Commentary ERVIN
EPSTEIN,
SR, MD
D
uring the 20th century, the world has made more progress than in any previous century. Medicine has kept pace with the world in general. Dermatology has changed along with progress in other fields. The therapeutic approaches that I learned as a resident in the thirties are now passe. Dermatologic surgery is a comparatively new and vital modality that is making progress literally in leaps and bounds. In 1956, I edited a book entitled Skin Surgery.’ It was an instant success. The first edition has now progressed through six editions. The original volume was a small book of 223 pages. The fifth edition was a two-volume monster of 1243 pages.2 The sixth edition was published in 1987.3 Instead of issuing a seventh edition, I decided to announce the progress in this specialty through this publication. The field has grown so wide and so diverse that it has become impossible for a single person to become an authority on every facet of the specialty. This makes it imperative that books on this subject be multiauthored. And as this publication demonstrates, the field is still developing new modalities and is improving on the older methods. For many years, Skin Surgery was the only book available on this subject. Today there are a plethora of books in this field and the number is still growing. Actually, a subspecialty of skin surgery has developed. Today, some trained dermatologists have given up the practice of medical dermatology and confine themselves to cutaneous surgery or such subspecialties as hair transplantation and Mohs surgery. Possibly at some time in the future, the plastic surgeon will perform reconstructive surgery, the dermatologic surgeon will cover cosmetic surgery of the skin, and the oncologic surgeon may include the removal of cutaneous tumors in her or his sphere. With the invasion of government and insurance
companies into medicine, such alterations are not impossible. Even the pioneer dermatologists performed surgical procedures such as the application of acids, simple cryosurgery, electroremoval of tumors and defects, and curettage. From these comparatively simple procedures dermatology has now grown to include skin transplantation and grafting, blepharoplasties, hair transplantation, advanced cryosurgery, Mohs surgery, more radical excisions, and so on. Newer tools such as lasers, tissue expanders, and liposuction have been adopted. We have seen the future and we will profit by incorporating it into our lives and therapeutic armentarium.
Address correspondence to Eroin Epstein, Sr., MD, 400 Thirtieth Street, Suite 205, Oakland, CA 94609.
The world has made fantastic progress during the past four decades since World War II. Consider
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
Renaissance of Skin Surgery The sixth edition of Skin Surgery was submitted to the publishers in 1985.3 Since then, there has been great progress in the world, in medicine and in skin surgery. Instead of publishing a seventh edition to bring these advances in this field to the readers, it was decided to present this new material in this shortened volume. To increase the knowledge of the reader, a short summary of what was discussed in the sixth edition is included. The field of dermatologic surgery has grown so rapidly and widely that no one can be an expert in all facets of this specialty today. This dictates the necessity of a multiauthored book. I anticipate that the volume will include 125 to 150 pages of text plus whatever photographs and line drawings are allowed. In 1984, I edited a short book on skin surgery.’ The statements made in the foreword to that book are as relevant today as they were 8 years ago. Therefore, the material in that volume is being reprinted in this introduction, as follows.
251
252
Clinics in Dermatology
EPSTEIN
1992;10:251-255
space travel, jet airplanes, the computer, nuclear power, television, the laser, and too many other major improvement in technology to list here. Interestingly, little has been accomplished in the staples of life such as food, clothing, housing, and automobiles. In medicine in general the progress has also been outstanding: open heart surgery, organ transplantation, microsurgery, computed tomography, ultrasound, antibiotics, corticosteroids, fiberoptic surgery, and so on. Although the field of dermatologic surgery has changed and improvements have been made, nothing of earth-shaking importance has evolved. Then why is this issue of Clinics in Dermatology necessary? The answer to this question can be found in the increasing popularity of skin surgery among dermatologists and its frequent new developments. When I entered the field of dermatology in 1935, skin specialists employed few surgical modalities. The most common procedure was electrosurgery, especially electrodesiccation and curettage. In southern California, hot-cutting cautery became popular because of the influence of Percy, the pioneer oncologic surgeon. Cryosurgery was used but only with solid carbon dioxide sticks and only for superficial lesions such as hemangiomas, Chemosurgery consisted of the local applications of trichloroacetic acid. The punch biopsy was popular. Intradermal nevi were shaved off by most practitioners. Fluctuant lesions were incised and evacuated. This constituted the surgical armamentarium of most practitioners. The period after 1945 initiated what might be called the “golden age” of skin surgery. Before World War II, syphilis provided the basic structure on which dermatologic practices were built. These infected patients received a weekly injection of a trivalent arsenobenzol or a heavy metal for a minimum period of 2 years. In many cases this was extended to cover even longer periods. This furnished continuity and stability to the practice. Then syphilis disappeared except in the male homosexual. Shortened therapeutic schedules were developed in the early 1940s that reduced the span of treatment from years to months. The advent of penicillin reduced the therapeutic schedule further to a matter of days. Internists manifested an interest in dermatoses with systemic manifestations, and we soon found that we were in competition with them for patients with systemic lupus erythematosus, scleroderma, and other systemic diseases. Pundits predicted the demise of the specialty of dermatology. Added to this, there was an increase in the number
of dermatologists competing for the attention of the patient. In these circumstances, many felt the need for a new skill that would rescue the specialty and their practices from extinction.
Dermabrasion At this critical time, Kurtin entered the picture.5 During World War II, a plastic surgeon named McEvitt6 introduced the procedure of “sanding” for the correction of war-induced traumatic scars. In sanding, a sheet of waterproof sandpaper is attached to a wooden block. Under general anesthesia in a hospital, two surgeons would devote an hour or more to the sanding of a patient’s face until it was bleeding freely. Anyone who has ever attempted to sand a piece of wood manually would recognize that this was a time-consuming, difficult, tiring task. Naturally, this procedure did not inspire any great interest among dermatologists. Then Kurtin reintroduced Kromayer’s7 “rasp” in the form of an electrically powered whirling brush to accomplish the same results in a matter of minutes. Furthermore, this ambulatory procedure was performed in the doctor’s office. Soon a respectable percentage of dermatologists were performing this operation, often without proper preparation or training. Most soon recognized the limitations of this modality and discontinued its use, basically because of disappointment with the cosmetic results; however, a hard core of dermatologic surgeons persisted in its usage. Furthermore, some dermatologic training centers continued to teach this procedure, and it is still being employed by many practitioners. Nearly half of the members of the American Society for Dermatologic Surgery state that they still perform dermabrasion. Dermabrasion always seemed illogical to me. In the first place, it is crude traumatic surgery. The pits in the skin following acne or acne surgery are caused by scar tissue deep in the skin that exerts a pull on the surface. Obviously, if one were to plane sufficiently deeply to eliminate this cicatricial tissue, one would produce new scarring. Also, the iatrogenie scarring might be more severe and disfiguring than that resulting from the preceding inflammatory lesions. It is, however, difficult “to keep one’s head when all about you are losing theirs,” and the wide acceptance of this modality by one’s peers makes one question the wisdom of resisting this popular approach. My holdout ended when a distaff dermatologist berated me for not offering my
Clinics in Dermatology 1992;10:252-255 patients everything that modern dermatology had to offer. As a result, I, too, became a planer. My experience with cosmetic defects treated by myself and by others convinced me of the accuracy of the aforementioned reasons for not performing dermabrasion. Yet I did stumble into a field where planing is of undoubted value as a therapeutic measure. In 1954, I planed 10 patients with “precancerous skin,“ attributable mainly to solar irradiation, except for one, in whom it was attributable to ionizing radiation. From this experience I learned several lessons. Planing is of value in these conditions. It not only removes the dangerous precancerous lesions, but also prevents or decreases the frequency of further keratoses or leukoplakia. Also, it was found that many areas of the body including the hands, lips, and ears could be safely and successfully dermabraded. Burks went even further.* He proved the accuracy of this observation by planing only one side of the face in such patients and following them for 14 years. He then compared the treated side with the untreated control. The treated side contained significantly fewer neoplasms than the contralateral side. At that time, the supply of patients seeking dermabrasion seemed endless. Basically this demand resulted from glowing, unrealistic claims made in the lay press. Today this source has been eliminated, as the sensational journalists have turned their attention to other beauty aids that are of greater public interest at the present time.
Chemosurgery At about the same time, a procedure of much greater importance and value was introduced by Mohs, a surgeon,* He realized that skin cancers, especially basal cell epitheliomas, grew basically by continuity rather than by metastases. He reasoned that it might be possible to eliminate large, therapeutically resistant, and recurrent cutaneous cancers by fixing the tissue in vivo, excising the fixed tissue, and then examining the bottom surface of the specimen histologically. He then treated the areas still showing cancerous alterations and followed the malignant changes until all evidence of malignancy had been eliminated. He introduced this technique under the title of chemosurgery. By this method he was able to salvage a large number of patients who would otherwise have perished from their “inoperable” tumors. It must be admitted that this technique was difficult and cumbersome and required considerable
EPSTEIN COMMENTARY
training to perform expertly. Although the microscopic control suggested that this was the most accurate method of handling skin cancers, it was too complex for use on the simple basal cell epithelioma. For this reason it did not gain immediate acceptance by the dermatologic profession. In all probability, chemosurgery has been the most important therapeutic improvement in cutaneous surgery to surface during the past four decades. This procedure should be available in every region of the country; however, its use requires training, histologic skill, special equipment, time, and technical assistance. Chemosurgery has been improved by substituting the fresh-tissue technique for the chemical fixation method. Plastic surgeons have for a long time excised lesions as dictated by clinical judgment and then examined the bottom of the specimen for histologic evidence of persistence of the cancer.9 The adequacy of excision was checked on frozen sections and further excision practiced if dictated by the findings. Tromovitch and Stegman modified this by removing the tumor a slice at a time to minimize the sacrifice of normal tissue and scarring.1°
Hair Transplantation Another successful application of dermatologic surgery has been hair transplantation. When Orentreich studied scalp transplantation in alopecia areata to determine if there was graft or recipient dominance, he found that there was donor dominance.‘O In other words, if a plug of hair were taken from an area of normal hair growth and inserted into a region of baldness, the hair in the new location would fall out but regrow in about 6 weeks. This regrowth was permanent unless the donor area became bald. In such circumstances, the transplanted hair would be shed also. Orentreich’s observation and brilliant recognition of the practical importance of this finding opened a new field in skin surgery that is standing the test of time. The punch technique of hair transplantation is a popular method for correcting male pattern baldness, a very common cosmetic defect. This method is also used for correcting other conditions characterized by alopecia. A large number of dermatologists are offering this procedure to those seeking a more youthful or pleasing appearance. Some practitioner limit their practices to this modality, the success and popularity of this procedure being adequate to keep them busy. Others, mainly plastic surgeons, have introduced
253
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Clinics in Dermatology
EPSTEIN
1992;10:251-255
shortcuts to the tedious procedure of transplanting six to eight hairs at a time by the punch method, introducing strips and grafts to cover the involved area more completely and quickly. The technical problems, complications, and morbidity of these major approaches have, however, allowed the punch method to maintain its popularity. It is claimed that the new hair can be patterned better with Orentreich’s technique. Unger and Unger offered a major improvement by introducing the concept of scalp reduction.” If an area of baldness were reduced in size, fewer plugs would be required to obtain a satisfactory appearance. Therefore, he excised a portion of the bald pate before instituting the transplantation. This, too, has been successful.
Cryosurgery Cryosurgery made important advances under the leadership of Zacarian, Ton-e, and Gage. The introduction of liquid nitrogen was also a step forward. In addition to being about 100 degrees colder than solid carbon dioxide, the liquid is much easier to obtain and to handle. The development of the sprays allowed for deeper freezing so that for the first time malignant lesions could be treated successfully with this modality. Furthermore, the thermocouple, which can be inserted under the skin or into the tumor mass, allowed for superior monitoring of the effect of the refrigerant. In addition, careful study of the properties of the refrigerants and the results of freezing have allowed for maturation of this field of therapy.
Collagen Injection Few dermatologists were able to acquire experience with the injection of silicone for cosmetic correction therapy. Now the availability of soluble collagen for injection of depressed soft scars and wrinkles is allowing for its evaluation by the practitioners. It is hoped that this approach will prove successful; however, it has already been recognized that a negative skin test reaction does not guarantee freedom from undesirable reactions such as granulomas from the therapeutic dose and that repeated injections are necessary because the collagen is absorbed. This is true despite the acceptance of overcorrection at the time of treatment. Collagen injection can be combined with dermabrasion or other techniques of cicatricial minimization.
Dermatopathology and Developments in the field of histopathology the increase in the availability of qualified trained histopathologists elevated the ability of the skin surgeon because better interpretation of slides allows for better planning of the operative approach. The utilization of the pathologist in guiding “the microscopic control of the surgeon” has been alluded to previously. His or her role in the diagnosis, prognosis, and management of melanoma is well recognized in this difficult and crucial field. The contributions of Clark, Breslow, and others are very important in the management of this hazardous neoplasm.
The Future Skin surgery has become increasingly popular as the years have rolled by. In addition to filling a void left by the ability to control syphilis and by the other changes mentioned earlier, it has improved our handling of certain therapeutic and cosmetic problems. Today no textbook of general dermatology, training program, or seminar can ignore this subspecialty in the care of skin diseases. The private practitioner must offer his patients more and better surgery than did his predecessors. In the older literature, skin surgery was mentioned only rarely. In 1956, the year that the book Skin Surgery was first published, only two presentations on such surgery were presented at the annual teaching meeting of the American Academy of Dermatology. By 1982, the number had increased to 24. The courses on dermatologic surgery are now among the most popular presented at that meeting. Seminars and courses on the basics of cold steel surgery, hair transplantation, or other surgical subjects are offered frequently, and they are very well attended by those anxious to learn new techniques or to improve their skills. A number of general dermatosurgical societies have been formed. Of these, the American Society for Dermatologic Surgery and the International Society for Dermatologic Surgery have been most successful in attracting members and conducting excellent annual meetings. At these conclaves, talks and demonstrations are presented by dermatologists, oncologists, plastic surgeons, and others. Another interesting development has been the founding of active societies concerned exclusively with cryosurgery, chemosurgery, and other techniques. “How much surgery is dermatologic surgery?” We must
EPSTEIN COMMENTARY
Clinics in Dermatology 1992;10:251-255 remember that our basic training is in the diagnosis and treatment of skin diseases. The surgeon, including the plastic surgeon, is trained in surgical techniques. The proper diagnosis of a cutaneous tumor, knowledge of its prognosis, and an understanding of the optimum extent of therapy required to eradicate it are of crucial importance. On the other hand, we must not forget that surgical skill is also crucial. Although we are developing a subspecialty of dermatologic surgeons who confine their activities to such procedures, we must not involve ourselves in modalities that we are not able to perform expertly because of lack of training, experience, or operating skills. If a given dermatologist can perform a blepharoplasty by plastic surgery, she or he should be allowed to pursue such procedures, but not if this criterion cannot be met. This brings us to the question of training opportunities To the best of my knowledge, no training program confined to dermatologic surgery is available. The best we can do so far is to offer a dermatologic residency or fellowship with surgery included. It would be preferable if candidates could spend 6 months or longer in general or plastic surgery if they intended to use skin surgery in their practice. Another problem faced by the skin surgeon is securing surgical privileges in a hospital. In some geographic locations, the dermatologist-surgeon is allowed to demonstrate her or his skill under supervision before being granted the right to perform dermatologic procedures in that institution. This is a reasonable requirement, Of course, the dermatologist can establish a sterile surgery in his or her own office or work in ambulatory surgical centers. Publications in this field are increasing both in quantity and in quality. The first edition of Skin Surgery was 223 pages in length and included 16
255
chapters.4 The fifth edition was a two-volume opus of 1209 pages and 87 chapters.’ Some may question the need for so much material, but the growth of the field not only justifies the space but makes its availability mandatory. The American ]ournal of Dermatologic Surgery and Oncology founded by Robins has filled a need in the field in excellent fashion. The future looks bright unless corrupted by government interference.
References 1. Epstein E. Skin surgery. Philadelphia: Lea & Febiger, 1956. 2. Epstein E, Epstein E Jr, editors. Skin surgery. 5th ed. Springfield (IL): Charles C Thomas, 1982. 3. Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Lea and Febiger, Springfield (IL): Charles C Thomas, 1987. 4. Epstein E, editor. Dermatologic surgery in dermatologic clinics. Philadelphia: WB Saunders, 1984. 5. Kurtin A. Corrective surgical planning of the skin. Arch Dermatol. 1953;68:389. 6. McEvitt WG. Acne pits: Supposed hopeless disfigurement. J Mich Med Sot 1948;47:1243. 7. Kromayer E. The cosmetic treatment of skin complaints. London: Oxford Union Press, 1930. 8. Burks JW. Dermabrasion and chemical peeling. Springfield (IL): Charles C Thomas, 1979. 9. Mohs FE. The chemosurgical method for the microscopic controlled excision of cutaneous cancer. In: Epstein E, editor. Skin surgery. Springfield (IL): Charles C Thomas, 1956. 10. Tromovitch TA, Stegman SJ. Microscopically controlled excision of skin tumors. Arch Dermatol 1974;110:231. 11. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann NY Acad Sci 1959;83:465. 12. Unger WE’, Unger MJ. Alopecia reduction. In: Epstein E, Epstein E Jr, editors. Skin surgery. 5th ed. Springfield (IL): Charles C Thomas, 1982.
EPSTEIN,
SR, MD
D
uring the 20th century, the world has made more progress than in any previous century. Medicine has kept pace with the world in general. Dermatology has changed along with progress in other fields. The therapeutic approaches that I learned as a resident in the thirties are now passe. Dermatologic surgery is a comparatively new and vital modality that is making progress literally in leaps and bounds. In 1956, I edited a book entitled Skin Surgery.’ It was an instant success. The first edition has now progressed through six editions. The original volume was a small book of 223 pages. The fifth edition was a two-volume monster of 1243 pages.2 The sixth edition was published in 1987.3 Instead of issuing a seventh edition, I decided to announce the progress in this specialty through this publication. The field has grown so wide and so diverse that it has become impossible for a single person to become an authority on every facet of the specialty. This makes it imperative that books on this subject be multiauthored. And as this publication demonstrates, the field is still developing new modalities and is improving on the older methods. For many years, Skin Surgery was the only book available on this subject. Today there are a plethora of books in this field and the number is still growing. Actually, a subspecialty of skin surgery has developed. Today, some trained dermatologists have given up the practice of medical dermatology and confine themselves to cutaneous surgery or such subspecialties as hair transplantation and Mohs surgery. Possibly at some time in the future, the plastic surgeon will perform reconstructive surgery, the dermatologic surgeon will cover cosmetic surgery of the skin, and the oncologic surgeon may include the removal of cutaneous tumors in her or his sphere. With the invasion of government and insurance
companies into medicine, such alterations are not impossible. Even the pioneer dermatologists performed surgical procedures such as the application of acids, simple cryosurgery, electroremoval of tumors and defects, and curettage. From these comparatively simple procedures dermatology has now grown to include skin transplantation and grafting, blepharoplasties, hair transplantation, advanced cryosurgery, Mohs surgery, more radical excisions, and so on. Newer tools such as lasers, tissue expanders, and liposuction have been adopted. We have seen the future and we will profit by incorporating it into our lives and therapeutic armentarium.
Address correspondence to Eroin Epstein, Sr., MD, 400 Thirtieth Street, Suite 205, Oakland, CA 94609.
The world has made fantastic progress during the past four decades since World War II. Consider
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
Renaissance of Skin Surgery The sixth edition of Skin Surgery was submitted to the publishers in 1985.3 Since then, there has been great progress in the world, in medicine and in skin surgery. Instead of publishing a seventh edition to bring these advances in this field to the readers, it was decided to present this new material in this shortened volume. To increase the knowledge of the reader, a short summary of what was discussed in the sixth edition is included. The field of dermatologic surgery has grown so rapidly and widely that no one can be an expert in all facets of this specialty today. This dictates the necessity of a multiauthored book. I anticipate that the volume will include 125 to 150 pages of text plus whatever photographs and line drawings are allowed. In 1984, I edited a short book on skin surgery.’ The statements made in the foreword to that book are as relevant today as they were 8 years ago. Therefore, the material in that volume is being reprinted in this introduction, as follows.
251
252
Clinics in Dermatology
EPSTEIN
1992;10:251-255
space travel, jet airplanes, the computer, nuclear power, television, the laser, and too many other major improvement in technology to list here. Interestingly, little has been accomplished in the staples of life such as food, clothing, housing, and automobiles. In medicine in general the progress has also been outstanding: open heart surgery, organ transplantation, microsurgery, computed tomography, ultrasound, antibiotics, corticosteroids, fiberoptic surgery, and so on. Although the field of dermatologic surgery has changed and improvements have been made, nothing of earth-shaking importance has evolved. Then why is this issue of Clinics in Dermatology necessary? The answer to this question can be found in the increasing popularity of skin surgery among dermatologists and its frequent new developments. When I entered the field of dermatology in 1935, skin specialists employed few surgical modalities. The most common procedure was electrosurgery, especially electrodesiccation and curettage. In southern California, hot-cutting cautery became popular because of the influence of Percy, the pioneer oncologic surgeon. Cryosurgery was used but only with solid carbon dioxide sticks and only for superficial lesions such as hemangiomas, Chemosurgery consisted of the local applications of trichloroacetic acid. The punch biopsy was popular. Intradermal nevi were shaved off by most practitioners. Fluctuant lesions were incised and evacuated. This constituted the surgical armamentarium of most practitioners. The period after 1945 initiated what might be called the “golden age” of skin surgery. Before World War II, syphilis provided the basic structure on which dermatologic practices were built. These infected patients received a weekly injection of a trivalent arsenobenzol or a heavy metal for a minimum period of 2 years. In many cases this was extended to cover even longer periods. This furnished continuity and stability to the practice. Then syphilis disappeared except in the male homosexual. Shortened therapeutic schedules were developed in the early 1940s that reduced the span of treatment from years to months. The advent of penicillin reduced the therapeutic schedule further to a matter of days. Internists manifested an interest in dermatoses with systemic manifestations, and we soon found that we were in competition with them for patients with systemic lupus erythematosus, scleroderma, and other systemic diseases. Pundits predicted the demise of the specialty of dermatology. Added to this, there was an increase in the number
of dermatologists competing for the attention of the patient. In these circumstances, many felt the need for a new skill that would rescue the specialty and their practices from extinction.
Dermabrasion At this critical time, Kurtin entered the picture.5 During World War II, a plastic surgeon named McEvitt6 introduced the procedure of “sanding” for the correction of war-induced traumatic scars. In sanding, a sheet of waterproof sandpaper is attached to a wooden block. Under general anesthesia in a hospital, two surgeons would devote an hour or more to the sanding of a patient’s face until it was bleeding freely. Anyone who has ever attempted to sand a piece of wood manually would recognize that this was a time-consuming, difficult, tiring task. Naturally, this procedure did not inspire any great interest among dermatologists. Then Kurtin reintroduced Kromayer’s7 “rasp” in the form of an electrically powered whirling brush to accomplish the same results in a matter of minutes. Furthermore, this ambulatory procedure was performed in the doctor’s office. Soon a respectable percentage of dermatologists were performing this operation, often without proper preparation or training. Most soon recognized the limitations of this modality and discontinued its use, basically because of disappointment with the cosmetic results; however, a hard core of dermatologic surgeons persisted in its usage. Furthermore, some dermatologic training centers continued to teach this procedure, and it is still being employed by many practitioners. Nearly half of the members of the American Society for Dermatologic Surgery state that they still perform dermabrasion. Dermabrasion always seemed illogical to me. In the first place, it is crude traumatic surgery. The pits in the skin following acne or acne surgery are caused by scar tissue deep in the skin that exerts a pull on the surface. Obviously, if one were to plane sufficiently deeply to eliminate this cicatricial tissue, one would produce new scarring. Also, the iatrogenie scarring might be more severe and disfiguring than that resulting from the preceding inflammatory lesions. It is, however, difficult “to keep one’s head when all about you are losing theirs,” and the wide acceptance of this modality by one’s peers makes one question the wisdom of resisting this popular approach. My holdout ended when a distaff dermatologist berated me for not offering my
Clinics in Dermatology 1992;10:252-255 patients everything that modern dermatology had to offer. As a result, I, too, became a planer. My experience with cosmetic defects treated by myself and by others convinced me of the accuracy of the aforementioned reasons for not performing dermabrasion. Yet I did stumble into a field where planing is of undoubted value as a therapeutic measure. In 1954, I planed 10 patients with “precancerous skin,“ attributable mainly to solar irradiation, except for one, in whom it was attributable to ionizing radiation. From this experience I learned several lessons. Planing is of value in these conditions. It not only removes the dangerous precancerous lesions, but also prevents or decreases the frequency of further keratoses or leukoplakia. Also, it was found that many areas of the body including the hands, lips, and ears could be safely and successfully dermabraded. Burks went even further.* He proved the accuracy of this observation by planing only one side of the face in such patients and following them for 14 years. He then compared the treated side with the untreated control. The treated side contained significantly fewer neoplasms than the contralateral side. At that time, the supply of patients seeking dermabrasion seemed endless. Basically this demand resulted from glowing, unrealistic claims made in the lay press. Today this source has been eliminated, as the sensational journalists have turned their attention to other beauty aids that are of greater public interest at the present time.
Chemosurgery At about the same time, a procedure of much greater importance and value was introduced by Mohs, a surgeon,* He realized that skin cancers, especially basal cell epitheliomas, grew basically by continuity rather than by metastases. He reasoned that it might be possible to eliminate large, therapeutically resistant, and recurrent cutaneous cancers by fixing the tissue in vivo, excising the fixed tissue, and then examining the bottom surface of the specimen histologically. He then treated the areas still showing cancerous alterations and followed the malignant changes until all evidence of malignancy had been eliminated. He introduced this technique under the title of chemosurgery. By this method he was able to salvage a large number of patients who would otherwise have perished from their “inoperable” tumors. It must be admitted that this technique was difficult and cumbersome and required considerable
EPSTEIN COMMENTARY
training to perform expertly. Although the microscopic control suggested that this was the most accurate method of handling skin cancers, it was too complex for use on the simple basal cell epithelioma. For this reason it did not gain immediate acceptance by the dermatologic profession. In all probability, chemosurgery has been the most important therapeutic improvement in cutaneous surgery to surface during the past four decades. This procedure should be available in every region of the country; however, its use requires training, histologic skill, special equipment, time, and technical assistance. Chemosurgery has been improved by substituting the fresh-tissue technique for the chemical fixation method. Plastic surgeons have for a long time excised lesions as dictated by clinical judgment and then examined the bottom of the specimen for histologic evidence of persistence of the cancer.9 The adequacy of excision was checked on frozen sections and further excision practiced if dictated by the findings. Tromovitch and Stegman modified this by removing the tumor a slice at a time to minimize the sacrifice of normal tissue and scarring.1°
Hair Transplantation Another successful application of dermatologic surgery has been hair transplantation. When Orentreich studied scalp transplantation in alopecia areata to determine if there was graft or recipient dominance, he found that there was donor dominance.‘O In other words, if a plug of hair were taken from an area of normal hair growth and inserted into a region of baldness, the hair in the new location would fall out but regrow in about 6 weeks. This regrowth was permanent unless the donor area became bald. In such circumstances, the transplanted hair would be shed also. Orentreich’s observation and brilliant recognition of the practical importance of this finding opened a new field in skin surgery that is standing the test of time. The punch technique of hair transplantation is a popular method for correcting male pattern baldness, a very common cosmetic defect. This method is also used for correcting other conditions characterized by alopecia. A large number of dermatologists are offering this procedure to those seeking a more youthful or pleasing appearance. Some practitioner limit their practices to this modality, the success and popularity of this procedure being adequate to keep them busy. Others, mainly plastic surgeons, have introduced
253
254
Clinics in Dermatology
EPSTEIN
1992;10:251-255
shortcuts to the tedious procedure of transplanting six to eight hairs at a time by the punch method, introducing strips and grafts to cover the involved area more completely and quickly. The technical problems, complications, and morbidity of these major approaches have, however, allowed the punch method to maintain its popularity. It is claimed that the new hair can be patterned better with Orentreich’s technique. Unger and Unger offered a major improvement by introducing the concept of scalp reduction.” If an area of baldness were reduced in size, fewer plugs would be required to obtain a satisfactory appearance. Therefore, he excised a portion of the bald pate before instituting the transplantation. This, too, has been successful.
Cryosurgery Cryosurgery made important advances under the leadership of Zacarian, Ton-e, and Gage. The introduction of liquid nitrogen was also a step forward. In addition to being about 100 degrees colder than solid carbon dioxide, the liquid is much easier to obtain and to handle. The development of the sprays allowed for deeper freezing so that for the first time malignant lesions could be treated successfully with this modality. Furthermore, the thermocouple, which can be inserted under the skin or into the tumor mass, allowed for superior monitoring of the effect of the refrigerant. In addition, careful study of the properties of the refrigerants and the results of freezing have allowed for maturation of this field of therapy.
Collagen Injection Few dermatologists were able to acquire experience with the injection of silicone for cosmetic correction therapy. Now the availability of soluble collagen for injection of depressed soft scars and wrinkles is allowing for its evaluation by the practitioners. It is hoped that this approach will prove successful; however, it has already been recognized that a negative skin test reaction does not guarantee freedom from undesirable reactions such as granulomas from the therapeutic dose and that repeated injections are necessary because the collagen is absorbed. This is true despite the acceptance of overcorrection at the time of treatment. Collagen injection can be combined with dermabrasion or other techniques of cicatricial minimization.
Dermatopathology and Developments in the field of histopathology the increase in the availability of qualified trained histopathologists elevated the ability of the skin surgeon because better interpretation of slides allows for better planning of the operative approach. The utilization of the pathologist in guiding “the microscopic control of the surgeon” has been alluded to previously. His or her role in the diagnosis, prognosis, and management of melanoma is well recognized in this difficult and crucial field. The contributions of Clark, Breslow, and others are very important in the management of this hazardous neoplasm.
The Future Skin surgery has become increasingly popular as the years have rolled by. In addition to filling a void left by the ability to control syphilis and by the other changes mentioned earlier, it has improved our handling of certain therapeutic and cosmetic problems. Today no textbook of general dermatology, training program, or seminar can ignore this subspecialty in the care of skin diseases. The private practitioner must offer his patients more and better surgery than did his predecessors. In the older literature, skin surgery was mentioned only rarely. In 1956, the year that the book Skin Surgery was first published, only two presentations on such surgery were presented at the annual teaching meeting of the American Academy of Dermatology. By 1982, the number had increased to 24. The courses on dermatologic surgery are now among the most popular presented at that meeting. Seminars and courses on the basics of cold steel surgery, hair transplantation, or other surgical subjects are offered frequently, and they are very well attended by those anxious to learn new techniques or to improve their skills. A number of general dermatosurgical societies have been formed. Of these, the American Society for Dermatologic Surgery and the International Society for Dermatologic Surgery have been most successful in attracting members and conducting excellent annual meetings. At these conclaves, talks and demonstrations are presented by dermatologists, oncologists, plastic surgeons, and others. Another interesting development has been the founding of active societies concerned exclusively with cryosurgery, chemosurgery, and other techniques. “How much surgery is dermatologic surgery?” We must
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Clinics in Dermatology 1992;10:251-255 remember that our basic training is in the diagnosis and treatment of skin diseases. The surgeon, including the plastic surgeon, is trained in surgical techniques. The proper diagnosis of a cutaneous tumor, knowledge of its prognosis, and an understanding of the optimum extent of therapy required to eradicate it are of crucial importance. On the other hand, we must not forget that surgical skill is also crucial. Although we are developing a subspecialty of dermatologic surgeons who confine their activities to such procedures, we must not involve ourselves in modalities that we are not able to perform expertly because of lack of training, experience, or operating skills. If a given dermatologist can perform a blepharoplasty by plastic surgery, she or he should be allowed to pursue such procedures, but not if this criterion cannot be met. This brings us to the question of training opportunities To the best of my knowledge, no training program confined to dermatologic surgery is available. The best we can do so far is to offer a dermatologic residency or fellowship with surgery included. It would be preferable if candidates could spend 6 months or longer in general or plastic surgery if they intended to use skin surgery in their practice. Another problem faced by the skin surgeon is securing surgical privileges in a hospital. In some geographic locations, the dermatologist-surgeon is allowed to demonstrate her or his skill under supervision before being granted the right to perform dermatologic procedures in that institution. This is a reasonable requirement, Of course, the dermatologist can establish a sterile surgery in his or her own office or work in ambulatory surgical centers. Publications in this field are increasing both in quantity and in quality. The first edition of Skin Surgery was 223 pages in length and included 16
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chapters.4 The fifth edition was a two-volume opus of 1209 pages and 87 chapters.’ Some may question the need for so much material, but the growth of the field not only justifies the space but makes its availability mandatory. The American ]ournal of Dermatologic Surgery and Oncology founded by Robins has filled a need in the field in excellent fashion. The future looks bright unless corrupted by government interference.
References 1. Epstein E. Skin surgery. Philadelphia: Lea & Febiger, 1956. 2. Epstein E, Epstein E Jr, editors. Skin surgery. 5th ed. Springfield (IL): Charles C Thomas, 1982. 3. Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Lea and Febiger, Springfield (IL): Charles C Thomas, 1987. 4. Epstein E, editor. Dermatologic surgery in dermatologic clinics. Philadelphia: WB Saunders, 1984. 5. Kurtin A. Corrective surgical planning of the skin. Arch Dermatol. 1953;68:389. 6. McEvitt WG. Acne pits: Supposed hopeless disfigurement. J Mich Med Sot 1948;47:1243. 7. Kromayer E. The cosmetic treatment of skin complaints. London: Oxford Union Press, 1930. 8. Burks JW. Dermabrasion and chemical peeling. Springfield (IL): Charles C Thomas, 1979. 9. Mohs FE. The chemosurgical method for the microscopic controlled excision of cutaneous cancer. In: Epstein E, editor. Skin surgery. Springfield (IL): Charles C Thomas, 1956. 10. Tromovitch TA, Stegman SJ. Microscopically controlled excision of skin tumors. Arch Dermatol 1974;110:231. 11. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann NY Acad Sci 1959;83:465. 12. Unger WE’, Unger MJ. Alopecia reduction. In: Epstein E, Epstein E Jr, editors. Skin surgery. 5th ed. Springfield (IL): Charles C Thomas, 1982.
