Growth in Skin Surgery C. WILLIAM HANKE, MD LISA A. FRANCIS, BS
kin surgery has undergone explosive growth in the specialty of dermatology especially since 1950. This abbreviated history begins with Mackee’s 50-year experience with chemical peels, which was reported in 1952. The history included in this chapter is not meant to be all-inclusive. Many important contributions and contributors have not been mentioned in the paragraphs that follow. We will attempt to include any omissions in future comprehensive historical reviews of skin surgery.
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Chemical Peels The art of peeling dates back to ancient times. Oils, salt, and alabaster were used by the early Egyptians to smooth and rejuvenate the skin. In modem times it is the dermatologist who has used chemical peeling to improve the appearance of skin. In 1903, the British dermatologist Mackee was the first to use phenol for acne scarring.’ LaGasse treated facial bum scars in 1918 in France.2 In 1941, Eller and Wolff studied and reported on the uses of phenol, resorcinol paste, sulfur, carbon dioxide snow, and phenol and salicylic acid combinations in various peels.3 They also studied the toxic effects of phenol on the kidneys. Phenol is one of the most commonly used peeling agents. In 1950 Winter used phenol to remove freckles, and in 1952 it was used by Mackee and Karp to correct acne scars.’ Another popular peeling agent was trichloroacetic acid (TCA). Trichloroacetic acid methods were described by Ayre$ and Monash5 during the 1960s. Brown and colleague@ and Litton’ also did studies on different formulas. From the Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana. Address correspondence to C. WilliamHanke, MD, 550 N. University Blvd., Indianapolis, IN 46202-5267.
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Baker of Miami was instrumental in making modemday peeling the acceptable procedure it has become.* In 1961, Baker studied different combinations of caustics used in peeling, analyzed the various toxicities, and documented the formulas that produce the greatest benefit to the patient. The 1980s brought forth the work of Stegman, who compared the histological depths of different peeling agents and of dermabrasion techniques.g,10 This work allowed dermatologists to better control the depth of the peels performed. In 1992, Harold J. Brody published a classic book entitled Chemical Peeling.”
Dermabrasion The first dermatologist in modem times to formulate a method of skin abrasion was the German physician Kromayer. In 1905, he first reported on this new treatment for postacne scarring. 12-15Kromayer’s many accomplishments in the field of dermabrasion included the recommendation to use carbon dioxide snow to firm and anesthetize the skin, the development of skin punches, and the concept of power-driven instruments.16 There was little interest in Kromayer’s new technique until 1928 when Stein used Kromayer’s method.” That same year, dental drills were used by Shie to remove tattoos.18 Tattoos were also removed by abrading with a stiff-bristled brush by Janson in 1935.19 In 1947, Iverson (an American general plastic surgeon) used common sandpaper (grid size 0 or 00) to remove traumatic tattoos of the face.*O In September 1953, he reported the implementation of this technique to treat postacne scarring. ** The procedure had less than favorable results; blood covered the surgical field and the sandpaper left small pieces of silica embedded in the skin, causing silica granulomas. McEvitt also used sandpaper abrasion (1948) for the treatment of acne scars.** He noted that the sharp, punched-out scars
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responded well to abrasion, whereas the deeper scars did not. Rosenberg was the first dermatologist to use this technique. 23 In 1952, he sanded an accidental facial tattoo. After 1 year, no scarring was evident and any residual pigmentation was not visible. Shortly after Iverson reintroduced sandpaper abrasion to the medical community, Kurtin, an American dermatologist, introduced the use of modified power-driven dental instruments and skin refrigerants to aid in dermabrasion.24 He, along with Robbins, produced the wire brushes, used in the early dermabrasions. Robbins founded the Robbins Instrument Company and marketed dermabrasion instruments including the wire brushes and diamond fraises that originated in the practices of Luikart, Ayres, and Wilson in 1957. Aside from the correction of scars, dermabrasion has been used to treat recurrent acne, neurofibromas, precancerous skin, blast tattoos,25 and other benign and malignant tumors. 26 Yarborough has been able to erase traumatic scars by early intervention with dermabrasion.27
Hair
Restoration
Because hereditary baldness affects over one half of adult males, hair transplantation is a common surgical procedure for men. The first successful hair transplants were performed by the Japanese dermatologist Okuda in 1939.*a He died during World War II and his work, published in TheJapanese Journal of Dermatology and TheJapanese Journal of Dermafology and Urology, was overlooked by western physicians until it was found by the German physician Friederich in 1970.29 Unaware of Okuda’s work, Orentreich popularized the autologous hair transplant technique in 1959 when he realized that hair taken from a donor area and transplanted to a bald area exhibited the characteristics of its original site. 3o He experimented with various autografts and found that in all cases, a hair-bearing graft transplanted to a hair-growing site continued to grow hair, a hair-bearing graft transplanted to a bald site grew hair, and a bald graft transplanted anywhere remained bald. This is known as Orentreich’s theory of donor dominance. Occasionally, a hair transplant patient will not have enough hair-bearing scalp to harvest donor grafts sufficient to cover a large balding area. In these cases, alternate methods must be used. In 1977, Blanchard and Blanchard published the first paper on correcting baldness by the removal of bald scalp. 31 Their work went unnoticed be-
Clinics in Dermatology 1992;10:257-263 cause of the low circulation rate of The ]ournaZ of the National Medical Association. At about the same time the Blanchards began working with scalp reduction, Walter and Martin Unger also began excising bald areas (spring 1976).32 After treating 60 men with alopecia in this manner, they submitted their findings for publication to the Journal of Plastic and Reconstructive Surgery in October of 1977. Their paper was rejected on the grounds the subject matter was “nothing new or important.” The following year, the Ungers presented their work on scalp reduction at the Annual Clinical and Scientific Meeting of the American Society for Dermatologic Surgery, and the same paper, previously rejected, was submitted to theJournal of Dermatologic Surgery and Oncology and published in September 1978.33 Others (Bosley, Sparkuhl, Stough, and Webster) had been using the same approach, but failed to publish. Regardless of the opinion of the editors of the Journal of Plastic and Reconstructive Surge y, scalp reduction has become an important addition to the treatment of alopecia. There have been a number of improvements in hair transplantation over the last several years that have greatly enhanced results. These include the advent of minigrafts and micrografts, the use of saline infiltration to make the donor site firm, donor site closure techniques, the application of the power punch, and the invention of carbon -steel punches. A minigraft is a small graft containing between three and eight hairs. Minigrafts are used to soften the abrupt hairline created when standard-sized grafts are used, A micrograft is a graft of one or two hairs transplanted to further create a natural appearance. Richard C. Shiell developed the micrograft technique in 1972 when he noted that 4-mm grafts could be dissected into units of one or two hairs apiece. In 1983, Bradshaw extended this technique to include minigrafts of three to eight hairs.34 One of the most important advancements in hair transplantation is the use of saline to firm the donor site. The donor site, after the infiltration of saline, resists the distortion caused by the pressure exerted by the punch. This prevents “lipping” and cone-shaped grafts.35 There are many different opinions on the advantages and methods of donor site closure. Originally, donor sites were allowed to heal by second intention, which left round, hypopigmented scars. There are many harvesting and closure techniques in current use by dermatologic surgeons. The advent of the power punch was another breakthrough in hair transplantation. The torque of the power punch greatly reduces the compression that occurs when using a hand punch. The resultant graft is smoother and
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specific for one of the absorption bands of hemoglobin (the one farthest from that of melanin).
Mohs Micrographic Surgery (Chemosurgery) Lasers In 19 17, Einstein proposed the theory of the laser using his principles of stimulated and spontaneous emission and absorption. 36When a state of excitement exists for an atom or a molecule and then it returns to a nonexcited state, it gives off a photon of energy that has a precise wavelength. When this photon collides with another excited atom or molecule, the atom or molecule will return to a nonexcited state and emit another photon that is synchronized with the incoming photon. These two photons collide with two more photons in a natural logarithmic fashion. Soon, many collimated, coherent, monochromatic photons are released. This gives rise to the laser beam.37 In 1958, Schawlow of Bell Telephone Laboratories and Townes of Columbia University proposed a way to create the first practical laser based on Einstein’s theory.38 It was not until 1960 that Maimon of Hughes Aircraft produced the first working ruby laser.39 Goldman, a dermatologist at the University of Cincinnati, was the first physician to apply Maimon’s laser to medicine and surgery. Goldman is known as the “father of laser medicine and surgery.” 4o The ruby laser, with a wavelength of 694 nm, was first used to remove tattoos and pigmented lesions by Goldman in 1961. The year 1964 saw the advent of the argon, krypton, and xenon lasers. The argon laser uses two wavelengths, 488 and 514 nm, to produce a blue-green light. The argon laser is instrumental in the resolution of vascular and other pigmented lesions. In 1965, Pate1 of Bell Laboratories introduced the CO, laser.41 In 1968, Polanyi and colleagues adapted the CO1 laser by adding mirrors and articulating arms to use this laser for cutting applications.42 The concept of the flashlamp-pumped pulsed dye laser (PDL) was developed by Parrish and Anderson in the early 1980s. Furamoto founded Candela and built the first PDL at Harvard. From 1983 to 1985, clinical trials in which the laser was tested for its efficacy in the treatment of vascular lesions were performed. The first patients were treated in 1984 by Oon Tian Tan at Harvard. The PDL was approved by the U.S. Food and Drug Administration (FDA) in 1988. The pulsed dye laser has been most valuable for the treatment of vascular lesions such as the port-wine birthmark. The wavelength of this laser is 585 nm, which is
In the early 193Os, Frederic E. Mohs was a medical student working as a research assistant with Professor Michael F. Guyer at the University of Wisconsin in the Department of Zoology. While performing an experiment on the differences in inflammatory reactions caused by irritants injected into cancerous tissue and normal tissue, Mohs and Guyer noticed that one of the irritants, a 20% solution of zinc chloride, caused tissue necrosis and produced fixation in situ with the same results that would have occurred had the tissue been surgically removed and later fixed in vitr~.~~ For the Brst time, a feasible approach to microscopically controlled surgery for cancer was available. After much thought and trial and error, the idea to examine microscopically the undersurface of each horizontally cut layer led to what is now known as Mohs micrographic surgery. Cancerous tissue is divided into small pieces whose nonepidermal edges are color-coded with different colored dyes. The orientation of the pieces, along with codes for the dyes, are mapped onto a sketch of the surgical site. During microscopic examination of the sections, the dyed edges and the epidermal edge of the piece of tissue allow the surgeon to align the specimen with the map. The remaining cancerous tissue is marked on the map and serves as a guide when the next surgical stage is performed. This procedure is repeated until no cancer remains. Mohs is known primarily for the fixation of tissue in situ before removal; however, in 1953, Mohs demonstrated the usefulness of the fresh-tissue technique when performing surgery on eyelid margins.” Occasionally, zinc chloride would irritate the eye when used on eyelid margins. Omission of the fixative (hence “fresh-tissue technique”) alleviated this problem. Mohs only extended the fresh-tissue technique to various eyelid tumors. In the 1960s Tromovitch began searching for a method that would eliminate the excruciating pain the zinc chloride fixative caused his patients. Tromovitch began omitting the fixative completely. Each year he increased the percentage of cases using the freshtissue method, finding that the cure rate was equal to that using the fixative. He presented his findings at the Annual Meeting of the American College of Chemosurgery in 1970. When Tromovitch and his colleague Stegman published their results on the advantages of the fresh-tissue technique applied to skin cancers located anywhere
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on the body, this procedure began to receive widespread acceptance.45 Stegman and Tromovitch called their method microscopically controlled excision (MCE). This fresh-tissue method of Mohs surgery eliminates the patient discomfort caused by zinc chloride, prevents the fixation of normal tissue at the surgical margin, and greatly increases the speed of complete removal of the cancerous tissue, as each time a stage is fixed with zinc chloride, it can take 24 hours.46 In 1967, the American College of Chemosurgery was formed and the first meeting held in December, preceding the meeting of the American Academy of Dermatology. Because of the widespread use of the fresh-tissue technique, the term chemosurgey no longer accurately described the procedure. The name of the college was changed in 1986 to The American College of Mohs Micrographic Surgery and Cutaneous Oncology, and the technique became known as Mohs micrographic surgery (MMS) or simply Mohs surgey.47 The first use of the term Mohs micrographic surgery occurred in an article by Hanke et al in 1985.48
Tissue Augmentation Injectable collagen, known by the trade names Zyplast and Zyderm, was developed in the early 19 70s by Rodney Perkins, John Daniels, Edward Lock, and Terrence Knapp at Stanford University. Under the consultative guidance of Samuel J. Stegman, the Collagen Corporation of Palo Alto, California, began manufacturing these products. Zyderm is manufactured from bovine dermis in two forms: Zyderm I and Zyderm II. Zyderm I (35 mg/ml) received FDA approval in 1981 and is used primarily for superficial wrinkle lines. Zyderm II (65 mg/ml) was approved in 1983 and is used for soft postacne scars and wrinkles. Zyplast, a form that is crosslinked with glutaraldehyde, was approved in 1985 and is used for deeper wrinkles, furrows, and scars. Fibrel is the end result of more than 20 years of research on fibrin foam by Spangler.4g,50 A porcine collagen derivative, Fibrel is used in much the same way as Zyplast. Fibrel is marketed by the Mentor Corporation of Santa Barbara, California. It received FDA approval in 1988 for use in scars and in 1990 for use in wrinkles.51 Free-fat grafts were first used by Neuber in 1893 to reconstruct a facial defect.52 The survival rate for these grafts was anywhere from 30% to 80%. The 1940s saw the use of dermal-fat grafts and artificial tissue augmentation agents (silicone, paraffin); autologous fat transplantation was no longer used. Because of the recent success of liposuction, autologous fat transplantation has regained popularity in the
correction of wrinkles and scars. In 1985, Illouz began using the fat extracted during liposuction to correct body contouring defects.53 Ottani and Fournier found that adding distilled water to the fat cells and then freezing caused the cells to become disrupted. 54 The fatty part of the cell fraction was removed. The cell membrane and interstitial tissue remained. This cell fraction is a rich source of autologous collagen, which can be used in much the same way porcine- or bovine-derived collagen is used, with little risk of allergic reaction.
Liposuction In 1929, the French surgeon Dujarrier was the first to attempt the removal of fat to improve cosmetic appearance.55 This crude precursor to what is now known as liposuction involved using a curette to dislodge the fat. His first patient was a dancer who wished to have slimmer calves. The result was less than favorable: one of the dancer’s legs needed to be amputated because of the damage to the blood vessels and underlying tissue. Although others attempted surgical removal of fat throughout the 20th century, little progress was made until 1975 when Arpard and Giorgio Fischer, a father and son team of aesthetic surgeons from Rome, Italy, introduced the first device for suctioning fat, which they called a “cellusuctiotome.” 56This instrument used a curette and a suction device to cut through and remove fat. They first demonstrated this technique at a meeting of the Intemational Academy of Cosmetic Surgery in 1977. Illouz of Paris learned of the Fischers’ work and proceeded to make modifications, the most important being the use of a blunt-tipped cannula instead of the sharp curette.57,58 Illouz also promoted the use of the “wet technique,“ which involves injecting the fat with various fluids and tunneling through the fat. These modifications greatly reduced bleeding, the chance of hematoma and seroma formation, and surface irregularities. Pierre F. Fournier, also in Paris, advocated the “crisscross” tunneling pattern. This minimized surface inconsistencies. A major breakthrough in liposuction technology came in 1987 with Klein’s description of the tumescent technique.5g Klein showed that using a dilute (0.1% or 0.05%) lidocaine solution with epinephrine (1: l,OOO,OOO) slowed the absorption rate of the local anesthetic so that the total doses given were in excess of five times the traditional “safe” doses. Increased doses of anesthetic enable large volumes of solution to be infiltrated into the subcutaneous fat. The large volume of fluid causes the tissue to swell and firm (i.e., tumescence). Capillary vasoconstriction is also achieved when this method is used.
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This allows liposuction to be an almost completely bloodless technique. The consequences of this discovery allow for a much larger amount of fat to be suctioned at one time. There is less pain for the patient, and the procedure can be done as an outpatient procedure. Liposuction under local anesthesia has been shown to be extremely safe.60
1986
Appendix: Important Milestones in Dermatologic Surgery
1987
1952 1953 1959 1961 1967 1970
1973 975 1 976 1’977
1979
1980
1981
1982
G. M. Mackee reports on his 50-year experience with chemical peels. Abner Kurtin introduces power-driven wire brushes for use in dermabrasion. Norman Orentreich transplants hair to correct androgenetic alopecia. Leon Goldman becomes the first physician to use a laser in medicine to treat patients. The American College of Chemosurgery (ACC) is founded by Frederic E. Mohs. The American Society for Dermatologic Surgery (ASDS) is founded; the first president elected is Norman Orentreich. Theodore A. Tromovitch and Samuel J. Stegman report on the Fresh Tissue Technique for Chemosurgery (Mohs micrographic surgery). The first one-year fellowship in Mohs chemosurgery is established at New York University by Perry Robins. First fellow: Henry Menn. The first ASDS annual meeting is held in San Francisco. TheJournal of Dermatologic Surgery and Oncology is founded by Perry Robins. Sheldon Gottlieb develops Fibrel. Lawrence A. Field becomes the first American physician to visit France to study liposuction. The International Society for Dermatologic Surgery (ISDS) is founded by Perry Robins. The American Society for Dermatologic Surgery contracts with Dermatology Services, Inc. for administrative support. Samuel J. Stegman becomes consultant to the Collagen Corporation for Zyderm. The Department of Dermatology at the University of Miami becomes the Department of Dermatology and Cutaneous Surgery. TheJournal of Dermatologic Surgery and Oncology becomes the official publication of the American Society for Dermatologic Surgery. The American Society for Dermatologic Surgery Core Curriculum for Dermatologic Surgery is developed by Edward A. Krull.
1988
1990
1991
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The American Society for Dermatologic Surgery submits an application for a seat in the American Medical Association House of Delegates. Pierre Fournier introduces the concept of microlipoinjection at the ASDS annual meeting in Palm Springs, California. The first Goldman award is presented by American Society for Dermatologic Surgery. The first recipient is Leon Goldman. The American Society for Dermatologic Surgery joins the National Council for Medicine, Surgery and Dentistry. Jeffery A. Klein develops the tumescent local anesthetic technique for liposuction. The American Society for Dermatologic Surgery Core Curriculum is revised by C. William Hanke. The American Society for Dermatologic Surgery becomes a member of the American Medical Association House of Delegates. The American Society for Dermatologic Surgery is seated in the American Medical Association House of Delegates. Edward A. Km11 founds the Association of Academic Dermatologic Surgeons (AADS). The first meeting is held in October 1989. The American Society for Dermatologic Surgery 20th Anniversary Issue of The Journal of Dermatologic Surge y and Oncology is published. Tromovitch and Stegman both die prematurely. Elsevier Science Publishing Company, Inc., acquires the publishing rights for the Journal of Dermatologic Surge y and Oncology. Thomas H. Alt is the first dermatologist elected President of the American Academy of Cosmetic Surgery (AACS). The third revision of the American Society for Dermatologic Surgery Core Curriculum is revised by Tom Meek (American Society for Dermatologic Surgery) and C. William Hanke (Association of Academic Dermatologic Surgeons) .
References 1. Mackee GM, Karp FL. The treatment of post acne scars with phenol. Br J Dermatol 1952;64:456-9. 2. Gross BG, Maschek F. Phenol chemosurgery for removal of deep facial wrinkles. Int J Dermatol 1980;19:159-64. 3. Eller JJ, Wolff S. Skin peeling and scarification in treatment of pitted scars, pigmentations and certain facial blemishes. JAMA 1941;116:934-8.
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in treating aging skin, 4. Ayres S. Superficial chemosurgery Arch Dermatol 1962;82:125. 5. Monash S. The uses of diluted trichloroacetic acid in dermatology. Urol Cutan Rev 1945;49:119. 6. Brown AM, Kaplan LM, Brown logical skin changes: Hazards, Plast Surg 1960;13:158. 7. Litton C. Chemical 1962;29:371.
face
ME. Phenol induced histotechniques, and uses. Br J
lifting.
8. Baker TJ. Chemical face peeling Reconstr Surg 1962;29:199.
Plast
Reconstr
and rhytidectomy.
Surg Plast
9. Stegman SJ. A study of dermabrasion and chemical peels in an animal model. J Dermatol Surg Oncol 1980;6:490. 10. Stegman SJ. A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 1982;6:123. 11. Brody HJ. Chemical peeling. St. Louis: Mosby Year Book, 1992:1-4. 12. Kromayer E. Rotationsinstrumente: Ein neues technisches Verfahren in der dermatologischen Kleinchirurgie. Dermato1 Z 1905;12:26-36. 13. Kromayer E. Die Heilung der Akne durch ein neues narbenloses Operationsverfahren: Das Stanzen. Illustr Monatsschr Aerztl Polytech 1905;27:101. 14. Kromayer E. Die Heilung der Akne durch ein neues narbenloses Operationsverfahren: Das Stanzen. Munchen Med Wochenschr 1905;52:942-4.
25. Hanke CW, Conner AC, Probst EL Jr. Blast tattoos resulting from black powder firearms. J Am Acad Dermatol 1987;17:819-25. 26. Hanke CW, Conner AC, Reed JC. Treatment of multiple facial neurofibromas with dermabrasion. J Dermatol Surg Oncol 1987;13:631-7. 27. Yarborough JM Jr. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol 1988;14:292-4. 28. Okuda S. Clinical and experimental studies on transplanting of living hair. Jpn J Dermatol Urol 1939;46:135-8. 29. Unger MG. Alopecia reduction: Scalp reduction. In: Unger WI’, Nordstrom REA, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988;1-3. 30. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann NY Acad Sci 1959;83:465. 31. Blanchard G, Blanchard B. Obliteration of alopecia by hairlifting: A new concept and technique. J Nat1 Med Assoc 1977;69:639-41. 32. Unger MG, Unger WI’. Management of alopecia of the scalp by a combination of excisions and transplantations. J Dermatol Surg Oncol 1978;4:670-2. 33. Orentreich D, Orentreich N. Androgenetic alopecia and its treatment. In: Unger WI’, Nordstrom REA, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988;435-6. 34. Norwood OT, Shiell RC. Hair transplant Springfield: Charles C Thomas, 1984;107.
surgery,
ed 2.
15. Kromayer E. Eine neue sichere Epitationsmethode: Das Stanzen. Dtsch Med Wochenschr 1905;31:179-80. 16. Alt TH, Coleman WE’ III, Hanke CW, Yarborough JM. Dermabrasion. In: Coleman WP III, Hanke CW, Alt TH, Asken S, editors. Cosmetic surgery of the skin. Philadelphia: BC Decker, 1991;147-9.
35. Pinski JB. How to obtain the “perfect” plug. J Dermatol Surg Oncol 1984;10:12. 36. Einstein A. Zur Quantum Theorie der Strahlung. Whys 1917;18:121.
17. Stein RO. Therapeutische Technizismen. Arch Dermatol Syph 1928;155:304. 18. Shie MD. Study of tattooing and methods for its removal. JAMA 1928;90:94-9. 19. Janson P. Eine einfache Methode der Entfemung von Tatowierungen. Dermatol Wochenschr 1935;101:894-5.
38. Schawlow AL, Townes CH. Infrared and optical masers. Phys Rev 1958;112:1940. 39. Maimon TH. Stimulated optical radiation in ruby. Nature 1960;187:493. 40. Choy DSJ. History of lasers in medicine. Thorac Cardiovasc Surgeon 1988;2:114-7. 41. Pate1 CKN. High-power carbon dioxide Lasers. Sci Am 1968;219:23. 42. Polanyi TG, Bredemeier HC, Davis TW. A CO2 laser for surgical research. Med Biol Eng 1970;8:5418. 43. Mohs FE, Guyer MF. Pre-excisional fixation of tissues in the treatment of cancer in rats. Cancer Res 1941;1:49-51. 44. Mohs FE. Chemosurgery: Microscopically controlled surgery for skin cancer. Springfield: Charles C Thomas, 1978;106-9. 45. Tromovitch TA. Mohs surgery, fresh-tissue technique. In: Commentary: The evolution of Mohs’ surgery. J Dermatol Surg Oncol 1982;8:651-3.
20. Iverson PC. Surgical removal of traumatic face. Plast Reconstr Surg 1947;2:427-32.
tattoos of the
21. Iverson PC. Further developments in the treatment of skin lesions by surgical abrasion. Plast Reconstruct Surg 1953;12:27-40. 22. McEvitt WG. Acne pits: Supposed hopeless disfigurement. J Mich Med Sot 1948;47:1243-4. 23. Rosenberg WA. Accidental tattooing Arch abrasion with sandpaper. 1952;65:466-70. 24. Kurtin A. Corrective surgical planning matol Syph 1953;68:389-97.
of face treated by Dermatol Syph of skin. Arch
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37. Garden JM, Geronemus RG. Dermatologic Dermatol Surg Oncol 1990;16:156-68.
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46. Tromovitch TA, Stegman SJ. Microscopically controlled excision of skin tumors. Arch Dermatol 1974;110:231-2. 47. Bernstein G, Cottel WI, Bailin PL, et al. Mohs micrographic surgery (editorial). J Dermatol Surg Oncol 1987;13:1. 48. Hanke CW, Temofeew RK, Miyamoto RT, Lingeman RE. Basal cell carcinoma involving the external auditory canal -Treatment with Mohs micrographic surgery. J Dermatol Surg Oncol 1985;11:1189-94. 49. Spangler AS. New treatment for pitted scars. Arch Dermato1 1957;76:708. 50. Spangler AS. Treatment of depressed scars with fibrin foam-Seventeen years of experience. J Dermatol Surg Oncol 1975;1:65. 51. Coleman WP III, Hanke CW, Ah TH, Asken S. Cosmetic surgery of the skin. Philadelphia: BC Decker, 1991;97. 52. Neuber F. Fettransplantation. Chir Kongr Verhandl Dtsch Gesellsch Chir 1893;22:66. 53. Illouz YG. The fat cell “graft”: A new technique pressions. Plast Reconstr Surg 1986;78:122.
to fiI1 de-
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54. Ottani F, Foumier P. A history and comparison of suction techniques until their debut in North America. In: Hetter G, editor. Lipoplasty: The theory and practice of blunt suction lipectomy. Boston: Little, Brown, 1984;19 -23. 55. Asken S. Liposuction Surgery and Autologous Fat Transplantation. Norwalk, CT: Appleton & Lange, 1988;1-2. 56. Fischer A, Fischer GM. Revised techniques for cellulitis fat: Reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977;2:40. 57. Illouz YG. Un nouveau traitement chirurgical sur les lipodistrophies localisees. Presentations at the Societe Francaise de Chirurgie Esthetique, June 1978 and 1979. 58. Illouz YG. Une nouvelle technique pour les lipodistrophies local&es. Rev Chir Esth Langue Fr 1980;6:3. 59. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermato1 Surg Oncol 1990;16:248-63. 60. Bernstein G, Hanke CW. Safety of liposuction: A review of 9478 cases performed by dermatologists. J Dermatol Surg Oncol 1988;14:1112-4.
kin surgery has undergone explosive growth in the specialty of dermatology especially since 1950. This abbreviated history begins with Mackee’s 50-year experience with chemical peels, which was reported in 1952. The history included in this chapter is not meant to be all-inclusive. Many important contributions and contributors have not been mentioned in the paragraphs that follow. We will attempt to include any omissions in future comprehensive historical reviews of skin surgery.
S
Chemical Peels The art of peeling dates back to ancient times. Oils, salt, and alabaster were used by the early Egyptians to smooth and rejuvenate the skin. In modem times it is the dermatologist who has used chemical peeling to improve the appearance of skin. In 1903, the British dermatologist Mackee was the first to use phenol for acne scarring.’ LaGasse treated facial bum scars in 1918 in France.2 In 1941, Eller and Wolff studied and reported on the uses of phenol, resorcinol paste, sulfur, carbon dioxide snow, and phenol and salicylic acid combinations in various peels.3 They also studied the toxic effects of phenol on the kidneys. Phenol is one of the most commonly used peeling agents. In 1950 Winter used phenol to remove freckles, and in 1952 it was used by Mackee and Karp to correct acne scars.’ Another popular peeling agent was trichloroacetic acid (TCA). Trichloroacetic acid methods were described by Ayre$ and Monash5 during the 1960s. Brown and colleague@ and Litton’ also did studies on different formulas. From the Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana. Address correspondence to C. WilliamHanke, MD, 550 N. University Blvd., Indianapolis, IN 46202-5267.
0 2992 by Elsevier Science Publishing
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0738-081x/92/$5.00
Baker of Miami was instrumental in making modemday peeling the acceptable procedure it has become.* In 1961, Baker studied different combinations of caustics used in peeling, analyzed the various toxicities, and documented the formulas that produce the greatest benefit to the patient. The 1980s brought forth the work of Stegman, who compared the histological depths of different peeling agents and of dermabrasion techniques.g,10 This work allowed dermatologists to better control the depth of the peels performed. In 1992, Harold J. Brody published a classic book entitled Chemical Peeling.”
Dermabrasion The first dermatologist in modem times to formulate a method of skin abrasion was the German physician Kromayer. In 1905, he first reported on this new treatment for postacne scarring. 12-15Kromayer’s many accomplishments in the field of dermabrasion included the recommendation to use carbon dioxide snow to firm and anesthetize the skin, the development of skin punches, and the concept of power-driven instruments.16 There was little interest in Kromayer’s new technique until 1928 when Stein used Kromayer’s method.” That same year, dental drills were used by Shie to remove tattoos.18 Tattoos were also removed by abrading with a stiff-bristled brush by Janson in 1935.19 In 1947, Iverson (an American general plastic surgeon) used common sandpaper (grid size 0 or 00) to remove traumatic tattoos of the face.*O In September 1953, he reported the implementation of this technique to treat postacne scarring. ** The procedure had less than favorable results; blood covered the surgical field and the sandpaper left small pieces of silica embedded in the skin, causing silica granulomas. McEvitt also used sandpaper abrasion (1948) for the treatment of acne scars.** He noted that the sharp, punched-out scars
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responded well to abrasion, whereas the deeper scars did not. Rosenberg was the first dermatologist to use this technique. 23 In 1952, he sanded an accidental facial tattoo. After 1 year, no scarring was evident and any residual pigmentation was not visible. Shortly after Iverson reintroduced sandpaper abrasion to the medical community, Kurtin, an American dermatologist, introduced the use of modified power-driven dental instruments and skin refrigerants to aid in dermabrasion.24 He, along with Robbins, produced the wire brushes, used in the early dermabrasions. Robbins founded the Robbins Instrument Company and marketed dermabrasion instruments including the wire brushes and diamond fraises that originated in the practices of Luikart, Ayres, and Wilson in 1957. Aside from the correction of scars, dermabrasion has been used to treat recurrent acne, neurofibromas, precancerous skin, blast tattoos,25 and other benign and malignant tumors. 26 Yarborough has been able to erase traumatic scars by early intervention with dermabrasion.27
Hair
Restoration
Because hereditary baldness affects over one half of adult males, hair transplantation is a common surgical procedure for men. The first successful hair transplants were performed by the Japanese dermatologist Okuda in 1939.*a He died during World War II and his work, published in TheJapanese Journal of Dermatology and TheJapanese Journal of Dermafology and Urology, was overlooked by western physicians until it was found by the German physician Friederich in 1970.29 Unaware of Okuda’s work, Orentreich popularized the autologous hair transplant technique in 1959 when he realized that hair taken from a donor area and transplanted to a bald area exhibited the characteristics of its original site. 3o He experimented with various autografts and found that in all cases, a hair-bearing graft transplanted to a hair-growing site continued to grow hair, a hair-bearing graft transplanted to a bald site grew hair, and a bald graft transplanted anywhere remained bald. This is known as Orentreich’s theory of donor dominance. Occasionally, a hair transplant patient will not have enough hair-bearing scalp to harvest donor grafts sufficient to cover a large balding area. In these cases, alternate methods must be used. In 1977, Blanchard and Blanchard published the first paper on correcting baldness by the removal of bald scalp. 31 Their work went unnoticed be-
Clinics in Dermatology 1992;10:257-263 cause of the low circulation rate of The ]ournaZ of the National Medical Association. At about the same time the Blanchards began working with scalp reduction, Walter and Martin Unger also began excising bald areas (spring 1976).32 After treating 60 men with alopecia in this manner, they submitted their findings for publication to the Journal of Plastic and Reconstructive Surgery in October of 1977. Their paper was rejected on the grounds the subject matter was “nothing new or important.” The following year, the Ungers presented their work on scalp reduction at the Annual Clinical and Scientific Meeting of the American Society for Dermatologic Surgery, and the same paper, previously rejected, was submitted to theJournal of Dermatologic Surgery and Oncology and published in September 1978.33 Others (Bosley, Sparkuhl, Stough, and Webster) had been using the same approach, but failed to publish. Regardless of the opinion of the editors of the Journal of Plastic and Reconstructive Surge y, scalp reduction has become an important addition to the treatment of alopecia. There have been a number of improvements in hair transplantation over the last several years that have greatly enhanced results. These include the advent of minigrafts and micrografts, the use of saline infiltration to make the donor site firm, donor site closure techniques, the application of the power punch, and the invention of carbon -steel punches. A minigraft is a small graft containing between three and eight hairs. Minigrafts are used to soften the abrupt hairline created when standard-sized grafts are used, A micrograft is a graft of one or two hairs transplanted to further create a natural appearance. Richard C. Shiell developed the micrograft technique in 1972 when he noted that 4-mm grafts could be dissected into units of one or two hairs apiece. In 1983, Bradshaw extended this technique to include minigrafts of three to eight hairs.34 One of the most important advancements in hair transplantation is the use of saline to firm the donor site. The donor site, after the infiltration of saline, resists the distortion caused by the pressure exerted by the punch. This prevents “lipping” and cone-shaped grafts.35 There are many different opinions on the advantages and methods of donor site closure. Originally, donor sites were allowed to heal by second intention, which left round, hypopigmented scars. There are many harvesting and closure techniques in current use by dermatologic surgeons. The advent of the power punch was another breakthrough in hair transplantation. The torque of the power punch greatly reduces the compression that occurs when using a hand punch. The resultant graft is smoother and
Clinics in Dermatology 1992;10:257-263
more cylindrical licles.
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specific for one of the absorption bands of hemoglobin (the one farthest from that of melanin).
Mohs Micrographic Surgery (Chemosurgery) Lasers In 19 17, Einstein proposed the theory of the laser using his principles of stimulated and spontaneous emission and absorption. 36When a state of excitement exists for an atom or a molecule and then it returns to a nonexcited state, it gives off a photon of energy that has a precise wavelength. When this photon collides with another excited atom or molecule, the atom or molecule will return to a nonexcited state and emit another photon that is synchronized with the incoming photon. These two photons collide with two more photons in a natural logarithmic fashion. Soon, many collimated, coherent, monochromatic photons are released. This gives rise to the laser beam.37 In 1958, Schawlow of Bell Telephone Laboratories and Townes of Columbia University proposed a way to create the first practical laser based on Einstein’s theory.38 It was not until 1960 that Maimon of Hughes Aircraft produced the first working ruby laser.39 Goldman, a dermatologist at the University of Cincinnati, was the first physician to apply Maimon’s laser to medicine and surgery. Goldman is known as the “father of laser medicine and surgery.” 4o The ruby laser, with a wavelength of 694 nm, was first used to remove tattoos and pigmented lesions by Goldman in 1961. The year 1964 saw the advent of the argon, krypton, and xenon lasers. The argon laser uses two wavelengths, 488 and 514 nm, to produce a blue-green light. The argon laser is instrumental in the resolution of vascular and other pigmented lesions. In 1965, Pate1 of Bell Laboratories introduced the CO, laser.41 In 1968, Polanyi and colleagues adapted the CO1 laser by adding mirrors and articulating arms to use this laser for cutting applications.42 The concept of the flashlamp-pumped pulsed dye laser (PDL) was developed by Parrish and Anderson in the early 1980s. Furamoto founded Candela and built the first PDL at Harvard. From 1983 to 1985, clinical trials in which the laser was tested for its efficacy in the treatment of vascular lesions were performed. The first patients were treated in 1984 by Oon Tian Tan at Harvard. The PDL was approved by the U.S. Food and Drug Administration (FDA) in 1988. The pulsed dye laser has been most valuable for the treatment of vascular lesions such as the port-wine birthmark. The wavelength of this laser is 585 nm, which is
In the early 193Os, Frederic E. Mohs was a medical student working as a research assistant with Professor Michael F. Guyer at the University of Wisconsin in the Department of Zoology. While performing an experiment on the differences in inflammatory reactions caused by irritants injected into cancerous tissue and normal tissue, Mohs and Guyer noticed that one of the irritants, a 20% solution of zinc chloride, caused tissue necrosis and produced fixation in situ with the same results that would have occurred had the tissue been surgically removed and later fixed in vitr~.~~ For the Brst time, a feasible approach to microscopically controlled surgery for cancer was available. After much thought and trial and error, the idea to examine microscopically the undersurface of each horizontally cut layer led to what is now known as Mohs micrographic surgery. Cancerous tissue is divided into small pieces whose nonepidermal edges are color-coded with different colored dyes. The orientation of the pieces, along with codes for the dyes, are mapped onto a sketch of the surgical site. During microscopic examination of the sections, the dyed edges and the epidermal edge of the piece of tissue allow the surgeon to align the specimen with the map. The remaining cancerous tissue is marked on the map and serves as a guide when the next surgical stage is performed. This procedure is repeated until no cancer remains. Mohs is known primarily for the fixation of tissue in situ before removal; however, in 1953, Mohs demonstrated the usefulness of the fresh-tissue technique when performing surgery on eyelid margins.” Occasionally, zinc chloride would irritate the eye when used on eyelid margins. Omission of the fixative (hence “fresh-tissue technique”) alleviated this problem. Mohs only extended the fresh-tissue technique to various eyelid tumors. In the 1960s Tromovitch began searching for a method that would eliminate the excruciating pain the zinc chloride fixative caused his patients. Tromovitch began omitting the fixative completely. Each year he increased the percentage of cases using the freshtissue method, finding that the cure rate was equal to that using the fixative. He presented his findings at the Annual Meeting of the American College of Chemosurgery in 1970. When Tromovitch and his colleague Stegman published their results on the advantages of the fresh-tissue technique applied to skin cancers located anywhere
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on the body, this procedure began to receive widespread acceptance.45 Stegman and Tromovitch called their method microscopically controlled excision (MCE). This fresh-tissue method of Mohs surgery eliminates the patient discomfort caused by zinc chloride, prevents the fixation of normal tissue at the surgical margin, and greatly increases the speed of complete removal of the cancerous tissue, as each time a stage is fixed with zinc chloride, it can take 24 hours.46 In 1967, the American College of Chemosurgery was formed and the first meeting held in December, preceding the meeting of the American Academy of Dermatology. Because of the widespread use of the fresh-tissue technique, the term chemosurgey no longer accurately described the procedure. The name of the college was changed in 1986 to The American College of Mohs Micrographic Surgery and Cutaneous Oncology, and the technique became known as Mohs micrographic surgery (MMS) or simply Mohs surgey.47 The first use of the term Mohs micrographic surgery occurred in an article by Hanke et al in 1985.48
Tissue Augmentation Injectable collagen, known by the trade names Zyplast and Zyderm, was developed in the early 19 70s by Rodney Perkins, John Daniels, Edward Lock, and Terrence Knapp at Stanford University. Under the consultative guidance of Samuel J. Stegman, the Collagen Corporation of Palo Alto, California, began manufacturing these products. Zyderm is manufactured from bovine dermis in two forms: Zyderm I and Zyderm II. Zyderm I (35 mg/ml) received FDA approval in 1981 and is used primarily for superficial wrinkle lines. Zyderm II (65 mg/ml) was approved in 1983 and is used for soft postacne scars and wrinkles. Zyplast, a form that is crosslinked with glutaraldehyde, was approved in 1985 and is used for deeper wrinkles, furrows, and scars. Fibrel is the end result of more than 20 years of research on fibrin foam by Spangler.4g,50 A porcine collagen derivative, Fibrel is used in much the same way as Zyplast. Fibrel is marketed by the Mentor Corporation of Santa Barbara, California. It received FDA approval in 1988 for use in scars and in 1990 for use in wrinkles.51 Free-fat grafts were first used by Neuber in 1893 to reconstruct a facial defect.52 The survival rate for these grafts was anywhere from 30% to 80%. The 1940s saw the use of dermal-fat grafts and artificial tissue augmentation agents (silicone, paraffin); autologous fat transplantation was no longer used. Because of the recent success of liposuction, autologous fat transplantation has regained popularity in the
correction of wrinkles and scars. In 1985, Illouz began using the fat extracted during liposuction to correct body contouring defects.53 Ottani and Fournier found that adding distilled water to the fat cells and then freezing caused the cells to become disrupted. 54 The fatty part of the cell fraction was removed. The cell membrane and interstitial tissue remained. This cell fraction is a rich source of autologous collagen, which can be used in much the same way porcine- or bovine-derived collagen is used, with little risk of allergic reaction.
Liposuction In 1929, the French surgeon Dujarrier was the first to attempt the removal of fat to improve cosmetic appearance.55 This crude precursor to what is now known as liposuction involved using a curette to dislodge the fat. His first patient was a dancer who wished to have slimmer calves. The result was less than favorable: one of the dancer’s legs needed to be amputated because of the damage to the blood vessels and underlying tissue. Although others attempted surgical removal of fat throughout the 20th century, little progress was made until 1975 when Arpard and Giorgio Fischer, a father and son team of aesthetic surgeons from Rome, Italy, introduced the first device for suctioning fat, which they called a “cellusuctiotome.” 56This instrument used a curette and a suction device to cut through and remove fat. They first demonstrated this technique at a meeting of the Intemational Academy of Cosmetic Surgery in 1977. Illouz of Paris learned of the Fischers’ work and proceeded to make modifications, the most important being the use of a blunt-tipped cannula instead of the sharp curette.57,58 Illouz also promoted the use of the “wet technique,“ which involves injecting the fat with various fluids and tunneling through the fat. These modifications greatly reduced bleeding, the chance of hematoma and seroma formation, and surface irregularities. Pierre F. Fournier, also in Paris, advocated the “crisscross” tunneling pattern. This minimized surface inconsistencies. A major breakthrough in liposuction technology came in 1987 with Klein’s description of the tumescent technique.5g Klein showed that using a dilute (0.1% or 0.05%) lidocaine solution with epinephrine (1: l,OOO,OOO) slowed the absorption rate of the local anesthetic so that the total doses given were in excess of five times the traditional “safe” doses. Increased doses of anesthetic enable large volumes of solution to be infiltrated into the subcutaneous fat. The large volume of fluid causes the tissue to swell and firm (i.e., tumescence). Capillary vasoconstriction is also achieved when this method is used.
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This allows liposuction to be an almost completely bloodless technique. The consequences of this discovery allow for a much larger amount of fat to be suctioned at one time. There is less pain for the patient, and the procedure can be done as an outpatient procedure. Liposuction under local anesthesia has been shown to be extremely safe.60
1986
Appendix: Important Milestones in Dermatologic Surgery
1987
1952 1953 1959 1961 1967 1970
1973 975 1 976 1’977
1979
1980
1981
1982
G. M. Mackee reports on his 50-year experience with chemical peels. Abner Kurtin introduces power-driven wire brushes for use in dermabrasion. Norman Orentreich transplants hair to correct androgenetic alopecia. Leon Goldman becomes the first physician to use a laser in medicine to treat patients. The American College of Chemosurgery (ACC) is founded by Frederic E. Mohs. The American Society for Dermatologic Surgery (ASDS) is founded; the first president elected is Norman Orentreich. Theodore A. Tromovitch and Samuel J. Stegman report on the Fresh Tissue Technique for Chemosurgery (Mohs micrographic surgery). The first one-year fellowship in Mohs chemosurgery is established at New York University by Perry Robins. First fellow: Henry Menn. The first ASDS annual meeting is held in San Francisco. TheJournal of Dermatologic Surgery and Oncology is founded by Perry Robins. Sheldon Gottlieb develops Fibrel. Lawrence A. Field becomes the first American physician to visit France to study liposuction. The International Society for Dermatologic Surgery (ISDS) is founded by Perry Robins. The American Society for Dermatologic Surgery contracts with Dermatology Services, Inc. for administrative support. Samuel J. Stegman becomes consultant to the Collagen Corporation for Zyderm. The Department of Dermatology at the University of Miami becomes the Department of Dermatology and Cutaneous Surgery. TheJournal of Dermatologic Surgery and Oncology becomes the official publication of the American Society for Dermatologic Surgery. The American Society for Dermatologic Surgery Core Curriculum for Dermatologic Surgery is developed by Edward A. Krull.
1988
1990
1991
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The American Society for Dermatologic Surgery submits an application for a seat in the American Medical Association House of Delegates. Pierre Fournier introduces the concept of microlipoinjection at the ASDS annual meeting in Palm Springs, California. The first Goldman award is presented by American Society for Dermatologic Surgery. The first recipient is Leon Goldman. The American Society for Dermatologic Surgery joins the National Council for Medicine, Surgery and Dentistry. Jeffery A. Klein develops the tumescent local anesthetic technique for liposuction. The American Society for Dermatologic Surgery Core Curriculum is revised by C. William Hanke. The American Society for Dermatologic Surgery becomes a member of the American Medical Association House of Delegates. The American Society for Dermatologic Surgery is seated in the American Medical Association House of Delegates. Edward A. Km11 founds the Association of Academic Dermatologic Surgeons (AADS). The first meeting is held in October 1989. The American Society for Dermatologic Surgery 20th Anniversary Issue of The Journal of Dermatologic Surge y and Oncology is published. Tromovitch and Stegman both die prematurely. Elsevier Science Publishing Company, Inc., acquires the publishing rights for the Journal of Dermatologic Surge y and Oncology. Thomas H. Alt is the first dermatologist elected President of the American Academy of Cosmetic Surgery (AACS). The third revision of the American Society for Dermatologic Surgery Core Curriculum is revised by Tom Meek (American Society for Dermatologic Surgery) and C. William Hanke (Association of Academic Dermatologic Surgeons) .
References 1. Mackee GM, Karp FL. The treatment of post acne scars with phenol. Br J Dermatol 1952;64:456-9. 2. Gross BG, Maschek F. Phenol chemosurgery for removal of deep facial wrinkles. Int J Dermatol 1980;19:159-64. 3. Eller JJ, Wolff S. Skin peeling and scarification in treatment of pitted scars, pigmentations and certain facial blemishes. JAMA 1941;116:934-8.
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in treating aging skin, 4. Ayres S. Superficial chemosurgery Arch Dermatol 1962;82:125. 5. Monash S. The uses of diluted trichloroacetic acid in dermatology. Urol Cutan Rev 1945;49:119. 6. Brown AM, Kaplan LM, Brown logical skin changes: Hazards, Plast Surg 1960;13:158. 7. Litton C. Chemical 1962;29:371.
face
ME. Phenol induced histotechniques, and uses. Br J
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8. Baker TJ. Chemical face peeling Reconstr Surg 1962;29:199.
Plast
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9. Stegman SJ. A study of dermabrasion and chemical peels in an animal model. J Dermatol Surg Oncol 1980;6:490. 10. Stegman SJ. A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 1982;6:123. 11. Brody HJ. Chemical peeling. St. Louis: Mosby Year Book, 1992:1-4. 12. Kromayer E. Rotationsinstrumente: Ein neues technisches Verfahren in der dermatologischen Kleinchirurgie. Dermato1 Z 1905;12:26-36. 13. Kromayer E. Die Heilung der Akne durch ein neues narbenloses Operationsverfahren: Das Stanzen. Illustr Monatsschr Aerztl Polytech 1905;27:101. 14. Kromayer E. Die Heilung der Akne durch ein neues narbenloses Operationsverfahren: Das Stanzen. Munchen Med Wochenschr 1905;52:942-4.
25. Hanke CW, Conner AC, Probst EL Jr. Blast tattoos resulting from black powder firearms. J Am Acad Dermatol 1987;17:819-25. 26. Hanke CW, Conner AC, Reed JC. Treatment of multiple facial neurofibromas with dermabrasion. J Dermatol Surg Oncol 1987;13:631-7. 27. Yarborough JM Jr. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol 1988;14:292-4. 28. Okuda S. Clinical and experimental studies on transplanting of living hair. Jpn J Dermatol Urol 1939;46:135-8. 29. Unger MG. Alopecia reduction: Scalp reduction. In: Unger WI’, Nordstrom REA, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988;1-3. 30. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann NY Acad Sci 1959;83:465. 31. Blanchard G, Blanchard B. Obliteration of alopecia by hairlifting: A new concept and technique. J Nat1 Med Assoc 1977;69:639-41. 32. Unger MG, Unger WI’. Management of alopecia of the scalp by a combination of excisions and transplantations. J Dermatol Surg Oncol 1978;4:670-2. 33. Orentreich D, Orentreich N. Androgenetic alopecia and its treatment. In: Unger WI’, Nordstrom REA, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988;435-6. 34. Norwood OT, Shiell RC. Hair transplant Springfield: Charles C Thomas, 1984;107.
surgery,
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15. Kromayer E. Eine neue sichere Epitationsmethode: Das Stanzen. Dtsch Med Wochenschr 1905;31:179-80. 16. Alt TH, Coleman WE’ III, Hanke CW, Yarborough JM. Dermabrasion. In: Coleman WP III, Hanke CW, Alt TH, Asken S, editors. Cosmetic surgery of the skin. Philadelphia: BC Decker, 1991;147-9.
35. Pinski JB. How to obtain the “perfect” plug. J Dermatol Surg Oncol 1984;10:12. 36. Einstein A. Zur Quantum Theorie der Strahlung. Whys 1917;18:121.
17. Stein RO. Therapeutische Technizismen. Arch Dermatol Syph 1928;155:304. 18. Shie MD. Study of tattooing and methods for its removal. JAMA 1928;90:94-9. 19. Janson P. Eine einfache Methode der Entfemung von Tatowierungen. Dermatol Wochenschr 1935;101:894-5.
38. Schawlow AL, Townes CH. Infrared and optical masers. Phys Rev 1958;112:1940. 39. Maimon TH. Stimulated optical radiation in ruby. Nature 1960;187:493. 40. Choy DSJ. History of lasers in medicine. Thorac Cardiovasc Surgeon 1988;2:114-7. 41. Pate1 CKN. High-power carbon dioxide Lasers. Sci Am 1968;219:23. 42. Polanyi TG, Bredemeier HC, Davis TW. A CO2 laser for surgical research. Med Biol Eng 1970;8:5418. 43. Mohs FE, Guyer MF. Pre-excisional fixation of tissues in the treatment of cancer in rats. Cancer Res 1941;1:49-51. 44. Mohs FE. Chemosurgery: Microscopically controlled surgery for skin cancer. Springfield: Charles C Thomas, 1978;106-9. 45. Tromovitch TA. Mohs surgery, fresh-tissue technique. In: Commentary: The evolution of Mohs’ surgery. J Dermatol Surg Oncol 1982;8:651-3.
20. Iverson PC. Surgical removal of traumatic face. Plast Reconstr Surg 1947;2:427-32.
tattoos of the
21. Iverson PC. Further developments in the treatment of skin lesions by surgical abrasion. Plast Reconstruct Surg 1953;12:27-40. 22. McEvitt WG. Acne pits: Supposed hopeless disfigurement. J Mich Med Sot 1948;47:1243-4. 23. Rosenberg WA. Accidental tattooing Arch abrasion with sandpaper. 1952;65:466-70. 24. Kurtin A. Corrective surgical planning matol Syph 1953;68:389-97.
of face treated by Dermatol Syph of skin. Arch
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37. Garden JM, Geronemus RG. Dermatologic Dermatol Surg Oncol 1990;16:156-68.
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46. Tromovitch TA, Stegman SJ. Microscopically controlled excision of skin tumors. Arch Dermatol 1974;110:231-2. 47. Bernstein G, Cottel WI, Bailin PL, et al. Mohs micrographic surgery (editorial). J Dermatol Surg Oncol 1987;13:1. 48. Hanke CW, Temofeew RK, Miyamoto RT, Lingeman RE. Basal cell carcinoma involving the external auditory canal -Treatment with Mohs micrographic surgery. J Dermatol Surg Oncol 1985;11:1189-94. 49. Spangler AS. New treatment for pitted scars. Arch Dermato1 1957;76:708. 50. Spangler AS. Treatment of depressed scars with fibrin foam-Seventeen years of experience. J Dermatol Surg Oncol 1975;1:65. 51. Coleman WP III, Hanke CW, Ah TH, Asken S. Cosmetic surgery of the skin. Philadelphia: BC Decker, 1991;97. 52. Neuber F. Fettransplantation. Chir Kongr Verhandl Dtsch Gesellsch Chir 1893;22:66. 53. Illouz YG. The fat cell “graft”: A new technique pressions. Plast Reconstr Surg 1986;78:122.
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54. Ottani F, Foumier P. A history and comparison of suction techniques until their debut in North America. In: Hetter G, editor. Lipoplasty: The theory and practice of blunt suction lipectomy. Boston: Little, Brown, 1984;19 -23. 55. Asken S. Liposuction Surgery and Autologous Fat Transplantation. Norwalk, CT: Appleton & Lange, 1988;1-2. 56. Fischer A, Fischer GM. Revised techniques for cellulitis fat: Reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977;2:40. 57. Illouz YG. Un nouveau traitement chirurgical sur les lipodistrophies localisees. Presentations at the Societe Francaise de Chirurgie Esthetique, June 1978 and 1979. 58. Illouz YG. Une nouvelle technique pour les lipodistrophies local&es. Rev Chir Esth Langue Fr 1980;6:3. 59. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermato1 Surg Oncol 1990;16:248-63. 60. Bernstein G, Hanke CW. Safety of liposuction: A review of 9478 cases performed by dermatologists. J Dermatol Surg Oncol 1988;14:1112-4.
