For example, during one week in June 2006 the following surgical cases occurred: 28 Mohs case; 4 full facelifts (includes neck lifts and submentoplasty); 7 blepharoplasties; 6 TCA peels; 6 laser resurfacing procedures; 1 body liposuction; and dozens of Botox, fillers, sclerotherapy, and laser procedures. Examples of cosmetic procedures can be found at in the Gallery page.

The fellow is expected to actively participate in all consultations, pre-operative visits, procedures, and post-operative visits. Ample opportunity will be provided for the fellow to perform a portion of the procedure as soon as possible and ultimately perform solo procedures once competent in the techniques.

Cosmetic procedures performed with local anesthesia that the fellow will assist in and perform solo include the following procedures numbers:

Tumescent liposuction of the face and body (approximately 150+/year)
Face-lifting procedures (approximately 75+/year and growing)
Neck-lifting procedures (performed in >80% of facelift procedures)
Submentoplasty/platysmal plication (done in >90% facelifts and 25% neck lipos)
Browlift (approximately 2-3/year)
Blepharoplasty (140+/year of 2 and 4-lid procedures)
Chin augmentation (approximately 25/year)
Scar revision surgery (dozens/year)
Hair transplant surgery (a few cases/year)
TCA Chemical peeling (120+/year)
Laser surgery (we own 11 laser wavelengths)—approximately 500+/year
Microlipoinjection/fat transfer (12+/year)
Sclerotherapy (approximately 120+/year)
Botox (approximately 500+/year)
Collagen, Restylane, Sculptra, and Radiesse (approx. 500+/year)

* The 2006-2007 fellow performed some of these procedures as primary surgeon. The fellow assisted and performed a portion of the surgery in the majority of the other procedures during the year. The most significant solo procedure performed by the fellow was a face lift, upper and lower blepharoplasty, periorbital and perioral laser resurfacing and facial TCA in one sitting in addition to 4 more solo face lifts.

Research and Publication Opportunities

The fellow will be expected to initiate a clinical research project at the beginning of the year and submit a paper to the ACMMSCO and ASDS annual meetings for the current or following year. Basic science research opportunities are available with Dr. Gladstone at Stanford University.

There is an enormous opportunity for an ambitious fellow to present and publish in both the reconstructive and cosmetic literature. In the first half of 2005, Dr. Morganroth authored or coauthored one paper and five book chapters covering different aspects of cosmetic and reconstructive surgery. Fellows are strongly encouraged to participate in these academic projects.

Interdisciplinary Interaction

Dr. Morganroth believes strongly in the multi-disciplinary experience that he had as a dermatologic surgery fellow. To that end, his Mohs fellow will interact frequently and operate with the Stanford Facial Plastic Surgery fellow and the Mittelman Facial Plastic Surgery fellow who frequently visit the practice. In addition, the UCSF Mohs fellows rotate through the practice on Fridays to participate in advanced cosmetic procedures allowing close interaction with UCSF. Dr. Levin’s (oculoplastic surgery) office is in the same building as Dr. Morganroth and will allow spontaneous visits to observe advanced cosmetic and reconstructive eyelid procedures.

Didactic teaching

Didactic teaching will consist of the following resources:

Stanford Dermatology Grand Rounds (Tuesday mornings)
Stanford Dermatology Surgical Lecture Series
Stanford Dermatologic Surgery Journal Club hosted by Dr. Gladstone
San Francisco Dermatology Society Meetings (4 Saturdays/year)
Stanford Otolaryngology/Facial Plastic Surgery Grand Rounds (Thursday evenings)
Stanford Otolaryngology/Facial Plastic Surgery Resident lectures (weekly)
Head and neck anatomy cadaver course at Stanford (Dermatologic Surgery & ENT faculty)
ACMMSCO and ASDS annual meetings

The fellow will also give one dermatologic surgery lecture to the Stanford dermatology residents, the Stanford ENT residents, and the dermatology residents at the University of California—San Francisco. The fellow will serve as faculty in the Stanford Dermatology Head and Neck Cadaver Course each June. In addition, the fellow may have the opportunity to be faculty at the Foundation for Facial Plastic Surgery meeting held during in February 2008 in Lake Tahoe and The Next Step IV: Mastering Outpatient Cutaneous Procedures in May 2008 at El Camino Hospital (formerly held at Stanford University).

Where are Dr. Morganroth’s previous fellows working now?

Both of Dr. Morganroth’s fellows decided to pursue an academic career to train other dermatologists in Mohs, reconstruction, and advanced cosmetic dermatologic surgery.

The 2004-2005 fellow is the second surgeon in the Department of Dermatology at The University of Connecticut in Hartford, CT.
The 2005-2006 fellow is the third surgeon in the Department of Dermatology at Oregon Health and Science University in Portland, OR.
The 2006-2007 fellow will join the faculty of the Department of Dermatology at the Philadephia College of Osteopathic Medicine where her husband will be a resident in dermatology.

California Skin Institute Advanced Dermatologic Surgery Fellowship
Application Requirements

This fellowship is in a very busy private practice and caters to an educated and demanding patient population living in Silicon Valley. Excellent interpersonal skills, patient care, and surgical techniques are necessary prerequisites for the fellow. Candidates must be a graduate of an ABMS-approved residency in dermatology, otolaryngology, plastic surgery, or ophthalmology.

The applicant should include the following information in their application packet:

Three letters of reference from faculty members with direct knowledge and observation of applicant’s surgical skills and patient interaction.
Curriculum vitae
Personal statement
A brief statement of applicant’s career plans following their fellowship
A brief summary of the applicant’s surgical training to date including:
- Names, addresses, and phone numbers of surgery mentors
- Description of training including education and experience in:
- Mohs Micrographic Surgery
- Flap and graft reconstruction
- Liposuction of the face and body
- Face and neck lifting techniques
- Blepharoplasty
- Chemical peeling
- Hair transplantation
- Laser surgery
- Fillers
- Botox
- Other
- Number and types of procedures performed by applicant during residency training

NOTE: We are interested in training individuals who want to work hard and be on the advancing edge of dermatologic surgery. We understand that not all applicants will have exposure to these cosmetic techniques during residency. Experience in these procedures is not a prerequisite for the fellowship and applicants with all levels of surgical training are encouraged to apply.

Send application packet to:

California Skin Institute Advanced Dermatologic Surgery Fellowship
c/o Darien Whang
525 South Drive, Ste. 115
Mountain View, CA 94040
650-969-5600 x208