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DERMATOLOGIC SURGERY: Pathways to Healthy Skin
WHAT IS DERMATOLOGIC SURGERY?
Dermatologic surgery is that discipline which deals with the diagnosis and treatment of conditions of the skin, hair, nails, mucous membranes and adjacent tissues by various surgical methods. It is a means of repairing and/or improving the function and appearance of skin tissue.
Dermatologic surgery is a sub-specialty of dermatology; one of 23 medical and surgical specialties recognized the American Board of Medical Specialties.
WHO IS A DERMATOLOGIC SURGEON?
A dermatologic surgeon is trained and experienced in the use of a wide variety of surgical and non-surgical modalities to treat an entire organ - the skin - and its problems. A dermatologic surgeon demonstrates competence in the diagnosis and surgical treatment of:
Diseases and disorders of the skin, hair, nails, veins and mucous membranes
Benign and malignant growths and skin cancers
Aging and sun-damaged skin.
Cosmetic improvement of the skin.
WHAT TRAINING DOES A DERMATOLOGIC SURGEON RECEIVE?
Dermatologic surgeons are physicians who have completed an internship and at least three additional years of specialized training in the medical and surgical treatment of skin disorders, including a core curriculum in the therapeutic, reconstructive and cosmetic treatment of skin conditions.
Clinical training in residency programs nationwide focuses on the treatment of allergies and immunology, cryosurgery, dermatologic surgery, laser surgery, dermatopathology, clinical pathology, parasitology, photobiology, physiotherapy, tropical and systemic pharmacology and microbiology, including sexually transmitted diseases. As a group, most dermatologic surgeons are board certified by the American Board of Dermatology
WHAT PROCEDURES DO DERMATOLOGIC SURGEONS TYPICALLY PERFORM?
Numerous procedures and techniques have been developed, refined and used by dermatologic surgeons. Treatment methods most commonly utilized are those that accomplish tissue removal, lesion removal, primary closure, adjacent tissue transfer and tissue augmentation. These include, but are not limited to:
Blepharoplasty - Upper and lower eyelid surgery to remove skin and excess fatty tissue.
Chemical peeling - Application of a chemical solution to remove the outer layer of skin to treat fine lines, wrinkles, mild scarring, acne, skin discoloration and pre-cancerous growths.
Cosmetic rejuvenative surgery - Aesthetic procedures to enhance the appearance of the skin, e.g., facial resurfacing, scalp reduction for hair loss, rhytidectomy, etc.
Cryosurgery — Freezing the skin tissue with liquid nitrogen to remove skin growths.
Curettage and desiccation - Use of a sharp instrument to scrap away skin tissue, followed by application of aheated electric needle to destroy skin growths.
Dermabrasion — Surgical sanding or planing of theouter layer of skin toimprove acne and other scars, remove tattoos and minimize age spots, wrinkles and certain types of skin growths.
Excision and closure - cutting into the skin to remove a growth and thenclosing the wound with stitches.
Flap surgery - Transfer of adjacent skin tissue, often used to move hair-bearing skin to cover balding areas of the scalp.
Grafting - Surgical transplantation of a patch of skin to repair a defect.
Hair replacement surgery - Avariety of techniques, such aspunch grafts, scalp reduction and scalp flaps, to correct baldness and restore a person'snatural hairline.
Laser surgery - Abeam of laser light directed at a site to selectively eliminate tissue abnormalities, such as skin lesions and tattoos and to resurface facial skin.
Micropigmentation - Apermanent method of implanting pigment into the skin to add color for the treatment of vitiligo, skin grafts or burn scars and for cosmetic purposes.
Mohs micrographic surgery - Precise removal of skin cancer layer by layer with the aid of a microscope.
Nail surgery - Removal or repair of a nail abnormality for the purposes of diagnosis and/or treatment.
Sclerotherapy - Injection of a solution to remove unwanted varicose and spider leg veins.
Soft tissue augmentation - Injection under the skin of filler, like collagen, Fibrel or one's own fat, to correct wrinkles, acne scars and other depressions.
Tissue expansion - Atechnique used to close large surgical wounds and aid in reconstructive surgery.
Tumescent liposuction - Aresculpturing technique to remove unwanted fat deposits from specific body areas using only local anesthesia.
WHERE IS TREATMENT USUALLY PERFORMED?
Most often, dermatologic surgical procedures are effectively and efficiently performed with utmost safety in a doctor's office, surgical suite or outpatient surgical center. This offers a cost-saving alternative to hospital stays. Under special circumstances, treatment may be delivered in a hospital operating room.
WHAT RESULTS CAN BE EXPECTED?
The results achieved largely depend not only on the skill and experience of the dermatologic surgeon, but also on a patient's age, general health, overall skin texture, healing capacity and the specific skin problem. A patient's realistic expectations also help contribute to a positive outcome.
Surgical excision, Mohs micrographic surgery, laser surgery cryosurgery electrosurgery and curettage
Spider and varicose veins
Sclerotherapy, intense pulsed light therapy, laser surgery
Warts, seborrheic keratoses
Cryosurgery, currettage, excision, electrosurgery, chemical treatment, laser surgery
What Are The Risks Of Dermatologic Surgery?
The risks involved in a most Dermatologic surgery procedures are minimal. However, there are inherent risks associated with any type of surgery, and these should be discussed with your dermatologic surgeon. Hundreds of thousands of dermatologic surgical treatments are performed successfully each year.
Laser stands for Light Amplification by the Stimulated Emission of Radiation. Lasers work by producing an intense beam of bright light that travels in one direction. This laser beam can cut, seal or vaporize skin tissue and blood vessels. The laser has the unique ability to produce one specific color (wavelength) of light, which can be varied in its intensity and pulse duration. Ordinary light from non-laser sources is composed of many different colors and appears white. The wavelength and power output of a particular laser determines its medical application.
When the laser light is directed at skin tissue, its light energy is absorbed by water or pigments found in the skin. Water is found in large amounts in all living cells. Pigments of the skin include hemoglobin, a protein that makes blood red, and melanin, the tan or brown colored pigment. All three absorb laser light of different colors.
WHAT ARE THE BENEFITS OF LASER SURGERY?
Lasers may offer you and your dermatologic surgeon the following general benefits:
Improved therapeutic results
Reduced risk of infection
Relatively bloodless" surgery
Precisely controlled surgery which limits injury to normal skin
An alternative to traditional scalpel surgery, in some cases
Potentially less scarring, in some cases
Safe and effective out-patient, same-day surgery for many skin conditions
WHAT TYPE OF LASER SHOULD BE USED?
In dermatology, many different types of lasers are presently being used to treat a variety of skin conditions, growths and cosmetic complaints. Further, no single laser is currently capable of treating all skin conditions, and some lasers have only limited usefulness in dermatologic applications. In addition, certain lasers can be tuned to a variety of colors of light or coupled to a robotized scanning device to expand their clinical effectiveness.
Your dermatologic surgeon will carefully evaluate your particular problem and then suggest the appropriate type of laser system that might be useful for therapy.
WHO IS QUALIFIED TO PERFORM LASER SURGERY?
Experts in skin care, dermatologic surgeons have extensive experience with laser surgery and were among the first specialists to use lasers for treating a variety of skin disorders. In fact, many of the latest advances in laser technology were pioneered and refined by dermatologic surgeons. Since results are often technique-sensitive, it's important to select a dermatologic surgeon with laser expertise.
WHAT ARE THE COMMON LASERS USED IN DERMATOLOGY?
The Carbon Dioxide (CO2) Laser
The C02 laser emits a colorless infrared light, which is highly absorbed by water containing tissue like the skin. This laser system can be used in several ways: "focused" for cutting skin without bleeding; "defocused" for superficially vaporizing skin; and "super pulsed" for facial resurfacing.
By delivering very powerful, rapid pulsing or scanning of the C02 laser beam, dermatologic surgeons are able to peel and resurface the facial skin for cosmetic improvement without damaging or scarring surrounding skin. Sometimes referred to as "laserbrasion," this technique removes fine lines and wrinkles of the face, smoothes acne scars and rejuvenates aging and sun-damaged skin as it gently smoothes and precisely contours the skin surface.
If the C02 laser's energy is defocused and not continuous (pulsed), a larger spot of light is created which is less intense. With this modification, the dermatologic surgeon can remove or vaporize thin layers from the skin surface without penetrating the deeper layers. This technique is particularly useful in treating warts, shallow tumors and certain precancerous conditions.
When the C02 laser energy is continuous and focused into a small spot of light, the beam is able to cut the skin. As an alternative to traditional scalpel surgery, the laser helps to limit blood flow during the treatment and reduce post-operative swelling. The carbon dioxide laser is used in this way to remove skin cancers, to treat a variety of nonvascular and pigmented lesions and for eyelid operations. This technique is also used to remove warts and for some surgical incisions.
The Argon Laser
The argon laseremits a blue-green colored light, which is absorbed by hemoglobin in blood cells. When hemoglobin absorbs the laser energy, it is converted to heat. The heat damages and seals the blood vessels, causing them to disintegrate and be reabsorbed into the body.
Because of this selective absorption of laser light by hemoglobin, the argon laser is most often used to treat blood vessel disorders and growths, especially those that are raised and bluish-red in color. The argon laser can flatten and lighten these types of growths with little risk of scarring. Specifically, it is capable of treating port wine stains, red birthmarks, hemangiomas (malformations of blood veins in the skin), enlarged blood vessels and the red-nose syndrome that results from rosacea or nasal surgery.
The Yellow Light Lasers
Through the use of an organic dye, short pulses of yellow colored light are produced. A popular yellow light laser is the pulsed dye laser,which uses a camera-like flash to stimulate the dye solution to produce yellow light. Because yellow light is more precisely absorbed by the hemoglobin than other colors, these lasers are effective in the treatment of blood vessel disorders, such as port wine stains, red birthmarks, enlarged blood vessels, rosacea, hemangiomas and red-nose syndrome. Like the other lasers, yellow light lasers can be used with minimal risk of scarring from treatment making them safe and effective in the treatment of infants and children.
Some yellow light laser systems can be adjusted to produce multiple colors of light For instance, the argon-pumped tunable dye laser, though more commonly used to make yellow light, can also be tuned to produce red light. This wavelength is used in an experimental technique known as "photodynamic therapy" for the treatment of skin cancer.
Similarly, the copper vapor laser heats elemental copper to produce both yellow and green colors of light. The uses of the yellow light are similar to those already described. The green light, in contrast, is used for the treatment of benign brown pigmented lesions, such as cafe-au-lait spots, the "old age" spots commonly found on the backs of the hands, and lentigines or freckles.
Another dual light system is the krypton laser. As a source of yellow light, it treats vascular lesions. When adjusted to produce a green light, the krypton laser can treat brown pigmented lesions.
The Red Light Lasers
The red light spectrum produced by the ruby laser is emitted in extremely short, high-energy pulses. This type of pulse is possible due to a technique known as Q-switching. The Q-switched ruby laser system was initially used to remove tattoos, particularly amateur tattoos, since it can effectively fade or eliminate the colored pigments with little risk of scarring or damage to the surrounding skin. In addition, this laser is now commonly used to treat many brown pigmented lesions, such as actinic lentigines, freckles, cafe-au-lait spots and nevus of Ota.
Bathe too long. Soap and water can cause skin to become excessively dry.
Use water that is too hot.
Scrub your skin with a brush or harsh sponge.
Rub yourself dry.
Shower or bathe too frequently, especially in winter.
Avoid exercise.
Skimp on drinking lots of water.
Lose sleep. Fatigue can slow your circulation and impede delivery of oxygen and nutrients to your skin.
Forget about what you eat. Your diet can affect your skin.
Overheat your home in winter.
Do
Get your "beauty sleep."
Use warm water. It's not as drying as hot water.
Bathe just long enough to cleanse yourself.
Fat a balanced diet. Fruits, vegetables, and fiber provide fluid and important nutrients to your skin.
Exercise. It increases the flow of nourishing blood and oxygen to the skin, which results in a healthy glow.
Drinks lots of water. The upper layer of your skin is about 10% water, while the deepest layers of skin are close to 60% water.
Use a humidifier in winter to keep the air from drying out your skin.
Take a bath or shower only once a day. It's enough!
Use hands to gently lather in circles.
Pat yourself dry with a soft towel
Use a mild soap. Example:
Aveeno
Caress
Cetaphil
Dove
Eucerin
Basis
Neutragena
Curel
12. Use a moisturizer. Example:
Tone
Aquaphor
Cetaphil
Neutragena
Aqua Glycolic
Curel
Know the Melanoma danger signs
BEWARE OF ANY OF THE FOLLOWING SIGNS IN LOCALIZED AREAS OF THE SKIN:
CHANGE IN SIZE; sudden increase in size is of special concern, slow change is much more common.
CHANGE IN COLOR: of special concern is sudden darkening of brown or black shades, or of mixing of shades red, white and blue.
CHANGES IN SURFACE CHARACTERISTICS; watch for scaliness, flaking, oozing, crusting, ulceration, bleeding, appearance of nodule bulging, mushrooming mass.
CHANGE IN CONSISTENCY; getting hard, soft or lumpy.
CHANGE IN SHAPE OR OUTLINE; finding an irregular notched border where it used to be regular, sudden elevation of a surface that used to be flat.
CHANGE IN THE SURROUNDING SKIN; spread of pigment from the edge of a mole into the skin that used to be normal looking. Finding redness or swelling (inflammation) development of satellite pigmentation (that is nodules of pigmentation next to but not a part of a mole)
CHANGE IN SENSATION; feelings of itchiness, tenderness or pain.
SUDDEN APPEARANCE OF A NEW PIGMENTED SPOT IN AN AREA THAT USED TO BE NORMAL.
Skin cancer is the most common of all cancers. Estimates vary on its occurrence but it is estimated that approximately 700,000 Americans develop skin cancer every year.
Sun avoidance is the best defense against skin cancer.
The principal cause of skin cancer is almost universally accepted by medical experts to be overexposure to sunlight, especially when it results in sunburn and blistering. Other less important factors would include: repeated medical and industrial x-ray exposure; scarring from diseases or burns; occupational exposure to such compounds as coal and arsenic, and family history.
Prevention is a matter of guarding the skin against the known causes. Since the sun and its ultraviolet rays would seem to be the main culprit, the most effective preventive method is sun avoidance. Limit the exposure of the skin to harmful rays by covering up and using sunscreens with at least a 15 SPE rating.Previous studies have shown that the average American receives 50% of their lifetime sun exposure by age 18. Skin protection must begin at a very young age in order to be most successful.
Early detection is the surest way to a cure.
It is a simple routine to inspect your body for any skin changes. Actinic keratosis and each of the skin cancers depicted in the following pages can be readily detected. If any growth, moles, sore or discoloration appears suddenly or begins to change, see your dermatologist.
Precancerous skin conditions
In addition to the types of skin cancers illustrated here, be alert for a precancerous lesion called actinic keratosis. These small scaly spots are most commonly found on the face and back of the hands in fair-skinned individuals who have had significant sun exposure. If they are not treated, some of them may become skin cancer, requiring more extensive treatment. If they are diagnosed in the early stages, actinic keratosis can be removed by cryo-therapy (freezing), by applying a topical form of chemotherapy or by other outpatient procedures.
There are three forms of skin cancer:
Basal cell carcinoma
This tumor of the skin usually appears as a small, fleshy bump or nodule on the head, neck and hands. Occasionally these nodules may appear on the trunk of the body, usually as flat growths. Basal cell carcinomas seldom occur in dark-skinned persons; they are the most common skin cancers found in Caucasians. It has been found that people who have this cancer frequently have light hair, eyes and complexions, and they don’t tan easily. These tumors don’t spread quickly. It may take many months or years for one to reach a diameter of one half inch. Untreated, the cancer will begin to bleed, crust over, and then repeat the cycle.
Although this type of cancer rarely metastasizes (spreads to other parts of the body), it can extend below the skin to the bone and cause considerable local damage.
Squamous cell carcinoma
These tumors may appear as nodules or as red, scaly patches. Squamous cell carcinoma is the second most common skin cancer found in Caucasians. It typically is found on the rim of the ear, the face, the lips and mouth. It is rarely found on dark-skinned persons. This cancer will develop into large masses. Unlike basal cell carcinoma, it can metastasize. It is estimated that there are 2,300 deaths from non- melanoma skin cancers every year.
The cure rate for both basal cell and squamous cell carcinoma is 95 percent, when properly treated.
Malignant melanoma
It is projected that this most virulent of all skin cancers develops on the skin of 32,000 Americans annually. And every year an estimated 6,800 Americans will die from melanoma. It is important to note that the death rate is at last declining, because patients are seeking help earlier. Melanoma, like its less aggressive cousins, basal cell and squamous cell carcinomas, is almost always curable in its early stages.
Melanoma has its beginnings in melanocytes; the skin cells that produce the dark protective pigment called melanin. It is melanin that is responsible for suntanned skin, acting as partial protection against sun. Melanoma cells usually continue to produce melanin, which accounts for the cancers appearing in mixed shades of tan, brown and black. Melanoma has a tendency to spread, making it essential to treat.
Melanoma may suddenly appear without warning but it may also begin in or near a mole or other dark spot in the skin. For that reason it is important that we know the location and appearance of the moles on our bodies so any change will be noticed.
Excessive exposure to the sun, as with the other skin cancers, is accepted as a cause of melanoma, especially among light-skinned people. Heredity may play a part, and also atypical moles, which may run in families, can serve as markers, identifying the person as being at higher risk for developing melanoma there or elsewhere in the skin.
Dark brown or black skin is not a guarantee against melanoma. African-Americans can develop this cancer, especially on the palms of the hands, soles of the feet, under nails, or in the mouth.
Other warning signs include: changes in the surface of a mole; scaliness, oozing, bleeding or the appearance of a bump or nodule; spread of pigment from the border into surrounding skin; and change in sensation including itchiness, tenderness, or pain.
How skin cancer is treated
If a laboratory test reveals that an area of the skin is cancerous, the dermatologist has an array of procedures to choose from, dependent on the needs of the individual patient. In the treatment of any of the skin cancers, early detection and removal is the best defense.
Fortunately, skin cancers are relatively easy to detect and most can be cured. Even malignant melanoma, if caught in its early stages, can be treated successfully.
Dermatologists recommend that one helpful way to guard against melanoma/skin cancer is to do periodic self-examinations. Get familiar with your skin and your own pattern of moles, freckles and "beauty marks." Be alert to changes in the number, size, and shape and color of pigmented areas. If any changes are noticed call your dermatologist.
In addition to the types of skin cancers illustrated here, be alert for a precancerous lesion called actinic keratosis. These small scaly spots are most commonly found on the face and back of the hands in fair-skinned individuals who have had significant sun exposure. If they are not treated, some of them may become skin cancer, requiring more extensive treatment. If they are diagnosed in the early stages, actinic keratosis can be removed by cryo-therapy (freezing), by applying a topical form of chemotherapy or by other outpatient procedures.
This tumor of the skin usually appears as a small, fleshy bump or nodule on the head, neck and hands. Occasionally these nodules may appear on the trunk of the body, usually as flat growths. Basal cell carcinomas seldom occur in dark-skinned persons; they are the most common skin cancers found in Caucasians. It has been found that people who have this cancer frequently have light hair, eyes and complexions, and they don’t tan easily. These tumors don’t spread quickly. It may take many months or years for one to reach a diameter of one half inch. Untreated, the cancer will begin to bleed, crust over, and then repeat the cycle.
These tumors may appear as nodules or as red, scaly patches. Squamous cell carcinoma is the second most common skin cancer found in Caucasians. It typically is found on the rim of the ear, the face, the lips and mouth. It is rarely found on dark-skinned persons. This cancer will develop into large masses. Unlike basal cell carcinoma, it can metastasize. It is estimated that there are 2,300 deaths from non- melanoma skin cancers every year.
It is projected that this most virulent of all skin cancers develops on the skin of 32,000 Americans annually. And every year an estimated 6,800 Americans will die from melanoma. It is important to note that the death rate is at last declining, because patients are seeking help earlier. Melanoma, like its less aggressive cousins, basal cell and squamous cell carcinomas, is almost always curable in its early stages.