ARTICLE
Auteur(s) : E Haneke
Definition
Dermatological surgery, also called surgical dermatology or
dermatosurgery, is an integral part of dermatology. Its four major
branches – general, oncologic, reconstructive, and aesthetic
dermatological surgery – span a broad spectrum. Dermatological
surgery is not a technique-defined specialty, such as surgery or
radiology. Instead, dermatologists are organ specialists – just as
are otorhinolaryngologists, ophthalmologists, and oral surgeons—
trained in normal and pathological biology, anatomy, and physiology
of their organ, the skin. This background is a prerequisite to
successfully perform modern, complex skin surgery. Dermatological
patients expect both diagnostic accuracy and proper
management–including dermatological surgery – for all skin
conditions from their dermatologist.
Introduction
Dermatological surgery is up to 4000 years older than dermatology
as evidenced by the Papyrus Ebers and other ancient Egyptian
documents. General dermatological surgery was also described by Ibn
Sina (Avicenna) and other medieval physicians. Initially
dermatological conditions–primarily scabies, putrid skin conditions
and venereal diseases–were treated in surgical departments since
all these patients were considered unclean. Thus, in Austria and
Germany, many of the first chairs of dermatology came from surgery,
favoring the transfer of surgical approaches and techniques into
dermatology. The term “dermatological plastic surgery” dates back
to 1850. Surgically oriented dermatologists helped develop the
burgeoning field.
Whereas dermatological surgery has a long tradition in some
European countries, it still remains an underdeveloped area in
others. Chairs of “Medical-Surgical Dermatology” have been
appointed in Portugal and Spain; surgical dermatology subdivisions
and wards are commonplace in most dermatology departments in
Germany. Societies and working groups of dermatological surgery
have sprung up in about two-thirds of European countries. In the
future, we hope that our colleagues from countries where
dermatological surgery is less established will have the
opportunity to train and gain expertise in order to offer their
patients the best possible treatment.
Spectrum
Dermatological surgery includes:
- – Surgical treatment of skin tumors, both benign and
malignant.
- – Correction of disfiguring skin conditions such as
congenital malformations or scars.
- – Debridement of necrotic tissue and wound closure by
grafting techniques.
- – Surgical treatment of lesions or disorders of hairs,
nails, and sweat glands, as well as of mucosal lesions adjacent to
skin.
- – Aesthetic dermatologic surgery.
- – Phlebologic, proctologic and andrologic (in some
countries) surgery.
In recent years, a major part of surgical dermatology practices
has become cosmetic procedures, designed to enhance the aesthetic
appearance of an individual.
Techniques
Dermatological surgery includes a broad variety of procedures:
- – Scalpel surgery: incisional and excisional biopsies,
excision of tumors and other lesions, all techniques of wound
closure and defect repair with different suture techniques, all
kinds of flaps and grafts, and wound treatment. In many
departments, both sentinel lymph node extirpation and lymph node
dissections are performed in patients with melanoma and other
tumors capable of metastasis.
- – Micrographic surgery to insure complete excision of
tumors.
- – Curettage, electrosurgery and cryosurgery.
- – Chemical peels.
- – Laser surgery: excisions, vaporization of lesions,
treatment of vascular and pigmentary lesions, cosmetic laser
surgery with ablative and non-ablative lasers as well as intense
pulsed light sources.
- – Hair restoration surgery: punch-, mini-, micrografts,
alopecia reduction, flaps.
- – Nail surgery.
- – Blepharoplasties and conservative face lifts.
- – Aesthetic chemodenervation with botulinum toxin for
the treatment of dynamic wrinkles.
- – Liposuction and liposculpturing.
- – Circumcision, both medical and ritual.
- – Hyperhidrosis treatment: excision, aspiration removal
of sweat glands, botulinum toxin A injection.
None of the above lists is meant to be exclusive. Almost all of
these dermatosurgical modalities can be performed under local
anesthesia. The surgical dermatologist has to be familiar with all
techniques of local and regional anesthesia, as well as the
management of potential emergencies.
Training
Every dermatologist is entitled to perform those procedures for
which they received training according to their national or the
European curriculum for dermatological training. Most countries
require some basic medical and surgical training either within or
before the specialty training. In Portugal, where dermatological
surgery has been included into the official training program, one
year of general surgery is a prerequisite to become a general
dermatologist. However, general surgery training provides only a
solid background; the dermatologic trainee must receive specialized
instruction in surgical dermatology. The list of possible
procedures is so vast that each individual will be limited by their
individual skills, available training, and financial resources.
Facilities
Dermatologic surgical facilities must conform to the country’s and
European standards for surgical facilities in all aspects –
training of personnel, availability of emergency equipment and
response of emergency teams, sterilization procedures. Every
physician performing injections or operations must be familiar with
the management of emergencies and have the appropriate
resuscitation equipment. The staff must be trained in dealing with
such emergencies. They must be familiar with aseptic, sterile or
semi-sterile techniques to protect both their patients and their
personnel.
Room, equipment and personnel requirements depend on the extent
of dermatological surgery that is intended to be performed. Minor
procedures such as cryosurgery and chemosurgery of small lesions
require no particular facilities. Simple surgery including
diagnostic biopsies, small excisions, curettage, punch, or
electrocautery require an operation table or resting chair, along
with basic surgical equipment; a nurse should immediately be
available upon request.
More advanced dermatosurgery like tumor excisions and small
flaps necessitate additional provisions including nurse/assistant,
surgical lighting, assorted instrument table, atraumatic surgical
instruments. Very advanced dermatological surgery like removal of
large skin tumors, flaps and grafts, surgery of varicose veins, and
most cosmetic operations must be carried out in sterile operating
rooms. Laser therapy requires special technical accessories such as
smoke and plume aspirators, and special personnel and patient
safety precautions.
Future of dermatological surgery in Europe
The future scenario we and all our patients would like to see is a
European standardization of dermatological training which will open
the horizon to the young generations of dermatologists in a way
that they comfortably approach skin diseases either medically or
surgically according to commonly accepted guidelines. Continuing
Medical Education (CME) must also be remembered because our
speciality, and especially the subspecialty of surgical
dermatology, are rapidly evolving. Residency training programs and
CME programs should work together to both maintain high standards
of training and to make it possible to obtain certification as new
procedures are introduced.
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