The role of surgery in dermatology

What is dermatologic surgery?

Dermatologic surgery is the treatment of medically necessary and cosmetic skin, nail, and hair conditions by various surgical methods. It is also called dermatological surgery.

Dermatologists are all trained in basic dermatologic surgery. Some dermatologists undergo additional training in advanced dermatologic surgery procedures. Non-dermatologists that may also perform skin surgery include plastic and reconstructive surgeons, otolaryngologists, ophthalmic surgeons, general surgeons and general practitioners.

What is dermatologic surgery used for?

Surgery is essential for the removal of skin cancers and suspected skin cancers, including:

• Melanoma
• Squamous cell carcinoma
• Many basal cell carcinomas
• Rare skin tumours

Mohs micrographic surgery is used to remove mid-facial skin cancers, especially if their margins are unclear or they are recurrent lesions.

Surgery is also used to remove benign growths that are causing a nuisance or are unsightly, such as large moles and seborrhoeic keratoses.

Cosmetic surgical procedures include:

• Dermabrasion
• Eyelid surgery
• Scar treatments such as subcision
• Hair replacement
• Liposuction
• Suction curettage for sweating

Dermatologic surgeons also employ non-surgical cosmetic techniques, such as:

• Laser resurfacing, tattoo removal, hair removal, and treatment of unwanted blood vessels
• Soft-tissue augmentation (fillers or implants)
• Chemical peels
• Platelet-rich plasma treatments
• Sclerotherapy

How is skin surgery carried out?

In most cases, dermatologic surgery can be undertaken using a local anaesthetic in a side room at the doctor’s office.

The most common procedure is a simple ellipse excision of a skin tumour, described here.

• A trolley is prepared with the instruments required for the procedure
• The procedure is explained to the patient
• The lesion may be photographed
• Surgical lines are marked out in an ellipse around the lesion, attempting to choose the direction of least skin tension
• Lidocaine/lignocaine is injected into the surrounding skin
• The skin is cleaned with surgical antiseptic and surgical cloths are applied
• The surgeon uses a scalpel to cut through the skin, following the marked lines
• The skin sample is removed and put in a pot containing buffered formalin
• Any bleeding is stopped using electrocautery
• One or more layers of sutures (stitches) are applied to hold the edges of the wound together
• A dressing is applied to the wound
• The request form is completed and sent with the labelled sample to a dermatopathology laboratory for reporting
• The patient is given instruction regarding care of the wound, removal of sutures, and follow-up

Sometimes an additional procedure is necessary to close the wound, such as a skin flap (skin taken from an adjacent area and moved to fill the surgical defect) or skin graft (skin taken from a distant area and placed on the surgical defect).

What are the possible complications of skin surgery?

Immediate complications include:

• Bleeding — especially in people with blood clotting abnormalities or on blood thinners
• Damage to important structures, such as sensory nerves, motor nerves or salivary glands
• Adverse reactions to medications used during surgery, such as local anaesthetics, non-non-steroidal anti-inflammatory drugs
• Difficulty in closing the wound

Delayed complications may include:

• Wound infection (1%)
• Wound breakdown
• Suture reactions
• Incomplete removal of skin lesion
• Delayed healing
• Persistent swelling
• Unsightly cosmetic result
• Diagnostic error