Introduction
Dermatologic surgery, or cutaneous surgery, is an ever-expanding and sought after field. The ever-increasing demand for surgery in dermatology is not the only reason for it. There is a growing demand for dermatologic surgery from many fields of medicine, including general surgery, otorhinolaryngology, ophthalmology, plastic and reconstructive surgery, and family practice. Dermatologic surgery was and is still being performed quite commonly using the “gold standard” scalpel or the favorite modalities of contemporary clinical dermatologists like electrocautery and cryosurgery.
Dermatologic surgery generally fits into the category of minor surgery. For decades general practitioners or family physicians performed these surgeries in their small setups. Dermatologic surgery in family practice started dwindling in the last three decades as more specialized surgical care became available with advanced technology. Technological advances and availability of different medical specialties even made family practice a specialty of its own. The dermatologic surgery also became specialized with the development of electrosurgery, radiofrequency surgery, and lasers. The development of punches facilitated doing skin biopsy.
Dermatologic surgery involves surgery related to all skin diseases for diagnostic and therapeutic purposes. Skin diseases include cutaneous, venereal, and leprologic diseases.
Decades earlier, before the advent of electrosurgery and lasers, lesions were removed using the modalities of a scalpel, hyfrecator, electrocautery, cryosurgery, or chemical cautery. Here, the final result involved complete removal of lesion where the residual scar hardly mattered.
In the modern era, there is an additional demand from patients due to cosmetic concern of facial skin and other body parts. This has expanded the scope of dermatologic surgery to the present stage where it involves giving more specialized surgical services to reduce the operative time and postoperative downtime as well as resulting in minimum complications and negligible residual scarring.
In the early 20th century the methods of dermatologic surgery were very crude. Some of these small skin surgeries were performed by licensed medical practitioners. But, I recall that in rural or semiurban areas such surgical work was carried out by unlicensed practitioners or quacks with complications. Though the scalpel and cryosurgery or electrocautery were used, most of the skin lesions on bodily skin and genitalia were removed leaving obvious scarring or suture marks (Figures 1.1 and 1.2). These were accepted without prejudice or mistrust.
Figure 1.1Postchemical cautery scabs and burnt skin.
Figure 1.2Postelectrocautery scars.
The better knowledge and applications of electric current, electromagnetism, laser physics and their connections as well as applications on the biological tissues made huge progress in the later part of the 20th century. The development of good quality electrosurgery equipment dates back to 1926 and is credited to Harvard physicist William Bovie. This was preceded by many earlier experiments to develop equipment using electric current for skin surgery. The Bovie electrosurgery equipment was reasonably complete comprising of both cutting and coagulation currents. This was further improvised to include more facilities for better removal of superficial as well as deep lesions. Thus the newer equipment using higher frequencies allowed electrosection, electrocoagulation, electrodesiccation, and fulguration, which led to more precise and effective dermatologic surgery. Lasers, which became available after 1960, have been a favorite of modern-day dermatologists.
The educational curriculum of dermatology at many institutions has yet to include modern electrosurgery and lasers. In fact, there is a need to update the educational curriculum to include these and modern radiofrequency surgery universally. Because of this drawback, dermatologists were hardly well equipped to surgically deal with skin lesions. This lack of confidence among dermatologists led to many skin lesions being tackled by surgeon colleagues. There was also a lack of awareness among the general public as to the best surgical treatment for skin lesions.
Dermatologic surgical care given by surgeons from any faculty, whether general surgery or others, appeared to lack in the dexterity compared to their dermatology colleagues. This lack is likely due to either use of their favorite scalpel or surgical diathermy or due to lack of awareness of the histopathology of the concerned dermatological lesions. The advantage dermatologists have in doing dermatologic surgery is that they are well aware of the histopathology of the concerned skin lesions. They know the best level to reach in order for complete removal with minimal or no scarring.
The dermatologic surgery described in this book is confined to the minor operating theater or office surgery, which is performed in a clinic-based setup. While performing such procedures, one must be perfectly clear in the scope and limitations of them. One must be fully confident in performing these procedures totally in the office with or without the help of staff. One must also be absolutely clear with the criteria of performing dermatologic surgical procedures in the hospital operation theater. Although these criteria may vary between professionals, the overall accepted ones are mentioned in Table 1.1.
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