Surgical Dermatology: What Procedures Does It Involve and When Do You Need One?

Surgical dermatology is a specialized skill built into the dermatologist’s practice. The procedures get rid of skin problems fast and usually achieve long-lasting, aesthetically pleasing results. However, surgery is not appropriate for every skin condition, and it can produce side effects that not everyone can tolerate.

What treatments fall under surgical dermatology? And what skin disorders can they address? This article explains the basics of surgical dermatology and the importance of entrusting a dermatologic surgical procedure to the right medical professional.

What Is Surgical Dermatology?

According to the American College of Surgeons (ACS), surgery is the alteration of a body part by using energy to destroy tissues.

• Mechanical energy is involved when the doctor uses a scalpel, needle or ultrasound equipment to make incisions.
• Thermal energy uses changes in heat content or temperature to cut away at tissues. Examples are cautery and cryotherapy.

• Electromagnetic energy uses powerful light beams, such as visible and invisible lasers, ionizing radiation, and radiofrequency, during operations.

• Chemical energy damages tissues by powering up molecular changes. Substances used for treating varicose veins work because of chemical energy.

Surgical dermatology is, simply, the application of these techniques to structures in the skin. The ACS excludes simple drug injections into the skin, muscle and blood vessels from this definition.

What Is the Difference Between Plastic and Dermatologic Surgery?

Plastic surgery overlaps with dermatologic surgery in that both can correct cosmetic flaws. But they differ primarily in terms of extent.

Plastic surgery can involve deeper structures like bones and cartilage. Plastic surgeons train in general surgery before they get into the specialty. They are certified by the American Board of Surgery.

Meanwhile, dermatologic surgery manipulates only the skin and skin-deep structures like the hair and nails. It is part of dermatology residency training, although a dermatologist can further pursue it as a subspecialty. Dermatologic surgeons are certified by the American Board of Dermatology.

How Different Is Cosmetic Dermatology from Surgical Dermatology?

Cosmetic and surgical dermatology also overlap considerably, but they differ in terms of intent.

Surgical dermatology corrects skin flaws that may or may not be medically problematic. An example is scar revision. Scars may or may not restrict movement, depending on their location and extent of involvement.

On the other hand, many cosmetic procedures use the principles of dermatologic surgery to improve the appearance of a normally functioning body part. Earlobe skin tag excision is one example.

Practitioners of both disciplines are certified by the American Board of Dermatology.

What Kinds of Disorders Are Cured by Dermatologic Surgery?

Surgical dermatology corrects the following issues:

Benign conditions of the skin

Belonging to this category are wrinkles, scars, moles, and slow-growing lumps that have a very low risk of progressing to cancer, such as the epidermoid cyst.

Infections

Warts and infected ulcers are some examples.

Precancerous growths

These masses are benign but are more likely to transform into skin cancer if left untreated. Actinic keratosis, which can become squamous cell carcinoma, is an example.

Malignant tumors

Basal cell carcinoma, squamous cell carcinoma and melanoma are some skin cancer types commonly treated by surgery.

Nail problems

They include erratic nail growth, infections and benign and cancerous conditions.

Hair problems

Surgical treatment is also appropriate for some cases of abnormal hair loss or growth.

Varicose veins

These are dilated superficial blood vessels that may cause health complications over time if not remedied.

Surgical conditions are typically confined to a limited anatomic area and respond poorly or not at all to medical therapy.

What Surgeries Can Dermatologists Do?

Dermatologists are experts in the surgical treatment of diseases involving the skin, hair and nails. The procedures they use include the following:

Surgical Excision

In a simple surgical excision, the dermatologist uses a scalpel to remove a skin blemish whole. Local anesthesia is typically injected in the surgical site beforehand, though other forms of pain management may be given depending on the lesion’s severity and location. This technique can treat benign and malignant tumors.

Mohs Micrographic Surgery

The Mohs procedure is a special type of skin cancer surgery. The Mohs surgeon removes thin slices of malignant tissue until the entire lesion is gone along with a small, tumor-free margin. This tissue-sparing technique is the gold standard of skin cancer treatment due to its superior cure rates and cosmetic outcomes. Local anesthesia makes it pain-free.

Reconstructive Surgery

Reconstructive surgery uses skin flaps and grafts to cover substantial surgical defects or improve the appearance of old scars and other blemishes. The patient is given local anesthesia preoperatively for pain management.

Flaps are partially detached portions of healthy skin that close up nearby defects. By comparison, grafts are taken from more distant sites.

In skin cancer surgery, reconstruction prevents the formation of large scars. It can be done as soon as tumor removal is complete or even long after. Same-day reconstruction is common after Mohs surgery, but that is not the case for simple surgical excision. Tumor clearance confirmation after a wide excision takes days.

Cryosurgery

During cryosurgery, the doctor uses a freezing agent, usually liquid nitrogen, to destroy a skin lesion. The treatment causes little or no pain, so it does not normally require numbing medication. Its indications include pigmented lesions and benign and cancerous skin growths.

Cryosurgery cannot be used on recurrent skin tumors and suspicious lesions requiring a biopsy for clearance, e. g. irregularly shaped moles. Cold urticaria—the tendency to develop rashes when exposed to low temperatures— and other signs of abnormal cold intolerance are additional contraindications of this procedure.

Electrosurgery

Electrosurgery cuts skin tissue using electricity or electrically generated heat. Alone, it can treat benign growths like warts and seborrheic keratosis. But it is more often used in combination with other surgical techniques to close up blood vessels and take out cancer cells.

Local anesthesia is injected into the surgical site at the start of the procedure. Electrosurgery is contraindicated in cardiac patients with ICDs.

Nail Surgery

Nail surgery uses metallic tools to remove diseased nails or nail parts. For pain management, the dermatologic surgeon injects local anesthesia close to the nail (distal digital nerve block) or at the base of the finger (proximal digital nerve block). The doctor may reconstruct the site afterward if necessary.

This treatment can get rid of dried blood, avulsed nails, pus, ingrown nails, abnormally growing nails and benign and malignant nail tumors. Doctors also use it for nail biopsies.

Varicose Vein Treatments

The dermatologic surgeon has several tools for eliminating huge, unsightly veins. They include:

Sclerotherapy

In a sclerotherapy procedure, the dermatologist injects a substance directly into the vein that irritates and injures its inner wall. The vein collapses and turns into a scar tissue cord within days while its blood reroutes to other vessels. Pain medication is normally not needed during the session.

Endovenous Ablation and Occlusion

Here, the doctor uses a radiofrequency or near-infrared laser instrument to heat up the vein’s interior. The damage leads to scarring and shrinkage of the blood vessel. Local anesthesia numbs the site during the procedure.

Ambulatory Phlebectomy

This technique lets the dermatologic surgeon pull out the problematic vein through a small skin incision. Local anesthesia is given preoperatively to eliminate pain.

Laser Surgery

Dermatologists may also use non-ablative, near-infrared laser equipment to get rid of sclerotherapy-resistant varicose veins, spider veins and abnormally connected vessels. The procedure does not require pain medication because the equipment sprays a cold mist on the skin.

Cosmetic surgical treatments are discussed in our article on cosmetic dermatology.

When Does a Dermatologist Consider Surgical Treatment for a Skin Problem?

Surgery can get rid of skin issues quickly, but it is not a cure-all. Dermatologists consider the following factors before recommending it:

Anatomic location

The lesion must be confined to a limited area and cannot encroach on nerves, vital organs or major blood vessels. Large defects create huge scars, and inadvertent damage to important structures can be fatal or cause lifelong dysfunction.

Risk of recurrence or spread

The risk of recurrence or spread depends on the procedure used and the type and location of the lesion. For example, Mohs surgery is more appropriate than other techniques for cancers in spread-prone areas like the center of the face. Meanwhile, recurrent conditions like psoriasis are not treated by surgical removal because repeated trauma will do more damage to the skin.

Age

The elderly heal more slowly and may have health conditions that make any type of surgery harmful to them.

The patient’s physical status

Surgery is often contraindicated in people with inborn or acquired disorders of the immune system, blood, metabolism and connective tissues.

Expected cosmetic outcome

There are instances when surgery is preferred over other modalities because the aesthetic results are expected to be better. For example, Mohs surgery is preferred in young skin cancer patients over radiotherapy, which causes gradual skin deterioration.

The lesion’s response to medical treatments

In some cases, drug therapy is either futile or unsafe. For instance, medications cannot treat the underlying causes of vascular birthmarks and varicose veins. Meanwhile, skin-peeling treatments that work on small warts will only ulcerate skin tags and make them prone to infection. Individuals with these skin issues will benefit more from surgical treatment.

Cost-effectiveness

The doctor may also consider surgery over medical therapy if it can lower the overall cost of treatment. One example is the highly effective Mohs surgery, which spares most patients from the costs of treating skin tumor recurrence. Another is reconstructive surgery of large burns, which reduces costs by preventing systemic complications and long hospitalization stays.

Patient preference

A doctor needs a patient’s informed consent before starting any form of therapy. But some people who want cosmetic enhancement actually prefer surgery, e. g. laser for wrinkles, over medical treatments.

The risk of developing adverse events after surgery varies from person to person. The dermatologic surgeon may ask for medical clearance during the evaluation process to ensure that a procedure poses little or no harm to a patient.

Doctors consider skin surgery when…
	The lesion is confined to a limited area and does not involve vital structures.
	The condition has a low risk of recurrence or spread.
	The patient is young and in good health.
	Surgery is expected to produce a good cosmetic result.
	Other forms of treatment are ineffective or unsafe.
	Surgery is the most cost-effective option.
	The patient prefers or consents to surgery.

What Can You Expect When Undergoing a Skin Surgical Treatment?

Each type of surgical procedure has specific requirements. But here, we explain what you can expect and the ones they share in common.

Before Your Surgery

Your dermatologist will evaluate you thoroughly to determine which treatment is the safest and most effective for you.

If you are currently receiving therapy for a chronic health condition, your doctor may ask you to present a medical clearance.

If you’re using a treatment that can make you overly sensitive to a surgical procedure or its parts, you may be instructed to stop temporarily. For instance, glycolic acid can sensitize your skin to lasers.

Except for urgent cases like skin cancer, your physician may recommend postponing surgery if you are pregnant.

A history of severe allergic reactions to local anesthesia, latex, tape adhesives and other materials used during surgery can make the doctor consider other options. The same is true if you’re prone to keloid scarring.

Smoking and drinking can interfere with blood function and wound healing. Your doctor will advise you to abstain one week before and one week after your appointment.

Local or topical pain meds are used most of the time, so you’re expected to be fully awake upon discharge. But your dermatologist may still advise you to bring a companion to help with aftercare, e. g. when the treatment involves your back, limits your mobility, etc.

During Your Surgery

At the start of the treatment session, your doctor will clean up and mark the surgical site. Some procedures will require shielding the surrounding areas with sterile fabric before giving numbing medication and making the first incision. Local anesthesia takes about 30 minutes to work in most patients.

The length of surgical sessions varies widely. Cryosurgery or laser treatment of small warts takes only a few minutes. By comparison, Mohs procedures with immediate reconstruction can take several hours.

After Your Surgery

Your doctor will give you instructions for proper wound care before sending you home. Water and mild soap are usually enough for cleaning. Some procedures will require daily dressing changes postop, while others will not.

The length of the recovery period depends on the procedure done, the lesion’s severity and location and your physical status. For example, non-ablative laser treatment usually requires only a little downtime. In contrast, recovery from toenail surgery or varicose vein sclerotherapy can take a week or two. Postop healing is generally delayed by systemic problems like immunosuppression and malnutrition.

The most common side effects of dermatologic surgery are pain, redness, and swelling, all due to inflammation. Vulnerable people may experience bruising. Your physician will instruct you to use a cold compress in the first 24 hours after surgery and a warm compress afterward to control the inflammation. You may take over-the-counter analgesics for pain.

Less common side effects include infection, excessive bleeding, allergies, severe scarring and pigmentation changes. High-risk skin cancers may recur. The rest are treatment-specific and will be discussed during your clinic visit. You may call your dermatologist for problems that you think are related to your surgery.

On follow-up, your doctor will examine the treated site and see if you need another session or a combination therapy.

Why Should You Choose a Dermatologist to Perform Your Skin Surgery?

As you can see, dermatologic surgeries require meticulous planning from start to finish. Many details need close attention, and missing any of them can make a procedure ineffective or even dangerous.

You must choose a board-certified dermatologist to perform your skin surgery because:

• They have specialized knowledge of the skin and its components, their diseases and how to treat them. Imagine if someone less qualified injected local anesthesia in the wrong place or took out an oversized piece of normal skin tissue!

• They have a sharp clinical eye for skin cancer, allowing them to remedy it promptly.

• They know a wide variety of alternative skin treatments that can give better cosmetic results, reduce costs, help avoid major complications or meet other patient needs.

You may check out our guide on finding a good dermatologist if you want more information on this subject.

There’s a Reason for the Term “Surgical Precision”

Dermatologic surgery is a medical specialty like no other. It allows a physician to use different forms of energy to remove skin blemishes while maintaining the cosmetic and functional integrity of the involved body part. Each procedure has unique features and treats different problems. But they all require that a health provider possess laser-sharp diagnostic skills and technique.

Whether you’re looking to eliminate a risky lesion or make your body look better, you must choose a board-certified dermatologist to perform your skin surgery. You need their expertise to ensure that the procedure is effective and safe. An inexperienced provider, while cheap, can do you more harm than good. But finding the right medical professional for your skin’s needs is as good a health investment as any.

Looking for a Great Skin Surgeon in LA? You Came to the Right Place!

In LA County, people need quick solutions to stubborn skin problems caused by sun damage, stress, pollution and more. Good thing, BHSkin Dermatology is here to provide! Our award-winning skin specialists are some of the best dermatologic surgeons in the area.

Visit us at our Glendale or Encino clinic or use our telehealth portal for a consult. Book your appointment today!

Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online