Dermatologic surgical procedure

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Dermatologic surgical procedure
Burn victim treated in Kandahar DVIDS256992.jpg
Skin grafting for a patient suffering from severe burns.
Other namesCutaneous surgery, dermatologic surgery, skin surgery
Specialty Dermatology
UsesMedically necessary procedures, cosmetic procedures
MeSH D062109

Dermatologic surgical procedures are treatments aimed at managing a wide range of medically necessary and cosmetic conditions, with a long history dating back to ancient times.

Contents

Medically necessary dermatologic surgical procedures include curettage and electrosurgery, and Mohs surgery for the treatment of skin cancer, as well as skin grafting for repairing damaged skin. Cosmetic dermatologic surgeries comprise anti-ageing procedures, and mole and scar removal surgeries. The former include Botulinum toxin treatments and face lifts, while the latter include shave excision and dermabrasion.

Although all dermatologic surgical procedures require post-operative treatment and present common risks and complications, the future development of dermatologic surgical procedures involving the use of technology shows promising improvements in patient outcomes.

History

Dermatologic surgery has a long history and has evolved significantly over time. Ancient civilizations such as Egyptians, Greeks, and Romans practiced early forms of dermatologic surgery, employing techniques such as tissue excision, cautery, and scarification for therapeutic and cosmetic purposes. [1]

The 19th century marked the emergence of dermatologic surgery as a distinct speciality, [1] where significant advancements in surgical techniques and instruments were made. For instance, the development of aseptic techniques and anesthesia allowed for infection-free and pain-free procedures respectively, while instruments such as forceps, retractors, and cauteries improved the precision and safety of dermatological surgical procedures. [2] The applications and safety of sutures were also enhanced by William Stewart Halsted, as he emphasized on the role of sutures in sterile tissue closure, managing hemorrhage and wound healing. [3]

In the early 20th century, electrosurgery and cryosurgery were introduced, [4] and surgical techniques continued to evolve from mid to late 20th century, with the introduction of surgical procedures such as skin grafting, laser surgery and Mohs microscopic surgery. [3] The establishment of dermatology surgery societies and training programs, such as the “American College of Mohs Surgery” founded by Frederic Mohs in 1967, as well as postgraduate courses on dermabrasion and chemical peels, also contributed to the progression of surgical techniques. [3] These advancements expanded the range of treatment options available in dermatologic surgery.

Medically necessary procedures

Skin cancer surgery

Skin cancer is the uncontrolled proliferation of abnormal skin cells, usually developing on skin exposed to ultraviolet radiation. Squamous cell carcinoma, basal cell carcinoma, and melanoma are the three main types of skin cancer, [5] with the former two being non-melanoma skin cancer.

Curettage and Electrosurgery

A scoop-shaped curette used in dermatologic surgeries. Curette face.jpg
A scoop-shaped curette used in dermatologic surgeries.

Most small, low-risk and superficial skin cancers, such as basal cell carcinoma and squamous cell carcinoma, could be treated by curettage and electrosurgery. [6] A clinical margin which includes areas around the lesion site is marked out, and local anesthesia or numbing medicine is applied. A curette, consisting of a fenestrated head with a semi-sharp blade, is used to debride the malignant tumour. This is done by mechanically scraping or peeling at the lesion until all cancerous tissues are removed. Electrodesiccation is followed up after each curettage by applying a high-voltage electric current to the tumour site. The heat could destroy the remaining tumours not eliminated by curettage, induce inflammatory response in tumour cells, and aid in hemostasis. [7] Treating small and superficial skin cancers with curettage and electrosurgery presents a high cure rate of over 90%. [8]

Mohs Surgery

Mohs surgery could target non-melanoma and melanoma skin cancers, and is recommended as a first-line treatment for large, high-risk tumours in anatomically critical areas. [9] After local anesthesia is applied, visible tumours are first excised using a scalpel. Then, a thin piece of tissue is removed circumferentially around the tumour and sectioned with a cryostat microtome. This is followed by tissue processing and viewing under a microscope. If any residual tumour could be identified microscopically, the tumour site could be marked for further tissue removal. This process is repeated until the absence of tumours is confirmed by these histological methods. [10] In most patients treated with Mohs surgery, complete elimination of cancerous cells, maximal conservation of healthy tissues, and high cure rates of up to 99% are observed. [11]

Skin grafts

Donor site 8 days after a skin graft. Skin graft donor site.jpg
Donor site 8 days after a skin graft.

Skin grafting is a surgical procedure where a piece of healthy skin, also known as the donor site, is taken from one body part and transplanted to another, often to cover damaged or missing skin. [12] Before surgery, the location of the donor site would be determined, and patients would undergo anesthesia. [13]

Full-Thickness Skin Grafts (FTSG)

FTSGs are the most frequently used grafts in dermatology, [14] which involves surgical removal of the epidermis and dermis layers of the skin. After the skin graft is harvested, the donor site is stitched close, and the graft is trimmed of any underlying hair or fat tissue, as well as contoured to match the size and shape of the defect. [15] The graft is then immediately placed onto the wound site and sutured. Finally, a bolster, which is a type of dressing, is placed over the graft to secure it in place. [16]

Split-Thickness Skin Grafts (STSG)

Skin graft with vacuum-assisted wound closure after 5 days. Skin graft treated with vacuum assisted closure for five days.jpg
Skin graft with vacuum-assisted wound closure after 5 days.

STSGs are suitable for large wounds and relatively avascular sites where FTSGs would have a high risk of failure. Only a portion of the skin, namely the epidermis and part of the dermis, is removed from the donor site using a powered dermatome. [17] If desired, meshing of the harvested skin graft allows it to be elongated. The graft is then applied to the defect and secured using skin staples or dissolvable sutures. [17] A bolster is placed over the graft to conclude the procedure, while for areas where bolstering is difficult, a negative pressure wound vacuum could reduce air pressure on the wound to promote healing. [18]

Composite Grafts

Composite grafts are used to repair defects that require contouring and support due to a loss of underlying muscle or bone. These grafts usually consist of different tissue layers, such as the skin, cartilage, and fat, and are frequently utilized to reconstruct structures such as the nose, ears, and fingertips. [14] Skin from the donor site is first excised precisely and contoured as needed, then the donor site is closed in multiple layers. The graft is subsequently placed over the wound and secured by suturing, followed by the application of a bolster if necessary. Typically, minor revisions of the graft are required after the initial surgery for fine-tuning and adjustment of the graft’s shape and appearance. [19]

Cosmetic procedures

Anti-ageing procedures

Botulinum toxin type A used for cosmetic purposes. Ampoule with Botulinum Neurotoxine (highly toxic for humans), used for "beauty injections" into the skin, with centimeter scale to indicate size.jpg
Botulinum toxin type A used for cosmetic purposes.

Botulinum toxin treatments

Botulinum toxin is a neurotoxin with cosmetic and dermatologic applications, such as treating hyperhidrosis, removing facial lines and wrinkles. Among the serotypes A to G, Botulinum toxin type A is the major type used for aesthetic and clinical purposes. Before injection, it has to be reconstituted using sterile saline as a diluent. The reconstituted solution should be refrigerated and used within 4 hours to prevent its loss of function. Then, by using a hollow teflon-coated, 30-gauge 1-inch needle, the toxin could be injected directly into the affected muscles. The dose of toxin for each injection is determined by the muscle mass, [20] while the injection site should be localized to overactive smooth muscles to induce muscle weakness. Overactive muscles can be determined by measuring the muscle's maximal response to a nervous stimuli with electromyography. [20] Botulinum toxin could be used to relax the corrugator and procerus muscles, orbicularis oculi, and the frontalis muscle to relieve glabellar lines (frown lines), lateral canthal lines (Crow’s feet) and forehead lines respectively. [21]

Face lift (Rhytidectomy) with temporal incision behind the hairline. Mid facelift (rhytidectomy) upper incision.png
Face lift (Rhytidectomy) with temporal incision behind the hairline.

Face lift (Rhytidectomy)

Rhytidectomy is a surgical method, often used for making the skin look smoother and younger. This is done by first making an incision at the temples that extend around the ear, then separating the skin from the underlying fascial layers and muscles, and removing the sagging facial skin. [22] [23] The remaining skin is subsequently pulled backward and upward, and sutured to a new position to achieve a tightened appearance. During this process, facial muscles might be tightened, while facial fat might be removed or redistributed. Sometimes, a jaw lift is performed in the same surgery by making an incision under the chin and tightening the skin of the jaw and neck. Immediately after the surgery, a drainage tube is used to remove excess fluid from the wound. [23] [24]

Mole and scar removal surgeries

Shave excision

Mole removal surgeries are performed for various reasons. Atypical mole removal is performed when moles look dysplastic, as this is associated with an increased risk of melanoma; Cosmetic mole removal is performed when moles are non-cancerous, but are preferred to be eliminated due to aesthetic or practical considerations. [25]

Shave excision is the most frequently used method for mole removal. Anesthesia is first administered to the area around the mole. With the use of a sharp razor, multiple horizontal cuts are then made to remove the mole. This is followed by electrosurgical feathering, where a small dermal loop electrode is used to gently shape the edges of the wound. This not only ensures any remaining cells of the mole are removed, but also minimizes scarring as the edges of the wound are blended with the surrounding skin. [26] At last, the surgical site is cleaned, applied with antibiotic ointment, and covered with a sterile bandage to prevent infection.

Dermabrasion

Scar revisions are cosmetic treatments to improve the appearance of scars, [27] with dermabrasion being a surgical procedure most often used for individuals with skin concerns such as scars caused by acne, surgery or injury. [28] This skin-resurfacing procedure makes use of dermabraders, a rapidly rotating device to exfoliate the outer layer of the skin, [28] thereby promoting the growth of new skin that is smoother in texture.

First, local or general anesthesia is employed. Next, the area to be treated is marked out, and a suitable dermabrasion tip is chosen to be used during the procedure. During dermabrasion, the skin being treated is held taut with one hand to maintain tension while the dermabrader is moved across the skin uniformly and gently. [29] Proper manipulation, appropriate pressure and precise control of the dermabrader is crucial to ensure the accurate layer of the skin is targeted and to reduce adverse effects. Following dermabrasion, a saline-soaked gauze coupled with occlusive ointment are applied to the treated skin to prevent infection and facilitate wound healing. [29]

Post-operative treatment and recovery

Surgeries for medically necessary conditions

For skin cancer surgeries, most wounds are relatively small. After removal of the dressing, the wound can be cleaned by washing with clean soapy water, and should be kept moist. It is also suggested to apply prescribed antibiotic ointments or any other medications to the wound, and protect the scar formed. [30]

For skin grafts, the newly grafted skin is fragile to damage. Slight bleeding may occur, which can be managed by removing serosanguineous material or necrotic debris using hydrogen peroxide. If eschar is present which affects the grafted skin, debridement should only be done when the area of necrosis is clearly defined. [31]

Surgeries for cosmetic conditions

Immediately after a dermatologic cosmetic surgery, it is generally recommended for the surgical site to be elevated to reduce swelling and maintain blood flow. [23] Analgesics, antibiotics and anesthetics are usually prescribed to relieve pain, inflammation and swelling. Patients should refrain from vigorous exercise for the first few days after surgery and exercise caution when gradually resuming their normal activities. [32] Showering should also be avoided during the first few days after surgery. Patients are also advised against submerging their wound in water for at least two weeks after surgery. [23]

Risks and complications

During dermatologic surgery, dissecting errors may give rise to damaged structures adjacent to the surgical site, such as nerves, glands, and blood vessels. This may result in numbness, muscle weakness or paralysis. Patients with risk factors such as blood clotting abnormalities or long-term use of certain medications may experience excessive bleeding at the incision site. This would prolong the healing process and increase the risk of bacterial wound infection. [33] Moreover, though uncommon, allergic reactions to anesthesia during surgery may also occur in some patients. [24]

After dermatologic surgery, the presence of suture materials at the wound site can cause redness and swelling, yet these suture reactions may not necessarily indicate allergy or infection. Other common complications include hypertrophic or keloid scars, bruises, suture marks, and skin color changes, which may be temporary or permanent. [34]

Future directions

Throughout the past 10 years, minimally invasive dermatological procedures have shown significant advancements, with the emergence of intradermal fillers, botulinum toxin injections and chemical peels. [35] These techniques require smaller incisions, which could lessen scarring and trauma, and decrease surgical complications. [36] Compared with traditional surgical methods, minimally invasive procedures are more likely to result in high patient satisfaction and treatment efficacy. [35] With the introduction of three-dimensional bioprinting [37] and robotic-assisted surgeries for tissue repair and reconstruction, [38] future technological advancements might continue to diminish recovery time and improve patient outcomes.

See also

Related Research Articles

<span class="mw-page-title-main">Plastic surgery</span> Medical surgical specialty

Plastic surgery is a surgical specialty involving the restoration, reconstruction, or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. While reconstructive surgery aims to reconstruct a part of the body or improve its functioning, cosmetic surgery aims to improve the appearance of it. A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills.

<span class="mw-page-title-main">Melanocytic nevus</span> Skin condition, mole

A melanocytic nevus is usually a noncancerous condition of pigment-producing skin cells. It is a type of melanocytic tumor that contains nevus cells. Some sources equate the term mole with "melanocytic nevus", but there are also sources that equate the term mole with any nevus form.

<span class="mw-page-title-main">Skin cancer</span> Medical condition involving uncontrolled growth of skin cells

Skin cancers are cancers that arise from the skin. They are due to the development of abnormal cells that have the ability to invade or spread to other parts of the body. Skin cancer is the most commonly diagnosed form of cancer in humans. There are three main types of skin cancers: basal-cell skin cancer (BCC), squamous-cell skin cancer (SCC) and melanoma. The first two, along with a number of less common skin cancers, are known as nonmelanoma skin cancer (NMSC). Basal-cell cancer grows slowly and can damage the tissue around it but is unlikely to spread to distant areas or result in death. It often appears as a painless raised area of skin that may be shiny with small blood vessels running over it or may present as a raised area with an ulcer. Squamous-cell skin cancer is more likely to spread. It usually presents as a hard lump with a scaly top but may also form an ulcer. Melanomas are the most aggressive. Signs include a mole that has changed in size, shape, color, has irregular edges, has more than one color, is itchy or bleeds.

Dermatology is the branch of medicine dealing with the skin. It is a speciality with both medical and surgical aspects. A dermatologist is a specialist medical doctor who manages diseases related to skin, hair, nails, and some cosmetic problems.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

<span class="mw-page-title-main">Abdominoplasty</span> Surgical procedure to make the abdomen thinner and firmer

Abdominoplasty or "tummy tuck" is a cosmetic surgery procedure used to make the abdomen thinner and more firm. The surgery involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall. This type of surgery is usually sought by patients with loose or sagging tissues, that develop after pregnancy or major weight loss.

<span class="mw-page-title-main">Basal-cell carcinoma</span> Most common type of skin cancer

Basal-cell carcinoma (BCC), also known as basal-cell cancer, basalioma or rodent ulcer, is the most common type of skin cancer. It often appears as a painless raised area of skin, which may be shiny with small blood vessels running over it. It may also present as a raised area with ulceration. Basal-cell cancer grows slowly and can damage the tissue around it, but it is unlikely to spread to distant areas or result in death.

<span class="mw-page-title-main">Melanoma</span> Cancer originating in melanocytes

Melanoma is the most dangerous type of skin cancer; it develops from the melanin-producing cells known as melanocytes. It typically occurs in the skin, but may rarely occur in the mouth, intestines, or eye. In women, melanomas most commonly occur on the legs; while in men, on the back. Melanoma is frequently referred to as malignant melanoma. However, the medical community stresses that there is no such thing as a 'benign melanoma' and recommends that the term 'malignant melanoma' should be avoided as redundant.

<span class="mw-page-title-main">Skin grafting</span> Surgical transplantation of skin

Skin grafting, a type of graft surgery, involves the transplantation of skin. The transplanted tissue is called a skin graft.

Otoplasty is a procedure for correcting the deformities and defects of the auricle, whether these defects are congenital conditions or caused by trauma. Otoplastic surgeons may reshape, move, or augment the cartilaginous support framework of the auricle to correct these defects.

<span class="mw-page-title-main">Blepharoplasty</span> Surgical modification of the eyelids

Blepharoplasty is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning of excess tissues, such as skin and adipocyte fat, and the reinforcement of the corresponding muscle and tendon tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the periorbita, which is the area from the eyebrow to the upper portion of the cheek. The procedure is more common among women, who accounted for approximately 85% of blepharoplasty procedures in 2014 in the US and 88% of such procedures in the UK.

<span class="mw-page-title-main">Platysma muscle</span> Human neck muscle

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<span class="mw-page-title-main">Buttock augmentation</span> Cosmetic and corrective surgery

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<span class="mw-page-title-main">Lentigo maligna</span> Medical condition

Lentigo maligna is where melanocyte cells have become malignant and grow continuously along the stratum basale of the skin, but have not invaded below the epidermis. Lentigo maligna is not the same as lentigo maligna melanoma, as detailed below. It typically progresses very slowly and can remain in a non-invasive form for years.

<span class="mw-page-title-main">Keratoacanthoma</span> Medical condition

Keratoacanthoma (KA) is a common low-grade rapidly-growing skin tumour that is believed to originate from the hair follicle and can resemble squamous cell carcinoma.

<span class="mw-page-title-main">Mohs surgery</span> Surgery used to treat skin cancers

Mohs surgery, developed in 1938 by a general surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat both common and rare types of skin cancer. During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery is the gold standard method for obtaining complete margin control during removal of a skin cancer using frozen section histology. CCPDMA or Mohs surgery allows for the removal of a skin cancer with very narrow surgical margin and a high cure rate.

<span class="mw-page-title-main">Skin biopsy</span> Removal of skin cells for medical examination

Skin biopsy is a biopsy technique in which a skin lesion is removed to be sent to a pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose Mohs surgery.

Aesthetic medicine is a branch of modern medicine that focuses on altering natural or acquired unwanted appearance through the treatment of conditions including scars, skin laxity, wrinkles, moles, liver spots, excess fat, cellulite, unwanted hair, skin discoloration, spider veins and or any unwanted externally visible appearance. Traditionally, it includes dermatology, oral and maxillofacial surgery, reconstructive surgery and plastic surgery, surgical procedures, non-surgical procedures, and a combination of both. Aesthetic medicine procedures are usually elective. There is a long history of aesthetic medicine procedures, dating back to many notable cases in the 19th century, though techniques have developed much since then.

Electrodesiccation and curettage is a medical procedure commonly performed by dermatologists, surgeons and general practitioners for the treatment of basal cell cancers and squamous cell cancers of the skin. It provides desiccation, coagulation/cauterization, and curettage to remove lesions from the skin.

June K. Robinson is an American dermatologist, academic and researcher. She is a Research Professor of Dermatology at Northwestern University’s Feinberg School of Medicine.

References

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  38. ↑ Wang, Peng; Su, Ying-Jun; Jia, Chi-Yu (2019). "Current surgical practices of robotic-assisted tissue repair and reconstruction". Chinese Journal of Traumatology = Zhonghua Chuang Shang Za Zhi. 22 (2): 88–92. doi:10.1016/j.cjtee.2019.01.003. ISSN   1008-1275. PMC   6487454 . PMID   30962128.
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