A history of dermatologic surgery in the United States

Procedural dermatology and its unmet need

Procedural dermatology includes invasive conventional dermatologic surgeries which involve significant use of knife and suture, minimally invasive procedures and device-based procedures. Device-based procedures are the easiest to learn and are less prone to human errors due to automation but can lead to monotony, while conventional surgeries require significant skill, craftsmanship and interest. There has been a recent shift in the approach to procedural dermatology as a therapeutic option with complementary and combination models replacing the conventional hierarchical model in which procedures were last in the step-ladder approach. The demand for both conventional dermatologic surgeries and minimally invasive cosmetic procedures is increasing. Unfortunately, this demand has not been met with adequate supply. Consequently, the number of trained professionals with expertise in these procedures is very limited; they are far outnumbered by unqualified practitioners. A limited number of dermatologic surgeons practicing conventional surgeries has resulted in huge waiting lists for vitiligo surgeries, inappropriate excisions for skin cancers and poor cosmetic outcomes of excisions without proper knowledge of flaps and grafts. Increasingly procedures are being performed by inadequately trained personnel, resulting in complications. There is also an absence of good quality research on the subject of procedural dermatology, which has resulted in a lack of standardisation of various procedures and knowledge about the efficacy of various drug-procedure and procedure-procedure combinations. An increasing variety of gimmicky but costly procedures are being offered to the public without much evidence of efficacy. Individual institutional and broad policy directives are needed to address these issues. Special emphasis is required on formal hands-on procedural dermatology training during residency and beyond it.

Correlation between the time elapsed after liposuction and the risk of fat embolism: An animal model

Background

Liposuction has become one of the most frequently performed procedures in the field of aesthetic surgery. Fat embolism syndrome after liposuction can easily be overlooked or underestimated; however, occasionally, fulminating fat embolism syndrome can develop and lead to a critical situation within 2–3 days after lipoplasty. Changes over time in the amount of circulating fat particles and the histology of major organs have not yet been studied.

Methods

This study was conducted using 18 male Sprague-Dawley rats aged 12 weeks and weighing 500–628 g (average, 562 g). Fifteen rats were used as the experimental group and 3 as the control group. Under general anesthesia, tumescent-technique liposuction was performed at the lateral flank areas and abdomen for 1 hour. Blood, lung, and brain tissue specimens were obtained at 1 hour, 1 day, and 2 days after the liposuction procedure.

Results

The average number of fat particles in the blood samples was 25,960/dL at 1 hour, 111,100/dL at 24 hours, and 21,780/dL at 48 hours. The differences between study groups were statistically significant. Both intravascular and extravascular fat particles with inflammation were seen in all 15 rats, as were inflammatory cell infiltration, hemorrhage, and consolidation with shrinkage of the lung alveoli.

Conclusions

These results imply that there is a strong possibility of fat embolism syndrome after liposuction in real clinical practice, and the first 24–48 hours after the operation were found to be the most important period for preventing pulmonary embolism and progression to fulminating fat embolism syndrome.

Transposition of intravascular lipid in experimentally induced fat embolism: a preliminary study

BACKGROUND

Liposuction is a procedure to reduce the volume of subcutaneous fat by physical force. Intracellular storage fat is composed of triglyceride, whereas circulating fat particles exist as cholesterol or triglycerol bound to carrier proteins. It is unavoidable that the storage form of fat particles enters the circulation system after these particles are physiologically destroyed. To date, however, no studies have clarified the fatal characteristics of fat embolism that occurs after the subclinical phase of free fat particles.

METHODS

A mixture of human lipoaspirate and normal saline (1:100, 0.2 mL) was injected into the external jugular vein of rats, weighing 200 g on average. Biopsy specimens of the lung and kidney were examined at 12-hour intervals until postoperative 72 hours. The deposit location and transport of the injected free fat particles were confirmed histologically by an Oil Red O stain.

RESULTS

Inconsistent with previous reports, free fat particles were transported from the intravascular space to the parenchyma. At 24 hours after infusion, free fat particles deposited in the vascular lumen were confirmed on the Oil Red O stain. At 72 hours after infusion, free fat particles were accumulated compactly within the parenchymal space near the perivascular area.

CONCLUSIONS

Many surgeons are aware of the fatal results and undiscovered pathophysiologic mechanisms of free fat particles. Our results indicate that free fat particles, the storage form of fat that has been degraded through a physiological process, might be removed through a direct transport mechanism and phagocytotic uptake.

Dermatologic subspecialties in German inpatient dermatology:a national survey

BACKGROUND

In German-speaking countries, the specialty of dermatology is characterized by a large amount of subspecialties. Data providing information whether and to what extent these subspecialties are represented in German dermatology departments and clinics is not available.

METHODS

A national questionnaire survey was performed to determine the extent of involvement of dermatological subspecialties in dermatologic hospitals.Methods of descriptive statistics were applied.

RESULTS

Overall, 90 dermatologic departments participated in this survey with a response rate of 78.3 %.The subspecialties allergology, dermatooncology,and dermatologic surgery are represented in over 90 % of departments; the sub-specialties andrology, aesthetic dermatology, dermatopathology, microbiology,phlebology,photobiology,proctology, and wound healing are represented in over 50 % of clinics. Furthermore, the subspecialties allergology, dermato-oncology, photobiology, and dermatopathology have strong research or academic representation.

CONCLUSIONS

The present survey demonstrates that dermatologic subspecialties are widely represented in dermatologic departments and clinics not only by individuals with specialty training but also by those in higher academic posts. This demonstrated high expertise should be maintained in German dermatology and could be promoted by academic programs.

[Current situation of dermatologic surgery in Germany]

BACKGROUND

Dermatologic surgery has become an increasingly important issue in dermatology in recent years. At present, no current epidemiologic or care-related data on cutaneous surgery procedures in dermatology are available.

METHODS

To determine the extent of cutaneous surgery procedures in dermatological hospitals, a national survey was performed. Both the procedure codes for 2004 based on the OPS-classification and the DRG figures grouped to the major diagnostic category 09 of G-DRG version 2004 were considered in detail. Methods of descriptive statistics were applied.

RESULTS

The submitted data reveal that the contributing hospitals provided 164487 cutaneous surgery procedures in the investigation period. The vast majority is represented by extensive procedures and plastic-reconstructive operations, as opposed to less complex surgeries such as simple excisions. Analysis of DRG assignment indicates that surgical procedures account for 44.2% of inpatient cases.

CONCLUSIONS

The present survey demonstrates that in Germany cutaneous surgery procedures are widely performed by dermatological hospitals and dermatologists. The increasing incidence of melanoma and nonmelanoma skin cancer including precursor lesions will increase the need for dermatologists to perform cutaneous surgery in the future.

Assessment of the Risk of Systemic Fat Mobilization and Fat Embolism as a Consequence of Liposuction: Ex Vivo Study

BACKGROUND

Adverse consequences of liposuction, including those associated with fat embolism, have been reported in the literature. Fat embolism syndrome after liposuction may be underestimated because of the unspecific nature of the symptoms. The aim of this study was to determine whether there is a generic risk of the generation of intravascular fat emboli as a consequence of liposuction.

METHODS

An animal study was conducted in which liposuction was performed on 10 Sprague-Dawley rats. The procedure was conducted with the animals under general anesthesia for 60 minutes, in a similar manner to that practiced clinically. Three blood samples were taken from each animal through a central line (one before liposuction and two at 30 and 60 minutes into liposuction) and examined for the presence of fat particles. The animals were then euthanized and the lungs and brain were removed for histological examination. In the control group, liposuction was not performed, but similar blood and histological samples were taken.

RESULTS

In the study group, stained fat particles were seen in all blood samples taken during liposuction but not in those taken before liposuction. The difference between the 30- and 60-minute samples and the preliposuction control ones was statistically significant (p < 0.001 minimum). The differences between the 30-minute and 60-minute samples were also statistically significant (p = 0.017), demonstrating that fat mobilization during liposuction is a cumulative process. Nothing of significance was seen in the blood samples of the control group. Lipid deposits were seen in the lungs of all study group animals but not in the control group. With one possible exception, no lipid deposits were confirmed in brain specimens.

CONCLUSIONS

The authors' experiments have demonstrated a significant risk of systemic fat mobilization and fat embolism after liposuction in the animal model. Further clinical investigation is required to evaluate the real clinical risk of this procedure from this perspective.

Dermatologic Surgery Practice and Skin Cancer Treatment in Canada: Results of a National Survey

BACKGROUND

Although traditionally considered a medical subspecialty, dermatology has rapidly evolved over the past two decades to encompass a wide variety of cutaneous surgical procedures.

OBJECTIVE

The study was carried out to evaluate the status of dermatologic surgery practice and skin cancer treatment in Canada.

METHODS

In 2003, 550 practicing Canadian dermatologists were surveyed.

RESULTS

Two hundred fifty-one dermatologists responded to the questionnaire, with the majority practicing in an urban part-time academic, part-time private setting. Statistics are presented on the types and demographics of dermatosurgical and cosmetic procedures performed, as well as on the specific dermatosurgical therapies used in the treatment of various cutaneous malignancies.

CONCLUSIONS

The survey provides a current picture of dermatologic surgery practice and skin cancer treatment in Canada. The data suggest that Canadian dermatologists are further embracing surgical and cosmetic procedures.

The cutaneous surgery experience of multiple specialties in the Medicare population

BACKGROUND

There has been tremendous growth in the performance of ambulatory surgical procedures. Traditional forms of peer review, commonplace for hospital-based procedures, are not typically performed in the office-based setting. Hospital credentialing of physicians has been suggested to be a means of assuring patient safety. Credentialing committees may be unaware of the level of experience of typical office-based physicians who perform cutaneous surgery.

PURPOSE

To compare the levels of cutaneous surgery experience of dermatologists and other surgical specialists.

METHODS

Medicare claims data on number of cutaneous surgery procedures performed by various medical disciplines, including dermatologists, plastic surgeons, general surgeons, and others, were obtained from the 1998-1999 Medicare Current Beneficiary Survey (MCBS) and analyzed. The number of physicians in each specialty was used to normalize the data to a per physician basis.

RESULTS

Dermatologists performed half (50%) of the complex repairs and most of the excisions (58%) and intermediate repairs (62%). Dermatologists performed more flaps (40% of all flaps) than any other specialty, while plastic surgeons performed more total grafts (38%) than any other specialty. Dermatologists and plastic surgeons performed similar numbers of full-thickness skin grafts, while plastic surgeons performed more split-thickness skin grafts.

CONCLUSION

As dermatologists seek hospital credentials for performing cutaneous surgery procedures, these data should help surgical colleagues understand the typical level of experience of their dermatologist colleagues.

Topical protease therapy as a novel method of epidermal ablation: preliminary report

BACKGROUND

For more than 50 years, proteolytic enzymes have been extensively used in laboratory settings for the purposes of in vitro epidermal separation and keratinocyte isolation. However, the topical, in vivo pharmacologic properties of these enzymes are virtually unknown. Previous therapeutic applications for topically applied proteases have been limited to wound debridement.

OBJECTIVE

To characterize the clinical and histologic effects of topically applied proteases as a method of therapeutic epidermal ablation.

MATERIALS AND METHODS

SKH-1 hairless mouse and human skin samples were exposed both in vitro and in vivo to varying concentrations of the proteases subtilisin, trypsin, and dispase for different exposure durations. The effects of protease exposure were then assessed by both clinical and histologic examination.

RESULTS

Exposure of both human and mouse skin samples to topical protease solutions resulted in reproducible, differential patterns of epidermal ablation: subcorneal, intraepidermal, and subepidermal. In a limited study, topical application of trypsin solution resulted in the scar-free ablation of lesions of seborrheic keratosis located on the lower extremity.

CONCLUSION

Topically applied proteases represent an alternative method of epidermal ablation with several potential advantages over existing techniques. Further studies are needed to delineate ideal enzyme formulations, vehicles, and applications.