Dermatologists as surgeons

Jul 01, 2007, 4:00am

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These innovations have come in the form of new and powerful medications (isotretinoin, biologic agents for psoriasis, botulinum toxin), physical agents combined with medications (PUVA and photodynamic therapy with ALA or DHE), unique devices to help diagnose and manage poorly treated or untreatable conditions (digital photography with mole mapping software for dysplastic nevus patients, dermatoscopes for assessing pigmented lesions in vivo, pulsed dye lasers for port wine stains and rosacea, and noninvasive lasers and light sources for skin rejuvenation), and new surgical techniques (liposuction, Mohs surgery, leg vein closure and filler agents for treating scars and the signs of aging).

Derms as innovators

Perhaps no greater change in dermatology has occurred than in the area of dermatologic surgery. The incorporation of new techniques and innovative devices by dermatologists has not occurred in a vacuum. Rather, over the past 50 years, the individual efforts of a number of leading dermatologists (Leon Goldman, M.D.; Perry Robins, M.D.; Sam Stegman, M.D.; Ed Krull, M.D.; Ted Tromovitch, M.D.; Larry Fields, M.D.; Tom Alt, M.D.; and O'Tar Norwood, M.D., to name just a few) who made a sustained effort - and suffered much criticism from less-enlightened colleagues while doing so - to develop significant surgical expertise and skills in their own areas of interest, have helped set the stage for many of the newer surgical devices and techniques to achieve wide acceptance by dermatologists.

It is my personal opinion that the combination of longitudinal surgical training throughout dermatology residency training and subsequent procedural fellowships, grant-supported research in areas of dermatologic surgery, development of new surgical techniques, as well as expertise and skill in existing surgical procedures, has transformed the specialty of dermatology into one with specific and unique characteristics that qualify it to be called a surgical specialty.

To offer further proof to support this opinion, one should know that the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Dermatology (June 2004) require the "structured study ... (of the) ... principles that underlie dermatologic surgery."

More specifically, the ACGME document requires that surgical "training should be sufficient to ensure a knowledge of and competence in the performance of ... cryosurgery, dermatologic surgery, (and) laser surgery."

Furthermore, that "among these disciplines, dermatologic surgery should be given special emphasis in the organization of and implementation into the training program. The surgical training should be directed by faculty who have had advanced training in dermatologic surgery. Dermatologic surgical training should include appropriate anesthesia, electrosurgery, cryosurgery, laser surgery, nail surgery, biopsy techniques and excisional surgery with appropriate closures, including flaps and grafts when indicated."

There are also additional ACGME requirements for dermatology residents' surgical training. The program requirements state the following: "Residents should become familiar with hair transplantation, dermabrasion, sclerotherapy, laser resurfacing, liposuction, chemical peel and tissue augmentation. In addition, residents should gain experience with Mohs micrographic surgery. The physical modalities are especially notable, since an understanding of the basic properties of the electromagnetic spectrum is needed for the resident to become knowledgeable about the effects of various forms of this energy in the cause of disease and about their use in dermatologic diagnosis and therapy. Electron beam, X-ray and laser are among these modalities."

As you can see from the above, to become a board-certified dermatologist requires the assimilation of much surgical knowledge and the mastery of many surgical skills. This is only appropriate, since many skin diseases are only treatable with surgery, and surgery has long been a part of every dermatologist's training. Over the years, there have been a number of skin surgery textbooks authored by dermatologists. The journal Dermatologic Surgery, dedicated to publishing information on the latest advances in skin surgery, was founded by a dermatologist and continues to be edited by a dermatologist today.

Dermatologists have also made a number of revolutionary advances in skin surgery techniques and concepts that have been widely adopted by other surgical specialties. A few of these include: hair replacement surgery, dermabrasion, tumescent liposuction, chemical peels, laser therapy for a variety of skin disorders and diseases, sclerotherapy, fresh tissue Mohs micrographic surgery, moist wound healing, botulinum toxin denervation and tissue augmentation with a variety of filler substances.

I believe that dermatologists are among the most qualified physicians to perform skin surgery, and I anticipate the surgical aspects of dermatology training and practice will assume an even greater role in the specialty of dermatology over the coming years.