Surgical Dermatology: Techniques, Oncology, and Cosmetic Interventions
Surgical dermatology plays a pivotal role in the management of cutaneous malignancies, benign growths, and cosmetic enhancement. For expert dermatologic surgeons, mastery of excisional design, tissue handling, histologic margin control, and aesthetic closure is essential to optimal patient outcomes. This article explores advanced surgical practices, procedural innovations, and reconstructive strategies in dermatologic surgery.
Excisional Surgery and Margin Control
Excisional surgery remains the gold standard for treating most non-melanoma skin cancers. Margin determination based on tumor subtype and location guides the approach.
Key Surgical Considerations:
-
Standard Excision: 4–6 mm margins for BCC/SCC with layered closure
-
Mohs Micrographic Surgery: Indicated for high-risk or facial tumors, offering maximal tissue conservation with immediate histologic evaluation
-
Staged Excision: For lentigo maligna and melanoma in situ when margins are ill-defined
Image: Stages of Mohs surgery and defect closure.
Reconstructive Techniques
Defect closure after excision is an art guided by location, tension vectors, and cosmetic subunits.
Reconstruction Options:
-
Primary Closure: Ideal for small defects under low tension
-
Skin Grafting: Split-thickness or full-thickness grafts for larger areas
-
Local Flaps: Advancement, rotation, and transposition flaps used in nasal, periocular, and auricular regions
-
Complex Repairs: Bilobed, rhombic, or interpolated flaps for challenging facial zones
Image: Crosshatch diagram of flap design around nasal ala.
Surgical Management of Benign and Pre-Malignant Lesions
Lesions such as dysplastic nevi, sebaceous hyperplasia, epidermoid cysts, and actinic keratoses may warrant surgical removal for diagnostic clarity or patient preference.
Common Techniques:
-
Shave Excision: For raised lesions and histologic confirmation
-
Punch Excision: Small nevi or cysts in high-tension zones
-
Electrosurgical Destruction: For superficial lesions with cosmetic consideration
Cosmetic Dermatologic Surgery
Aesthetic skin surgery intersects with cosmetic dermatology to enhance facial symmetry and skin texture.
Procedures Include:
-
Blepharoplasty: Upper and lower lid rejuvenation
-
Scar Revision: Z-plasty, W-plasty, and dermabrasion
-
Subcision and Microneedling: For acne scars and dermal tethering
-
Laser Surgery: For telangiectasias, lentigines, and post-surgical erythema
Oncologic Surveillance and Multidisciplinary Integration
Postoperative surveillance following excision of high-risk tumors such as melanoma includes:
-
Serial Skin Exams: Every 3–6 months for 2 years, then annually
-
Sentinel Lymph Node Biopsy: For intermediate-thickness melanoma
-
Interdisciplinary Coordination: With oncology, ENT, and oculoplastic teams
Conclusion
Surgical dermatology is an elegant fusion of oncologic rigor and reconstructive finesse. With advancing techniques and a growing demand for aesthetic outcomes, dermatologic surgeons are uniquely positioned to manage skin pathology from excision to cosmetic restoration with precision and artistry.
Disclaimer: This article is intended for dermatologic surgeons and assumes advanced procedural expertise.