Dermatologic surgery is a subdiscipline of dermatology that uses invasive means for diagnosis and treatment. It is also an interdisciplinary discipline that integrates dermatologic theory with many surgical and cosmetic techniques. The technical scope of dermatologic surgery has both broad and narrow meanings. In a broad sense it covers a variety of treatments and techniques such as surgery, laser, physical therapy (freezing, electrolysis, etc.), hair transplantation, liposuction and fat transplantation, botulinum toxin injections, filler injections, etc. In a narrow sense, dermatologic surgery refers exclusively to surgical dermatologic surgery. At the beginning of the development of dermatologic surgery, the aim was to completely and thoroughly remove benign skin masses and various skin cancers and to perform fine restoration and shaping, but with the development of technology and the changing needs of society, treatments for cosmetic purposes are now increasingly carried out.
As a sub-discipline of dermatology, dermatologic surgery, as the name implies, is aimed at treating skin diseases or defects. In order to achieve a perfect treatment effect, the scope of operation can include multiple levels of tissue such as epidermis, dermis and subcutaneous tissue. In short, dermatologic surgery can be both for the purpose of treatment, but also to meet the cosmetic needs.
1, dermatologic surgery and the relationship between dermatology
Dermatologic surgery is not an emerging discipline, it is an inherent subbranch of dermatology. From a historical point of view: the origins of medicine, the ancients tried to use invasive methods to treat simple skin lesions, dermatologic surgery can be described as a long history [1]; late 19th century, when dermatology was established as an independent discipline, most dermatologists are surgical, they and their descendants have always used surgical techniques to treat skin disorders, so that modern Western dermatology has always included surgical The modern Western dermatology has always included surgical techniques [1]. From a practical point of view: dermatologic surgery has become an essential and important treatment tool in modern dermatology. In the United States, for example, there are currently more than 3,000 physicians practicing dermatologic surgery, which represents a large proportion of the total number of dermatologists. The American Society for Dermatologic Surgery has become the second largest subspecialty section of the American Academy of Dermatology. Dermatologic surgery is inherent to dermatology and is also reflected in the fact that dermatologic surgery is based on dermatology. Dermatologic surgery is a subspecialty because the dermatologist doing the surgery is familiar with skin pathology and can correctly grasp how deep to cut, how large to cut, and what the prognosis is for the lesions he or she is dealing with. Therefore, the dermatologic surgeon should be a dermatologist first. In essence, dermatologic surgery is an extension of dermatology, which enriches the treatment of dermatological diseases and expands the use of dermatologists. This is the need for the sustainable development of dermatology itself, but also the expectations of the majority of patients.
2, the relationship between dermatologic surgery and cosmetic surgery
The birth of dermatologic surgery originated from the demand for treatment of superficial lesions, the establishment of modern dermatologic surgery and the birth of skin tumor treatment technology – Mohs microscopic tracing surgery, and the treatment of androgenetic alopecia – the development of hair transplantation technology is closely related, it can be said that dermatologic surgery is the original face of the treatment. For example, although pigmented nevus is a textbook skin disease, many patients nowadays have it removed for cosmetic purposes. At the same time, new technologies are rapidly developing to meet more of the aesthetic needs of people. As a result, dermatologic surgery has become more and more involved in aesthetics, to the point that many people now equate dermatologic surgery with cosmetic surgery. To be precise, cosmetic surgery is a vague concept, it is the development of many disciplines to a certain extent to meet the needs of patients, it is not unique to any one discipline, it is a big intersection. At present, cosmetic surgery is developing on two highways: on the one hand, plastic surgeons take advantage of technology to treat from head to foot, from outside to inside; on the other hand, it is divided by organ system, ophthalmology, maxillofacial surgery, ear, nose and throat and other disciplines of physicians in their own disciplines to carry out cosmetic surgery to meet patients’ pursuit of beauty. As the skin is the largest organ of the human body, dermatologists have the responsibility and obligation to perform cosmetic surgery within the skin. However, if dermatologists are obsessed with the pursuit of cosmetic surgery, it is a departure from the main body of dermatologic surgery, which is to put the cart before the horse and will certainly have a negative impact on the development of the discipline. From a historical point of view, the source of the development of dermatological surgery comes from the development of dermatological science, and the advantage of dermatological surgery also lies in the profound knowledge of skin science. A physician who only performs cosmetic surgery is not the same as a dermatologic surgeon.
At present, the national health administration is regulating the medical cosmetic behavior and market, initially establishing four major fields of cosmetic surgery, cosmetic dermatology, cosmetic dentistry and cosmetic Chinese medicine, respectively regulating plastic surgeons, dermatologists, dentists and Chinese physicians in the field of cosmetic as a qualification rather than technology, so there is crossover between these four fields, especially in terms of technology and types of surgery. We believe that dermatologists can serve people in the field of aesthetics together with their sister disciplines and create a “beautiful” tomorrow.
3.The relationship between dermatologic surgery and sister disciplines
Since dermatologic surgery is still in the initial stage of revitalization in China (see below for more details on the history and current status of dermatologic surgery in China), its development is not understood or even misunderstood by many people. The history and current status of dermatologic surgery in developed countries in Europe and the United States objectively proves that dermatologic surgery is an independently existing subdiscipline of dermatology. Firstly, dermatologic surgery has unique procedures that distinguish it from other branches of surgery, such as Mohs microscopic tracing; secondly, historically, dermatologists have created and developed many procedures [1], which later spread to multiple disciplines, such as hair transplantation, botulinum toxin injections, and laser therapy. These results prove that dermatologic surgery has a sustainable source of development; again, dermatologic surgery focuses on a variety of procedures in the skin range, and its sophistication is recognized by the majority of patients, firmly occupying the corresponding medical market in developed countries in Europe and the United States.
It is undeniable that dermatologic surgery draws on the techniques of many sister disciplines, but the technique itself has a communal nature, it does not belong to any one discipline exclusively, and is not directly related to the independence of the discipline, just as “cutting and suturing” are the basic skills of all surgical systems. The cornerstone of the development of dermatologic surgery is the removal of superficial masses, and when it comes to the high-end, especially when it comes to aesthetics, there is indeed crossover with other sister disciplines. This crossover is inevitable and necessary for the development of medicine, and it will translate into market competition in clinical practice, which in turn will be the driving force for the development of the discipline. Monopoly leads to stagnation, competition promotes development, the development of dermatological surgery in Europe and the United States tells us that the crossover with sister disciplines, not only does not hinder the independence of the discipline of dermatological surgery, but also prompt dermatological surgery practitioners to continuously improve technology, enhance competitiveness, this competitiveness for the development of sister disciplines is also a driving force. In short, dermatologic surgery and sister disciplines learn from each other, promote each other, but at the same time independent of each other, not replace each other.
4, the mode of training dermatologic surgeons
At present, Chinese dermatologic surgeons have two sources: ① dermatologists were sent to study in surgery; ② directly from the surgical system to hire talent. In fact, dermatologic surgeons do not lie in origin, as long as they have sufficient knowledge of dermatology and related surgical skills are qualified dermatologic surgeons. From the experience of developed countries in Europe and the United States, most dermatologic surgeons are currently completing their dermatology residency training and then learning surgical skills and undergoing specialized training in dermatologic surgery. The Chinese Association of Dermatologists is also in accordance with this model to develop a dermatologic surgery specialty training process and assessment indicators.
5.Thinking about the development of dermatologic surgery
5.1 Correct positioning of dermatologic surgery, looking for the entry point to carry out dermatologic surgery: many hospitals are still blank in the field of dermatologic surgery, but have a strong desire to develop the field. As dermatologists, first of all, they should correctly position themselves in dermatologic surgery. As mentioned before, dermatologic surgery is mainly for the purpose of treatment, especially in the diagnosis and treatment of skin tumors, which has unparalleled advantages of other sister disciplines. As dermatologists should also recognize that dermatologic surgery is an inherent subdiscipline of dermatology, dermatologic surgeons must be a qualified dermatologist, dermatology is the foundation of dermatologic surgery, the source of development, to try to avoid the division between dermatologic surgeons and conventional dermatologists. As a dermatologist it is more important to take the responsibility of promoting dermatologic surgery in order to increase the public’s attention to skin tumors.
5.2 From simple to complex, step by step: At present, many hospitals have the desire to carry out dermatologic surgery, but are afraid to do so.
Many hospitals have the desire to develop dermatologic surgery, but they are afraid of the difficult and high-risk surgical techniques. The scope of dermatologic surgery is very wide, and the technique is also from simple to complex. At the beginning of dermatologic surgery, we can choose simple and easy operations, such as skin biopsy, CO2 laser treatment, pike excision and simple closure of non-exposed areas. Later, through study, we will gradually start to perform excision of head and facial masses, Mohs microscopic tracing, flap formation and skin implants. As a dermatologist, if you dare to take the first step, you will feel that the sky is wide open. It is the right of every dermatologist to carry out dermatologic surgery, and it is also the responsibility and obligation of dermatologists to their patients. I believe that with the development of the work of the Chinese Association of Dermatologists, the training of dermatologic surgeons will become more and more formalized and routine.
5.3 Focus on inclusiveness and innovation by combining basic and clinical: The driving force of a discipline’s development is innovation. In retrospect, every technological leap in dermatologic surgery has been the result of a close integration of basic and clinical aspects: Mohs microscopic tracing is a combination of dermatology, pathology, and surgical techniques [2]; hair transplantation is a cross product of hair physiology, surgical techniques, and aesthetics [3]; botulinum toxin injection is the result of a perfect collaboration between ophthalmologists and dermatologists (husband and wife), which involves local anatomy, toxicology, and the use of a combination of the two. connotation involves local anatomy, toxicology, kinetics of wrinkle formation and histological knowledge [4]. In conclusion, the cross-fertilization of disciplines is a major trend in the development of science, as dermatologists should grasp the pulse of the times, focus on inclusion, focus on the combination of basic and clinical innovation, only then can dermatologic surgery sustainable development, in technology to stand up to the tide, for the benefit of patients and promote medical development. Although dermatologic surgery has a long history and is currently in full swing in foreign countries, it is still at the initial stage of development in China, and there is a long way to go as a dermatologic surgeon. However, the mature and advanced experience of foreign countries can help us to learn from them, and we believe that the level of dermatologic surgery in China can quickly catch up with the world advanced level in a short time.
5.4 Emphasis on non-technical factors in carrying out dermatologic surgery [5]: exquisite surgical technique is an important indicator for evaluating dermatologic surgeons, however, purely surgical technical factors are not enough to ensure the successful development of dermatologic surgery. During surgery, there is no doubt that the physician must have excellent technique, but there are many other requirements for the physician himself, such as responsibility, ability to communicate with the patient, sensitivity to anticipate unexpected events, and flexibility and decisiveness in handling problems, and even the physical and mental state of the physician at the time of surgery, which can directly affect the outcome of the surgery. Imagine if a physician is careless and careless in surgery, or if he or she has a stiff attitude in communicating with patients, causing them to feel annoyed, or if he or she is busy and confused in the face of surgical accidents, or if he or she is extremely tired, how can the surgical results be guaranteed? How can they get the patients’ approval? This will eventually lead to an increase in the incidence of medical disputes.
The patient is the target of the surgery, and his or her influence on the outcome of the surgery is often overlooked. For example, in the case of superficial mass removal for cosmetic purposes, patients often have high expectations of the surgical outcome, making the final evaluation of the surgical outcome much less favorable. There are also patients who do not agree with the risks of surgery or who are unable to actively cooperate with the surgery, such as children and overly stressed patients, which can also have a negative impact on the outcome. Therefore, the physician must do a good job of preoperative education and communication with the patient before the surgery, so that the patient can achieve an optimal state of psychological and physical adaptation to the surgery, making the patient a plus factor for the success of the surgery.
The surgical procedure is actually a matter of process. Many surgeons devote a lot of energy to techniques such as flap shaping, but neglect many important aspects of the procedure, such as preoperative evaluation and postoperative follow-up. It is important not to neglect a thorough preoperative evaluation because of the small size of the procedure, which can have unimaginable consequences if a small probability event occurs. Post-operative follow-up is also very important. Standardized post-operative follow-up ensures that patients’ complications are treated in the first place, and is also very meaningful for physicians to accumulate clinical experience. Emphasis on surgical procedures also ensures homogeneity and efficiency of surgical quality. As a dermatologist you should develop a standardized workflow with your own characteristics according to the specific conditions of your own operating room.
An excellent team of nursing and technical staff is also very important for the successful performance of dermatologic surgery. The operating room nurse usually plays the role of a big housekeeper, she is responsible for the maintenance of the operating room, communication between the operating room and other departments of the hospital, and the organization of many materials in the operating room; before and after the surgery, the nurse can also assist the physician to communicate with the patient and help the physician to complete certain medical treatment; during the surgery, the nurse is also the physician’s right hand on the table; for Mohs microscopic tracing surgery, hair transplantation surgery, the nurse and For Mohs microscopy and hair transplantation, nurses and technicians play a key technical support role. In short, without a competent team of nurses and technicians, the operating room cannot work properly. The successful development of dermatologic surgery also requires that efforts be devoted to the formation and training of a team of professional nurses and technicians.
In addition to personnel factors, the success of surgery also benefits from the configuration of hardware. Not only does the surgical space require relative medical sterility, but attention should be paid to comfort and the protection of patient privacy. From the surgical bed to the surgical lights, from surgical instruments such as knives, scissors and wires to the electrocoagulant, all of them have an important impact on the quality of surgery. The proper preparation and storage of surgery-related drugs will also directly affect the outcome of the surgery. In addition, attention should be paid to whether the surgical hardware is well matched and its maintenance is in place. Sometimes these factors are easily overlooked by the surgeon and have a direct or indirect negative impact on the surgery. “A good horse with a good saddle”, as a surgeon not only needs to be familiar with and understand the various hardware facilities required for surgery, but also should change from passive acceptance and application to active concern, mastering every aspect of surgical hardware from acquisition to maintenance, and truly being the master of the operating room.
As a discipline, dermatologic surgery should also achieve the purpose of sustainable development of the discipline through medical education and research. In order to meet the needs of medical education and research, in addition to the above factors, there are many perioperative management elements that are also very important. For example, how to irradiate preoperative and postoperative photos or videos under a uniform standard, and how to save them for easy retrieval? Some physicians take photos randomly, resulting in the difference between pre- and post-operative photographic conditions, so that the meaning of the photo itself is lost; furthermore, some physicians fail to organize surgical photos in a timely manner, resulting in a large number of pre- and post-operative photos mixed in the computer can not be retrieved, resulting in the waste of valuable information. In addition, some physicians believe that dermatologic surgery is a purely medical practice, but in fact, under the conditions of socialist market economy, dermatologic surgery must make health economics statistics on its income and expenditure, otherwise it is difficult to ensure the sustainable development of this discipline, and engage in these so-called “economic” work will also take up a lot of energy. In conclusion, the implementation of dermatologic surgery is an important task.
In short, the implementation of dermatologic surgery is a systemic project, only to meet the standards in order to satisfy patients, in order to make the discipline sustainable development, otherwise, under the principle of the barrel, the lack of any one link may lead to immeasurable negative effects.