Surgical dermatology is a specialized field focusing on the diagnosis and treatment of conditions affecting the skin, hair, nails, and adjacent mucous membranes through invasive procedures. This subspecialty bridges the diagnostic knowledge of general dermatology with surgical technical skills. It applies a range of techniques to manage benign and malignant skin diseases, emphasizing functional and cosmetic outcomes. The practice incorporates procedures for removal, repair, and restoration when conditions require more than topical or systemic medical therapy.
Defining the Practice of Surgical Dermatology
A surgical dermatologist is a physician who completes a standard dermatology residency followed by additional specialized training. This education is frequently obtained through an accredited, one-year fellowship in Micrographic Surgery and Dermatologic Oncology, providing comprehensive experience in advanced surgical and reconstructive techniques.
Most procedures in this specialty are conducted in an outpatient setting, such as a dedicated clinic or office surgical suite. These operations are typically performed using local anesthesia, which numbs only the specific area being treated. This outpatient approach minimizes patient downtime and avoids the need for a hospital stay in most cases.
Treating Common Skin Conditions
Surgical dermatologists routinely manage common, non-cancerous growths that require removal for diagnostic, functional, or cosmetic reasons. These procedures often involve a simple excision, where the lesion is cut out entirely and the resulting wound is closed with sutures. Examples include benign melanocytic moles (nevi), which are often excised if they appear atypical or cause chronic irritation.
Other frequently treated conditions are subcutaneous lumps like epidermoid cysts (keratin-filled sacs) and lipomas (soft, fatty deposits beneath the skin). The surgical approach for these removes the entire structure, including the cyst wall or lipoma capsule, to reduce recurrence. Simpler methods, such as curettage or cryosurgery, may also be used for superficial lesions like common warts or seborrheic keratoses.
Simple biopsies are also a core function, involving the removal of a small tissue sample for microscopic examination by a pathologist. This diagnostic step determines if a suspicious lesion is benign, precancerous, or malignant. The precise nature of these excisional procedures ensures that surrounding healthy tissue is conserved.
Specialized Techniques for Skin Cancer
The most recognized application of surgical dermatology is in the treatment of skin cancer, particularly through specialized, tissue-sparing techniques. Mohs Micrographic Surgery (MMS) is the premier method for removing high-risk basal cell and squamous cell carcinomas, offering superior cure rates compared to traditional excision. This unique procedure involves the surgeon acting as both the operator and the pathologist, examining tissue margins immediately in an on-site laboratory.
The Mohs technique is performed in stages. A thin layer of cancerous tissue is removed, mapped, and flash-frozen for microscopic analysis. The surgeon examines 100% of the peripheral and deep margins of the excised tissue to ensure no cancer cells remain. If residual cancer is detected, the surgeon precisely removes only the involved margin, repeating the process until the margins are clear.
This layer-by-layer removal is indicated for tumors in cosmetically sensitive or functionally important areas, such as the face, ears, and hands. Mohs surgery prioritizes the maximum preservation of healthy tissue, minimizing the resulting defect size while ensuring complete tumor removal. For more aggressive cancers, such as melanoma, a surgical dermatologist may perform a wide local excision, removing the tumor with a larger, predetermined margin of surrounding normal tissue.
Post-Surgical Repair and Restoration
Following lesion removal, the focus shifts to the repair and restoration of the resulting surgical defect. The goal of this repair is to achieve functional integrity and an optimal cosmetic appearance. The simplest method is primary closure, where the skin edges are brought together and closed with sutures to create a linear scar.
For larger defects or those under high tension, the surgeon may employ sophisticated reconstructive techniques. A skin graft involves transplanting a thin piece of skin from a donor site on the patient’s body, such as behind the ear or on the collarbone, to cover the wound. A local flap involves carefully mobilizing and repositioning a section of adjacent, healthy skin to cover the defect.
The choice of repair method depends on the size and location of the wound, skin elasticity, and the need to preserve underlying structures. Proper post-operative wound care is essential for restoration, often involving keeping the wound moist with an occlusive ointment to prevent scab formation. This moist environment promotes faster healing and can lead to a less noticeable final scar.