From fantasy to factuality

I took the one less traveled by, And that has made all the difference.

Robert Frost

The great Albert Einstein once said, “Imagination is more important than knowledge.” I always believe this statement has a great meaning. Only having knowledge will be in vain if there are no ideas or innovative thinking to create new uses.

The right brain has qualities of imagination and creativity, whereas the left brain has qualities of intelligence and knowledge. For innovative thinking, a harmonious coordination and synergy of both brains is required. (See Figure 22.1.)

Figure 22.1In lighter vein.

Here I remember one quotation that was displayed outside the pathology specimen hall at B. J. Medical College that said, “To know is not only to know, but to know and to doubt, hence not to know everything.” I liked it so much that it has become my inspiring thought all these years.

Henry Thoreau once said, “A good question is never answered. It is not a bolt to be tightened into place, but a seed to be planted and to bear more seeds toward the hope of greening the landscape of ideas.” Nothing in the world is as great as an idea.

A dermatologic surgeon too must have “fantasy” in order to be successful. But he or she should make the best use of pathological knowledge to plan and execute the “factual” elements. Using the best of today’s technology he or she can develop innovative methods to generate new applications or improvise older methods.

A patient’s fantasy is many times unimaginable. Some young males and females try to copy their most favorite film stars and come with some fantastic demands that can never be fulfilled. For example, some ladies request that all the moles on their face be removed. They have the impression that they can have “a clean skin” (clean and clear skin). They are misguided either by media or friends. They are of firm belief that they can have clean and clear skin by using a laser just the same way how they can have a hairless body with laser. They see any and all small pigmented macules as unwanted defects on their facial skin that should be removed without leaving any blemishes. They see any and all tiny depressions on the facial skin as scars and demand removal.

This patient fantasy can be turned into a reality with the help of factuality, which can be explained with the help of science and technology. Patients need to be made to understand the difference in the morphology of the particular pigmented macules and their feasibility to best treatment without leaving scars.

Modern-day technological advancements have seen the development of high-power lasers (large variety), radiofrequency, and ultrasound. Out of these, lasers have become the most sought after technology by medical professionals. Huge sums of money have been pumped into developing new lasers (ablative, nonablative, fractionated, ultrapulsed, superpulsed, nanosecond, picosecond, dual wavelength, and many more). Newer lasers keep hitting the market with huge investments by medical professionals for improving their own results (quality-wise) and reducing side effects, thus offering patients the “latest and most advanced” every few years for the same indications. There is also a plethora of presentations and publications from company-sponsored workshops or actual unbiased clinical experiences from the medical professionals globally trying to prove how the latest technology is better than the previous one. There is no doubt that lasers are perhaps the most amazing achievements of our time and enjoy a wide array of indications in the field of medicine, but at the same time medical professionals need to understand the basics that lasers are color sensitive (wavelength-specific color absorption) and hence if used blindly can damage the skin irreparably.

Lasers have amazing precision and the programs are computer based. These programs may be tailor-made for certain indications but they have to be modified to suit the skin of color and the lesion in focus. This is pure science and has to be applied from case to case. Hence, lasers cannot be considered a universal remedy by any medical professional. A single laser can never treat vast indications. For that medical professionals need to have either a range of lasers or a platform having different heads used for different indications. The cost for such investment is phenomenal, plus the ever-changing research and technology bringing newer models every year. I have seen few patients being spoiled by using a single laser for many unindicated lesions or using higher-than-indicated energy. Lasers have a longer learning curve where the most important subjects are laser–tissue interactions and laser physics.

When doing dermatologic surgery using modalities other than the scalpel, three effects are most important:

Vaporization (cellular and extracellular water evaporation and boiling)
Coagulation (blood clotting, protein denaturation)
Carbonization (tissue charring)

The first and second are desired and utilized in dermatologic surgery. This is adequately covered in earlier chapters. Radiofrequency surgery has its clear advantages in the aforementioned effects as you know now. Hence, I consider radiofrequency surgery a refinement in dermatologic and aesthetic surgery. It holds the following advantages not only over other modalities, as discussed earlier, but scores over lasers due to the following characteristics:

Small, portable equipment
Very affordable
Very versatile (many applications with single equipment)
No more modifications or updating
Low maintenance costs
Consumes much less power, easily works on simple inverters in case of power failures
Single electrode can last for dozens of procedures
Color-blind, hence can treat many disorders or lesions
No fixed parameters or protocols (case individuality)
No lengthy learning curve
Therapeutic and diagnostic (biopsy possible) value

Last, I would like to enumerate once again the many benefits of radiofrequency surgery for dermatologic surgery:

Absolutely precise incision
Pressureless incision
Least lateral tissue thermal damage, hence least charring
Very fine cut as though tissue is just “split” or “divided” by touch
Almost bloodless operative field due to simultaneous hemostasis
Incision always sterile
Easy modifications of power and waveform to suit the applications
Very clean postoperative wounds
Postoperative pain or discomfort is far less
Fast postoperative healing
Minimal postoperative complications
Soft or negligible postoperative scarring
Versatility of applications
Superior results

With radiofrequency surgery, the art of dermatologic surgery to give superior aesthetic results is very much possible making best use of the scientific knowledge of this technique. Finally, it is the patient who judges the result he or she experiences. It is the patients themselves who have recommended or endorsed radiofrequency surgery as their choice.

In a concert or orchestra, if you have a keyboard player, you do not have to depend upon availability of other musicians for performance, as the keyboard is a versatile musical equipment (Figure 22.2). Similarly, in dermatologic surgery if you have radiofrequency surgery equipment and have mastered its use, you are miles ahead of your colleagues when it comes to dermatologic surgery.