Current issues in dermatologic office-based surgery

FROM THE ACADEMY mm II

Current issues in d e r m a t o l o g i c o f f i c e - b a s e d surgery Joint American Academy of Dermatology/American Society of Dermatologic Surgery Liaison Committee*

Published jointly with Dermatologic Surgery (1999;25:805-14) TABLE OF CONTENTS I. I n t r o d u c t i o n : D e r m a t o l o g i c office surgery, a history o f a d v a n c e s . . . . . . . . . . . II. Training in d e r r n a t o l o g i c s u r g e r y A. I n t r o d u c t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. D e r m a t o l o g y training p r o g r a m r e q u i r e m e n t s a n d Board certification by t h e A m e r i c a n B o a r d o f D e r m a t o l o g y (ABD) . . . . . . . . . . . . . . . . . . . . . . . C. P o s t g r a d u a t e training in n e w t e c h n o l o g i e s . . . . . . . . . . . . . . . . . . . . . . . . . . . D. P r o c t o r e d s u r g e r y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Dermatology, advances from s t r o n g scientific training . . . . . . . . . . . . . . . . . . III. S e l e c t e d a d v a n c e s in d e r m a t o l o g i c office s u r g e r y A. T u m e s c e n t l i p o s u c t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Laser s u r g e r y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. D e r m a b r a s i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D. Chemical p e e l s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. S c l e r o t h e r a p y a n d a m b u l a t o r y p h l e b e c t o m y . . . . . . . . . . . . . . . . . . . . . . . . . E Filling materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G. Hair t r a n s p l a n t a t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H. Skin c a n c e r (excisions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I. Use o f a n e s t h e s i a in d e r m a t o l o g i c s u r g e r y . . . . . . . . . . . . . . . . . . . . . . . . . . . IV. C u r r e n t issues in credentialing, privileges and a c c r e d i t a t i o n for d e r m a t o l o g y A. I n t r o d u c t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. C r e d e n t i a l i n g a n d privileging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D. A c c r e d i t a t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Hospital credentialing: T h e p r o b l e m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E Alternative c r e d e n t i a l i n g / a c c r e d i t a t i o n ( n o n h o s p i t a l c r e d e n t i a l i n g ) . . . . . . . . G. AAD r e c o m m e n d a t i o n s for c r e d e n t i a l i n g a n d privileging for office-based cosmetic surgery ............................................... H. F u t u r e d i r e c t i o n s for office-based s u r g e r y . . . . . . . . . . . . . . . . . . . . . . . . . . . V. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Dermatologists and dermatologic surgeons have played major roles in the development and refinement of many office-based cutaneous surgical procedures. The comprehensive scientific education in the structure and function of skin that dermatologists receive during formal residency training programs has contributed directly to these advances. This long tradition of comprehensive training and strong basic research activities in skin biology has s u p p o r t e d a scholarly approach to cutaneous surgery. As a result, many pioneering cutaneous surgical techniques have been created by dermatologists and dermatologic surgeons. One example of this creativity can be seen in the field of laser surgery, in which techniques to effectively treat tattoos, benign pigmented lesions, port-wine stains and other vascular conditions, premalignant and malignant skin *Members: Roy Geronemus, MD, Chairman, Emil Bisaccia, MD, Harold J. Brody, ME), David A. Gaston, MD, Richard J. Glogau, ME),C. William Hanke, MD, Bruce E. Katz, MD, Elizabeth I. McBurney, MD, Dirk B. Robertson, MD, James M. Spencer, MD, and Ronald G. Wheeland, MD.AAD Staff: Susan L.Tibbitts, MA, and Barbara J. Lowery, MPH.

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Reprint requests: American Academy of Dermatology, Attn: Jill Mlodoch, PO Box 4014, Schaumburg, IL 60168-4014. Copyright 9 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16111101499

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lesions, wrinkles and sun-damaged skin, and excess or unwanted hair were developed by dermatologists. Some of the most innovative procedures, like tumescent liposuction, have focused primarily on improving patient safety while preserving the highest standards of care. Virtually every aspect of cutaneous surgery, including Mohs micrographic surgery for the treatment of skin cancers, hair replacement surgery, sclerotherapy of leg veins, the correction of scars and sun-damaged skin with the injection of filler materials, dermabrasion or chemical peels, and new anesthesia techniques, have been favorably affected by the unique education and skills of many dermatologists and dermatologic surgeons. This article reviews the important historic role that has been played by dermatologists and dermatologic surgeons in developing and improving outpatient cutaneous surgical procedures and examines current issues and future directions in credentialing, privileging, and accreditation. (J Am Acad Dermatol 1999;41:624-34.)

I. I N T R O D U C T I O N : DERMATOLOGIC OFFICE SURGERY, A HISTORY OF ADVANCES Dermatology is a medical and surgical specialty with a distinguished history in the d e v e l o p m e n t and advancement of diagnostic, therapeutic, and cosmetic office-based surgical procedures. Recent activity at the state level to regulate office-based surgery through physician credentialing and privileging, and accreditation has led the American Academy of Dermatology (AAD) to direct its Joint AAD/American Society of Dermatologic Surgery (ASDS) Liaison Committee to provide historical information on the safety and effectiveness of officebased dermatologic surgery and on the significant role played by dermatologists and dermatologic surgeons in the development and refinement of many cutaneous surgical procedures. II. TRAINING IN DERMATOLOGIC SURGERY A. Introduction In the United States, specialty training in dermatology and dermatologic surgery takes place primarily during the 3 years of dermatology residency in programs that have been approved by the Accreditation Council for Graduate Medical Education (ACGME). The 3 years of dermatology residency are traditionally preceded by an introductory year of residency usually in internal medicine. Residency training is progressive and systematic and encompasses the breadth of training in the specialty, which includes both medical and surgical modalities in the diagnosis and treatment of dermatologic conditions. This educational foundation, established during medical school and residency training and augmented in fellowship programs, is sustained and built upon in subsequent years of practice through courses and symposia accredited by the Accreditation Council on Continuing Medical Education (ACCME) and offered by educational institutions and professional societies such as the AAD and ASDS. Fellowships and postresidency educational programs are the main vehicles for physicians t{} acquire knowledge, training, and skill in newly developed techniques and technical advances. B. Dermatology training program requirements and Board certification by the American Board o f Dermatology (ABD) As detailed in the AAD "Recommendations for Credentialing and Privileging, ''1 there is a core of medical and surgical knowledge and skills for all graduates of accredited dermatology residency programs that is derived from the requirements for dermatology residency training. These requirements are established and monitored by the Residency Review Committee (RRC) for Dermatology and accepted by the ACGME. 2 Training should be sufficient to ensure knowledge of and competence in the performance of cryosurgery, dermatologic surgery and laser surgery. Dermatologic surgery should be given special emphasis and shoukt . include appropriate anesthesia, electrosurgery, cryosurgery, laser surgery, nail surgery, biopsy techniques and excisional surgery with appropriate closures, including flaps and grafts when indicated. Residents should become familiar with hair transplantation, dermabrasion, sclerotherapy, laser resurfacing, liposuction, chemical peels and tissue augmentation. In addition, residents should gain experience with Mohs micrographic surgery. Dermatologists are specialists with expertise in the diagnosis and treatment of pediatric, adolescent and adult patients with benign and malignant disorders of the skin, mouth, external genitalia, hair and nails. Dermatologists have extensive training and experience in the diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin, contact dermatitis and other allergic and nonallergic disorders, and in the recognition of the skin manifestations of infectious and systemic diseases including a number of sexually transmitted diseases and internal malignancies. The dermatologist also has expertise in the management of cosmetic disorders of the skin such as removal of excess or unwanted hair, wrinkles, sun-damaged skin, hair loss and scars. Among the techniques used by dermatologists for the correction of cosmetic defects are dermabrasion, chemical face peels, hair transplants, injections of materials into the skin for scar revision, sclerosis of veins, and laser surgery. 1

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C. Postgraduate training in n e w technologies Medical education appropriately spans the entire professional life of every dermatologist. Professional education represents a continuum of instruction and experience that begins in medical school and extends to the postgraduate years of internship, residency, fellowship, and beyond. This process is sustained in subsequent years of practice by voluntary attendance at formal continuing medical education courses and symposia sponsored by hospitals, medical schools, and professional medical societies and organizations. Following completion of residency, educational opportunities and training are widely available to master the latest advances in dermatologic surgery including diagnostic, therapeutic, and cosmetic procedures. One m e t h o d to assess the competence of the physicians who pursue additional postgraduate training in surgical procedures is a local assessment or test that is usually required upon completion of the training.

D. Proctored surgery Dermatologic surgery fellowships and numerous continuing medical education courses are offered in various surgical procedures as part of the scientific meetings of many regional and national professional medical societies. The acquisition of appropriate knowledge and skills for dermatologists performing surgery is an essential factor in ensuring patient safety and high-quality care. Consequently, it is important to evaluate and support high-quality postgraduate courses that provide training in the latest surgical technologies and techniques. Such courses are intended to inform the physician of advances in the field and to discuss important issues related to patient selection and the safe performance of the various procedures. Traditionally this goal is achieved by didactic lectures, practical skill sessions with hands-on technology laboratories, and live surgery observational experience. Participation in these courses by experienced and knowledgeable colleagues who act as proctors while assisting the participants in actually performing the surgical procedure is becoming the standard by which all similar types of educational opportunities are now being judged. In each of the last 3 years approximately 70 to 85 courses in dermatologic surgery have been offered at the AAD Annual Meeting and an additional 20 to 35 courses were offered during the AAD summer meeting. Approximately 30 courses in dermatologic surgery are offered each year at the ASDS Annual Meeting. Consistent with the educational mission of the AAD and the ASDS, and to ensure that our membership has the opportunity to gain additional knowledge and skills subsequent to residency completion, the topics covered in these courses include didactic instruction and live or video presentations to provide experience in procedures such as excisional surgery, cryosurgery, laser surgery, Mohs micrographic surgery, complex repair, flaps and grafts, chemical peeling, hair transplantation, liposuction, soft tissue augmentation, sclerotherapy, and others. Many of these procedures were developed or refined by dermatologists. Instruction on issues such as office safety, anesthesia, anatomy, and the complications of various procedures are also included in the continuing medical education offerings. Dermatologists have shared their surgical knowledge and experience as key invited faculty at postgraduate courses that are sponsored by other surgical specialties. Dermatologists have been instrumental in the develo p m e n t of a long list of surgical advances, which are often assimilated by other specialties without mention of their origin in dermatology. Such procedures include hair transplantation and scalp reduction, tumescent liposuction, tumescent anesthesia, sclerotherapy and ambulatory phlebectomy, cutaneous laser surgery, chemical skin peeling, dermabrasion, soft tissue augmentation, Mohs micrographic surgery-fresh tissue technique, and skin cancer surgery. E. Dermatology, advances from strong scientific training Dermatology has built a strong research tradition and base, supporting a scholarly approach to cutaneous surgery. The development of significant new surgical therapies for the skin and associated structures during the 20th century has frequently c o m e from dermatologists. Many of these advances, particularly in cosmetic surgery, are described later in more detail. As the scientific specialists of the skin, it is not surprising dermatologists have been pioneers and innovators in cutaneous surgery. The list of surgical advances introduced by dermatologists is lengthy. III. SELECTED ADVANCES IN DERMATOLOGIC OFFICE SURGERY A. Tumescent liposuction Liposuction is the aesthetic removal of undesirable localized collections of subcutaneous adipose tissue. It was developed in Italy and France in the 1970s and introduced in the United States in 1982. Dermatologists cosmetic and plastic surgeons were the first specialists to utilize the technique in America) Liposuction was initially performed under general anesthesia in a hospital setting. Dermatologic surgeons were among the group

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first trained in this technique and immediately began seeking ways to perform it safely and more economically under local anesthesia in an ambulatory setting. 2,3 Dermatologist J. A. Klein developed the tumescent anesthesia technique in 1987. This advance in anesthetic procedure allowed for the safe extraction of larger volumes of fat on an outpatient basis without general anesthesia. 4 The tumescent technique is the accepted standard in liposuction surgery today. 1 This technique has dramatically decreased blood loss, which results in a safer procedure and faster recovery.5, 6 The development of the tumescent anesthesia technique stimulated increased interest in liposuction a m o n g dermatologic surgeons and other cosmetic and plastic surgeons, transforming liposuction procedures into an entirely outpatient technique with an u n p r e c e d e n t e d safety record. 7 We do not encourage removal of m o r e than 5000 cc of supernatant fat per operative session. Liposuction p e r f o r m e d in a physician's office or ambulatory surgical center is convenient, safe, and economical and minimizes the risk of nosocomial infections. 1 To date, in the face of tens of thousands of cases, we are unaware of any liposuction fatalities from tumescent anesthesia alone. B. Laser s u r g e r y Dr Leon Goldman (1909-1997), former chairman of the Department of Dermatology at the University of Cincinnati, was the first physician to use therapeutic laser energy on the skin. He published his initial studies in 1963.1 T h r o u g h his pioneering work using the ruby, argon, n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t (Nd:YAG), copper vapor, and argon lasers, he established the specialty of dermatology as an early leader in laser surgery. 2-5 Dr Goldman served as an inspiration and m e n t o r to many dermatologists and was instrumental in spawning the clinical research of the 1970s and early 1980s. Many dermatologists, including Arndt, McBurney, Wheeland, Bailin, Ratz, Brauner, and others, p e r f o r m e d the early clinical research on the argon and CO 2 lasers for skin disorders. 6-12 In 1983, dermatologists Parrish and Anderson published the visionary theory of selective photothermolysis, which revolutionized the entire cutaneous laser field. 13 The theory inspired the d e v e l o p m e n t of all the current pulsed lasers used in the treatment of vascular lesions, pigmented lesions, and skin resurfacing. Their design of the pulsed dye laser dramatically changed the treatment and prognosis of cutaneous vascular lesions as supported in the work of dermatologists Garden, Tan, G e r o n e m u s and others.14-18 In the early 1990s, the development of the high-energy pulsed CO 2 laser augmented the armamentarium for skin rejuvenation. It became possible to selectively remove photodamaged skin layer by layer in a precisely controlled manner while leaving behind a very narrow zone of thermal damage. Dermatologists David, Lask, Dover, Fitzpatrick, Hruza, Lowe, Kauvar, and others p e r f o r m e d the initial clinical and histologic studies for laser skin resurfacing. 19-24 Dermatologists such as Kilmer and Anderson have led the use of the new Q-switched lasers to treat tattoos. 25,26 Recent work by dermatologists Dierickx, Grossman, and colleagues has led to the use of lasers to eradicate unwanted hair. 27 New applications of lasers for treating scars by Alster and others, 28 removing leg veins, as well as for hair transplantation, 29 have also generated tremendous interest. C. D e r m a b r a s i o n In 1953 Kurtin, a New York dermatologist, developed the m o d e r n technique of ambulatory dermabrasion which is used for facial skin rejuvenation and for i m p r o v e m e n t of acne and o t h e r scarring. 1 As originally described, the procedure was called corrective surgical planing of the skin. 1 In 1954, Blau, whose close collaborative work with Robbins resulted in the developnqent of the m o d e r n equipment necessary to perform dermabrasion on an outpatient basis, coined the t e r m dermabrasion. 2 Other dermatologists, including Burks, Orentreich, Luikart, Ayres, Wilson, Pierce, and Rattner helped to further refine the dermabrasion technique. 3 In the 1970s, further research in this technique and evaluation of alternative techniques with anesthesia was carried out by dermatologists Tromovitch, Stegman, Alt, Roenigk, Yarborough, Hanke, and others.3 Dermatologists Coleman and Klein showed that the tumescent anesthetic technique, introduced for liposuction, was an effective anesthesia for dermabrasion. 4 Yarborough has shown that dermabrasion 6 weeks after surgical or traumatic injury may dramatically improve the degree of scarring.5,6 The older technique of manual dermabrasion has been repopularized by dermatologist J. R. Harris. 7 D. C h e m i c a l p e e l s Dermatologists pioneered skin peeling for therapeutic benefit. In 1882, Unna, a German dermatologist, described the use of salicylic acid, resorcinol, phenol, and trichloroacetic acid (TCA) for cutaneous chemical peel. George Miller Mackee, a British dermatologist who eventually became chairman of the dermatology department at New York University (NYU), began using phenol peels for acne scarring in 1903 and published his results in 1952.1

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In 1941, dermatologist Eller and his associate Wolff2 summarized the peeling formulas available for exfoliation at that time. Phenol, salicylic acid combinations, and carbon dioxide snow peels were detailed. In 1964, Urkov described dermatologic exfoliation by methods including occluded phenol and applying a mixture of resorcinol with lactic and salicylic acids under occlusion.3 Dr Max Jessner utilized his salicylic acid, lactic acid, and resorcinol combination at NYU in the 1950s. The work of dermatologist Ayres4, 5 in the 1960s combined the TCA experiments of Monash in 1945 with his own conclusions based on clinical experience and histology using both TCA and phenol. r In the early 1960s, Marthe Brown, a dermatologist, p e r f o r m e d histologic studies on skin peeling with phenol. 7 Dermatologist S. J. Stegman's work in the early 1980s on animal and on human models compared the histologic depth of TCA and phenol chemical wounding agents to dermabrasion, paving the way for chemical peeling in a controlled and scientific fashion.8, 9 These excellent histologic concepts for the evaluation of peeling influenced the development of a medium-depth peel by dermatologists Brody, Hailey, Monheit, Coleman, and Futrell.10,11 Dermatologist Van Scott began investigating the {z-hydroxy acids (AHAs) in the late 1970s. 12 The AHAs and I3-hydroxy acids have been added to the cutaneous peel armamentarium. 12

E. Sclerotherapy and ambulatory phlebectomy The treatment of venous disease of the legs is ancient, with Hippocrates mentioning compression and bloodletting in the fourth century uc. 1 Primitive vein stripping was mentioned by the Roman physician Celsius in 30 AD.1 However, until the advent of sterile surgery in the 19th century, therapy of varicose veins consisted of compression, while telangiectases were treated with cosmetics only. At the turn of the century, high ligation of the saphenous vein combined with stripping led to successful inpatient surgical management of varicose veins. No treatment was offered for telangiectases other than scarring electrosurgery until the 1900s when sclerotherapy and ambulatory phlebectomy were developed. These minimally invasive outpatient procedures are routinely performed by dermatologists and allow the safe and effective treatment of varicosities and telangiectases. Modern sclerotherapy began in 1934 with the description of sodium morrhuate for the treatment of telangiectases. Since that time, multiple sclerosing solutions have been developed, and this minimally invasive office procedure is now widely used by dermatologic surgeons for superficial telangiectases and larger varicosities. Multiple studies have compared sclerotherapy to conventional surgery for varicosities. These studies have demonstrated that the clinical outcome between the two procedures is comparable with sclerotherapy demonstrating a higher safety profile. 2 In the case of superficial telangiectases, the procedure remains the treatment of choice. In 1956, Swiss dermatologist Robert Muller advanced ambulatory phlebectomy, as a second minimally invasive office treatment for varicose veins. Forty years of experience with this technique have shown that it is effective, extremely safe, and has only minor complications. 3 In a series of 320 consecutive patients, bleeding was seen in 0.1% of patients, hematoma in 0.1%, lymphocele in 0.6%, sensory nerve damage in 0.3%, and persistent foot edema in 0.1%.

E Filling materials The injection of various materials into the skin to correct contour defects, such as depressed scars, has been pursued for over 100 years. Dermatologists have been actively involved in the evolution of this field. Fibrin foam, a by-product of plasma fractionation first developed as a hemostatic agent in neurosurgery, was first utilized as a filling agent by dermatologist Spangler in 1957.1 Although the technique was simple and effective, the difficulty in preparing the material precluded its wider use. However, his fundamental idea, that the process of coagulation and wound healing would stimulate new collagen formation and the filling of the defect, stimulated dermatologist McBride to develop the gelatin aminocaproic acid-plasma repair (GAP) technique. 2 In this technique, coagulation is induced with a fibrin stabilizer by mixing a gelatin powder to serve as a matrix for the collection of blood and tissue factors important in clot formation. This is mixed with aminocaproic acid to inhibit fibrinolysin, and the patient's own plasma to increase locally available fibrinogen. This technique proved to be safe and effective, and led to the marketing of the Food and Drug Administration-approved product Fibrel. During the 1970s Knapp and colleagues developed injectable collagen derived from animal sources. Dermatologists Stegman and Tromovitch first reported the use of Zyderm injections, the commercial product for human use prepared from bovine collagen,3 while dermatologist Klein reported the injection techniques most widely used today. 4 Although a low incidence of allergy is a reported side effect, injectable collagen has been given to hundreds of thousands of patients in an outpatient setting with an excellent safety and efficacy record.

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Currently, active research continues for a m o r e p e r m a n e n t filler material. Under active investigation are products containing hyaluronic acid, which may have a significantly longer half-life than collagen. Also currently available are permanent implants derived from expanded polytetrafluoroethylene. Dermatologists are actively involved in the use and development of these new filling materials. G. Hair t r a n s p l a n t a t i o n a n d s c a l p r e d u c t i o n The surgical treatment of alopecia is another area in which dermatologists have taken the lead in the develo p m e n t and refinement of cutaneous surgery:. The hair transplant was first described by New York dermatologist Norman Orentreich in 1959.1 In this technique, small grafts from hair-bearing scalp are transplanted to bald areas where they persist and continue to grow hair. Since the initial description, dermatologists have continued to refine and develop the technique. The use of smaller and smaller grafts, leading to the term micrograft, was first outlined by dermatologist Ayres in 1977. 2 Dermatologists have continued advancement in this field in areas such as instrumentation, graft size and shape, and the use of lasers. This office-based procedure, develo p e d and practiced by dermatologists, is one of the most widely requested cosmetic procedures by men. Surgical scalp reduction is another outpatient procedure developed by dermatologists to manage alopecia. There is a long history of a variety of surgeons using local skin flaps to reconstruct the scalp following cancer surgery or trauma. However, the idea of excising bald scalp and using surgical repair techniques to move hairbearing scalp into its place first appeared in the late 1970s. At the same time, dermatologists Unger and Unger3 and Stough and Webster 4 p r o p o s e d essentially the same idea. Scalp reduction is typically utilized in conjunction with hair transplants in the treatment of alopecia. Over the last 20 years dermatologists have utilized and refined the technique in an office-based setting.5, 6 H. S u r g i c a l p r o c e d u r e s f o r t h e t r e a t m e n t o f s k i n c a n c e r Effective and safe treatment of skin cancer is certainly one of the most significant contributions of dermatology and dermatologic surgew. There are an estimated one million plus cases of skin cancer diagnosed annually in the United States, and the vast majority are managed in the outpatient offices of dermatologists) Skin cancers can be effectively and safely treated on an outpatient basis with cryosurgery, curettage and electrodesiccation, 2 or excisional surgery. Excision of melanomas is also similarly performed in an outpatient setting by dermatologists. Reconstruction options are routinely offered including simple side-to-side, intermediate, and complex closures, flaps, and grafts on an ambulatory basis. Utilization and refinement of the Mohs technique by dermatologists has produced an effective treatment for skin cancer and is indicated for difficult and recurrent tumors and for tumors in anatomic locations in which maximal preservation of normal tissue is required. This technique is an office-based procedure and was initially developed by Dr Frederic Mohs beginning in the 1930s. Dr Mohs has written that he initially thought the technique would be of interest to a wide variety of surgeons, but indeed it was dermatologists who pursued and developed the technique. Dr Mohs writes this is not surprising because "being a skin disease, skin cancers usually are seen first by dermatologists who are familiar with their clinical and microscopic appearance and the differential diagnosis from similar appearing noncancerous lesions. ''3 Dr Mobs' original technique utilized a zinc chloride paste for in situ fixation of the tumor. The technique was refined by dermatologists Tromovitch and Stegman by utilizing frozen tissue rather than chemically fixed sections. This innovation allowed for greater efficiency of the procedure. The reported 5-year cure rates of 99% for primary basal cell carcinomas and 95% for recurrent tumors is unparalleled by any other modality or discipline. 2 Forty years of experience proves this office-based surgery an effective, safe, and cost-effective technique for the removal of difficult and recurrent skin tumors.4, 5 I. U s e o f a n e s t h e s i a in d e r m a t o l o g i c s u r g e r y Office-based surgical procedures have been safely performed under local anesthesia for over a century.l,2 Local anesthesia is ideal for most cutaneous surgery, producing effective anesthesia without the risks associated with the use of general anesthetics. Recent innovations in topical delivery systems, iontophoresis, and tumescent infiltration have provided dermatologists with other means of achieving local anesthesia besides the standard local infiltration technique. Dermatologists receive specific instruction in all aspects of local anesthesia use during residency training and enjoy particularly safe use of these techniques with extremely low incidence of complications. Local infiltration anesthetics commonly contain epinephrine in concentrations of 1:100,000 or 1:200,000, which shortens the onset and prolongs the duration of the anesthesia. Epinephrine improves hemostasis as its

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vasoconstrictive action counteracts the inherent vasodilatory action of the anesthetic agent. Epinephrine also increased the anesthetic's potency so that less infiltration is necessary as c o m p a r e d to the same anesthetic being injected without epinephrine. On the other hand, epinephrine-induced local vasoconstriction significantly slows anesthetic absorption, which reduces peak serum levels and thus m o r e anesthetic can be safely used without risk of toxicity. 3,4 Most of the local and systemic reactions to amide local anesthetics are due to epinephrine. The local reaction of tissue necrosis has rarely been reported recently,5,6 but was seen earlier in this century before standard concentration anesthetic solutions with epinephrine were available. 7-12 Physicians are now careful to avoid this complication by using anesthetics without epinephrine when injecting into an area with anatomically restricted circulation such as a finger or toe and the penis. Systemic reactions to epinephrine are due to its adrenergic effects on the heart and distal vessels and include nervousness, tachycardia, lightheadedness, palpitations, tremor, diaphoresis, headache, increased blood pressure, and rarely chest pain. 13,14 These reactions most often follow injection of a large quantity of epinephrine into a highly vascular area such as the scalp and face or from inadvertent intravascular injection. Patients who are very anxious, are hyperthyroid, have significant cardiac disease, or are taking a nonselective beta-blocker are m o r e likely to experience these effects. The incidence of these systemic reactions is minimized by carefully injecting the smallest quantity of the lowest concentration of epinephrine-containing anesthetic necessary to achieve the desired effect, and by properly selecting out those patients who are likely to be highly sensitive to epinephrine. When they do occur, these systemic epinephrine reactions are almost always short-lived and not deleterious, but should alert the physician to a possible concomitant toxic reaction of the amide anesthetic agent itself. Central nervous system and cardiovascular reactions from local anesthetics are quite rare. Patient o u t c o m e is usually satisfactory when the reactions are recognized early and treated appropriately. The possibility of these reactions is extremely low when physicians choose their anesthetics properly, inject carefully, and follow accepted maximal safe injection dosage guidelines.3,4 Use o f i n t r a v e n o u s o r g e n e r a l a n e s t h e s i a Dermatologists do utilize intravenous sedation or general anesthesia to provide the unique services that they have developed either exclusively or in conjunction with other specialties. Such procedures would include but are not limited to the use of lasers for the removal of congenital malformations in children where general anesthesia is required for the purposes of immobilization; or for facial resurfacing, where intravenous sedation or anesthesia may be necessary to provide the appropriate comfort level to adequately perform the procedure. Under these circumstances, the sedation or anesthesia is generally performed in the appropriate setting where monitoring and emergency care can be provided. Tumescent anesthesia Tumescent anesthesia deserves special mention when examining the safety of local anesthesia. Originally developed by dermatologist Klein as a safe means to anesthetize large areas of adipose tissue for liposuction,5 the tumescent technique is now also utilized for other dermatologic surgical procedures such as hair transplantation, facial resurfacing, ambulatory phlebectomy, and large cutaneous excisions. This technique involves the careful, slow infiltration of adipose tissue with large volumes of dilute lidocaine solution (0.05% to 0.2%) with low epinephrine concentration (1:1,000,000), resulting in long-lasting anesthesia. The slow rate of lidocaine absorption results in low peak serum lidocaine concentrations, thus permitting much higher maximal lidocaine dosage than with regular infiltration anesthesia. 6 Experienced dermatologic liposuction surgeons routinely use up to 55 mg/kg lidocaine for liposuction without complications. 17-20 In summary, local anesthesia for office-based surgical procedures is safe and effective, and anesthetic complications are extremely rare. This is largely because relatively small and thus inherently safe amounts of lidocaine are necessary for most dermatologic procedures and because dermatologists are particularly knowledgeable about all aspects of local anesthetic use.

IV. C U R R E N T I S S U E S IN C R E D E N T I A L I N G , PRIVILEGES, A N D A C C R E D I T A T I O N F O R DERMATOLOGY A. I n t r o d u c t i o n To understand current issues in office-based surgery, it is important to be able to distinguish among the terms certification, credentialing and privileging, and accreditation. B. Certification The ABD acknowledges that an eligible physician "has completed the required course of graduate study and

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clinical training...and has passed the examination conducted by the Board." Recertification will be required by the ABD every 10 years beginning in 2001.

C. Credentialing and p r i v i l e g i n g These terms are often used interchangeably, and the use of the terms, as well as the requirements for acquiring privileges, vary among institutions. This is because such requirements are determined by the governing board of an institution in consultation with its organized medical staff. Nevertheless, we will distinguish these terms by defining credentials as documentation of specified criteria (eg, Board certification, current licensure). An appropriate body within an organization reviews these documents, may interview the applicant, and then recommends to the governing body denial or approval of the requested privileges, which allow the physician to do specific things, such as admit a patient, perform appendectomies, etc. Privileges are usually reviewed and renewed periodically. D. Accreditation The term accreditation has typically been applied to organizations such as hospitals and other types of health care facilities. Philosophically, the focus of accreditation is the quality of care provided by the organization, and the process is designed to verify that the organization meets specified criteria that are assumed to be indicative of quality care. In addition to standards for the physical environment, medical records, ancillary services, etc., the criteria also include standards for the physician/medical staff. The physician criteria minimally include standards for licensure, medical education and board certification status, information from the National Practitioner Data Bank, and professional liability coverage. In essence, the credentialing process, as outlined above, is a component of accreditation. Accreditation is time limited. E. Hospital credentialing: The problem As noted in our definitions of credentialing and privileging, an appropriate body makes a recommendation to the governing board. In the current environment, this body is usually the medical staff credentialing committee of a hospital, which typically consists of representatives from the various medical staff departments. As dermatology is an outpatient specialty that is often subsumed under a larger department, dermatology is rarely represented on credentialing committees. Hospitals may compete economically with physicians who utilize ambulatory surgery centers and office surgical facilities. However, the Joint Commission on Accreditation of Healthcare Organizations has recently established a standard that will require physicians to perform a minimum number of procedures in the hospital each year in order to retain privileges, even for procedures which are typically performed in an outpatient setting. This requirement will further impede the dermatologist from receiving and retaining hospital privileges and credentials. For all of these reasons, regulatory, legislative, or administrative requirements mandating or requiring the dermatologist to obtain hospital credentialing and privileging in order to perform office-based dermatologic surgery limit the choice of specialists for patients, unnecessarily increase costs, are anticompetitive, and unreasonably restrict patient access to high-quality health care. E Alternative credentialing/accreditation (nonhospital credentialing) States that are considering office surgery regulations should be mindful of those factors unrelated to quality patient care that influence a physician's ability to obtain hospital privileges. Consideration should be given to an alternative credentialing system. Any alternative credentialing system should be comparable to hospital credentialing requirements. While some states may establish their own alternative credentialing body, national credentialing bodies may provide a more comprehensive system. G. AAD r e c o m m e n d a t i o n s for credentialing and privileging for office-based cosmetic surgery As stated in the AAD Guidelines" of Care, and reiterated by AAD representatives who testified before the Medical Board of California on this issue in 1998 and 1999, it is the position of the AAD that physicians performing cosmetic surgery should have in-depth knowledge of the skin and subcutaneous tissue and, based on the type of surgery performed, knowledge of fluid and electrolyte balance, management of potential complications, and knowledge of the type of anesthesia employed. The physician should have evidence of training for the particular procedure, obtained during residency (ACGME-approved), fellowships, or through ACCMEaccredited courses, or preceptorships. Documented experience at the surgical table conducted by an appropriately trained and experienced physician is r e c o m m e n d e d for procedures such as liposuction, complex closures, flaps and grafts, and sclerotherapy.

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Dermatologists who can provide evidence of satisfactory completion of an appropriate training course for specific surgical procedures or technologies should be permitted to perform that procedure. Ideally, confirmation of clinical competence to permit appropriate credentialing should result from an evaluative process performed by an organization independent of course faculty. Although such systems are not currently in place, verification of on-going clinical competence is a major topic of discussion among our specialty societies (AAD and ASDS), the ABD, and the American Board of Medical Specialty Societies. H. F u t u r e d i r e c t i o n s f o r o f f i c e - b a s e d s u r g e r y The AAD and the ASDS are actively involved in efforts to improve patient safety, quality of care, and physician accountability in a cost-effective manner. In dialogue with state medical boards, ()thor medical specialty societies, the AMA and others, the AAD and the ASDS are monitoring regulatory, legislative, and administrative developments in office-based surgery, offering information and expertise to members affected directly by proposed changes.

V. REFERENCES Training in dermatologic surgery I. Drake LA, Goltz RW, Livingood CS, et al. Recommendations for credentialing and privileging. J Am Acad Dermato11998;39:765-86. 2. Program Requirements for Graduate Medical Education in Dermatology; ACGME revised;to be implemented July I, 1999.

S e l e c t e d a d v a n c e s in d e r m a t o l o g i c office s u r g e r y Tumescent liposuction 1. 2. 3. 4. 5.

Guiding principles for liposuction, The American Society for Dermatologic Surgery, February 1997. Dermatol Surg 1997;23:1127. Field LM, Sumrall AJ, et al. Liposuction surgery: a review. J Dermatol Surg Oncol 1984;10:530-8. Coleman WP III. Liposuction and anesthesia. J Dermatol Surg Onco11987;13:1295-6. Klein JA.lhe tumescent technique.Am J Cosmet Surg 1987;4:263-7. Lillis R Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988;14:1145-8. 6. KleinJA.Tumescent technique for regional anesthesia permits lidocainedoses of 35 mg/kg for liposuction:peak plasma lidocainelevels are diminished and delayed 12 hours.J Dermatol Surg Onco11990;16:248-63. 7. Hanke CW, BernsteinG, Bullock S.Safety of tumescent liposuctionin 15,336 patients.Dermatol Surg 1995;21:459-62.

Laser s u r g e r y 1. Maiman TH. Stimulated optical radiation in ruby. Nature 1960;187:493-6. 2. Goldman L, Blaney DJ, Kindel DJ, et al. Effect of the laser beam on the skin: preliminary report. J Invest Dermato11963;40:121-2. 3. Goldman L,Wilson R, Hornby P.Radiation from a Q-switched ruby laser: effect of repeated impacts of power output at 10 megawatts on a tattoo of a man.J Invest Dermatol 1965;44:69-71. 4. Goldman L, Rockwell J, Meyer R, et al. Laser treatment of tattoos: a preliminary survey of three year's clinical experience. JAMA 1967;201 : 841-4. 5. Soloman H, Goldman L, Henderson D, et al. Histopathology of the laser treatment of port-wine lesions. J Invest Dermatol 1968;50:141-6. 6. Arndt KA. Argon laser therapy of small cutaneous vascular lesions. Arch Dermato11982;I 18:220-4. 7. Wheeland RG, Bailin PL, Norris MJ. Argon laser photocoagulative therapy of Kaposi's sarcoma: a clinical and histologic evaluation. J Dermatol Surg Onco11985;I I :I 180-5. 8. Arndt K. Adenoma sebaceum: successful treatment with argon laser. Plast Reconstr Surg 1982;70:91-3. 9. Arndt KA, Nee JM, Northam DBC, et al. Laser therapy: basic concepts and nomenclature. J Am Acad Dermato11981;5:649-54. I 0. Bailin PL, Ratz JL, Lutz-Nagey L. CO2 laser modification of Mohs' surgery. J Dermatol Surg Oncol 1981 ;7:621-3. 1 I. Brauner GJ, Schliftman A. Laser surgery for children. J Dermatol Surg Oncol 1987;I 3:178-86. 12. McBurney El. Carbon dioxide laser treatment of dermatologic lesions. South Med J 1978;71:795-7. 13. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7. 14. Tan OT, Sherwood K, Gilchrest BA.Treatment of children with port-wine stains using the flashlamp-pulsed tunable dye laser. N Engl J Med 1989;320:416-21. 15. Garden JM, Tan OT, Kerschmann R, et al. Effect of dye laser pulse duration on selective cutaneous vascular injury. J Invest Dermatol 1986;87:653-7. 16. Garden JM, Burton CS, Geronemus R. Dye laser treatment of children with port-wine stains. N Engl J Med 1989;321:901-2. 17. Garden JM, Bakus AD, Pallor AS.Treatment of cutaneous hemangiomas by the flashlamp pumped pulsed dye laser: prospective analysis. J Pediatr 1992;I 20:555-60. 18. Geronemus RG. Pulsed dye laser treatment of vascular lesions in children. J Dermatol Surg Onco11993;I 9:303-I0. 19. David LM, Same AJ, Unger WP. Rapid laser scanning for facial resurfacing. Dermatol Surg 1995;21 :I 031-3.

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20. Fitzpatrick RE,Tope WD, Goldman MP, et al. Pulsed carbon dioxide laser, trichloroacetic acid, Baker Gordon phenol, and dermabrasion: a comparative clinical and histologic study of cutaneous resurfacing in a porcine model. Arch Dermato11996;132:469-71. 21. Fitzpatrick RE,Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 1996;132:395402. 22. Waldorf HA, Kauvar ANB, Geronemus ARG. Skin resurfacing of fine to deep rhytides using a char-free carbon dioxide laser in 47 patients. Dermatol Surg 1995;21:940-6. 23. Hruza GJ. Skin resurfacing with lasers. Fitzpatrick's J Clin Dermatol 1995;3:38-41. 24. Lowe N, Lask G, Griffin ME, et al. Skin resurfacing with the Ultrapulse carbon dioxide laser: observations on 100 patients. Dermatol Surg 1995;21:1025-9. 25. Kilmer SL, Anderson RR.Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 and 532 nm) lasers for treatment of tattoos. J Dermatol Surg Onco11993;19:330-8. 26. Kilmer SL, Lee MS, Grevelink JM, et al. The Q-switched Nd:YAG laser effectively treats tattoos: a controlled dose-response study. Arch Dermato11993;129:971-8. 27. Dierickx CC, Grossman MC, Farinelli WA, et al. Permanent hair removal by normal-mode ruby laser. Arch Dermato11998;134:837-42. 28. Alster TS, Williams CM. Treatment of keloid sternotomy scars with 585nm flashlamp-pumped pulsed-dye laser. Lancet 1995;345: 1198-200. 29. Unger WP, David L. Laser hair transplantation.J Dermatol Surg Onco11994;20:515-21.

Dermabrasion I. 2. 3. 4.

Kurtin A. Corrective surgical planing of skin. AMA Arch Dermatol Syphilo11953;68:389-97. Blau S, Rein CR. Dermabrasion of the acne pit. AMA Arch Dermatol Syphilo11954;70:754-66. Coleman WP III, Aft ToDermatologic cosmetic surgery.J Dermatol Surg Oncol 1990;I 6:170-6. Coleman WP, Klein JA. Use of the tumescent technique for scalp surgery, dermabrasion, and soft tissue reconstruction. J Dermatol Surg Oncol 1992;I 8:130-5. 5. Yarborough JM Jr, Alt TH. Current concepts in dermabrasion. J Dermatol Surg Onco11987;13:595-6. 6. Yarborough JM Jr. Dermabrasive surgery: state of the art. Clin Dermato11987;5:75-80. 7. Harris DR, Noodleman FR. Combining manual dermasanding with low strength trichloroacetic acid to improve actinically injured skin. J Dermatol Surg Oncol 1994;20:436-42.

Chemical peels 1. 2. 3. 4. S. 6. 7. 8. 9. 10. 11. 12. 13.

Mackee GM, Karp FL.The treatment of post acne scars with phenol. Br J Dermato11952;64:456-9. Eller JJ, Wolff S. Skin peeling and scarification. JAMA 1941:116:934-8. Urkov JC. Surface defects of skin: treatment by controlled exfoliation. III Med J 1946;89:75. Ayres S~Dermal changes following application of chemical cauterants to aging skin. AMA Arch Dermato11960;82:578-85. Ayres S: Superficial chemosurgery in treating aging skin. Arch Dermato11962;85:385-93. Monash S.The uses of diluted trichloroacetic acid in dermatology. Urol Cutan Rev 1945;49:119-20. Brown AM, Kaplain LM, Brown ME. Phenol induced histological skin changes: hazards, techniques, and uses. Br J Plast Surg 1960;13:158-69. Stegman SJ.A study of dermabrasion and chemical peels in an animal modeI.J Dermatol Surg Onco11980;6:490-7. Stegman SJ. A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sun damaged skin. Aesthet Plast Surg 1982;6:123-35. Brody HJ, Hailey CW. Medium depth chemical peeling of the skin: a variation of superficial chemosurgery. J Dermatol Surg Oncol 1986;12:1268-75. Monheit G.The Jessner's + TCA peel: a medium-depth chemical peel. J Dermatol Surg Onco11989;15:945-50. Van Scott EJ, Yu RJ. Hyperkeratinization, corneocyte cohesion and alpha hydroxy acids. J Am Acad Dermatol 1984;11:867-79. Coleman WP, Futrell JM.The glycolic acid and trichloroacetic acid peel. J Dermatol Surg Onco11994;20:76-80o

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Filling materials 1. 2. 3. 4.

Spangler AS. New treatment of pitted scars, preliminary report. Arch Dermato11957;76:708-11. McBride G. New boost for depressed scars.JAMA 1978;240:1477. Stegman SJ,Tromovitch TA. Implantation of collagen for depressed scars.J Dermatol Surg Onco11980;6:450-3. Klein AW. Implantation techniques for injectable collagen. J Am Acad Dermatol 1983;9:224-8.

Hair t r a n s p l a n t a t i o n and scalp r e d u c t i o n 1. Orentreich N.Autographs in alopecias and other selected dermatologic conditions.Ann N Y Acad Sci 1959;83:463-79. 2. Ayres S. Prevention and correction of unaesthetic results of hair transplantation for male pattern baldness. Cutis 1977;19:117-21. 3. Unger MG, Unger WR Management of alopecia of the scalp by a combination of excisions and transplantation. J Dermatol Surg Oncol 1978;4:670-2. 4. Stough DB, Webster RC. Esthetics and refinements in hair transplantation. The International Hair Transplantation Symposium, Lucerne, Switzerland, Feb 4, 1978. S. AIt TH. Scalp reduction as an adjunct to hair transplantation: review of the relevant literature and presentation of an improved technique. J Dermatol Surg Onco11980;6:1101-8.

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6. Cohen BH. The Burow's triangle scalp reduction: a new and improved technique for paramedian scalp reduction. Dermatol Surg 1995;21:705-10.

S u r g i c a l p r o c e d u r e s f or t he t r e a t m e n t o f skin c a n c e r 1. Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: incidence.J Am Acad Dermato11994;30:774-8. 2. Rowe DE, Carroll RJ, Day CL. Long term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28. 3. Mohs FE. Origin and progress of Mohs micrographic surgery. In: Mikhail GR, Editor. Mohs micrographic surgery. Philadelphia:WB Saunders; 1991. p. 1-10.

4. Rowe DE, Carroll RJ, Day CL Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Onco11989;15:424-31. 5. Cook J, Zitelli J. Mohs micrographic surgery: a cost analysis. J Am Acad Dermatol 1998;39:698-703.

U s e o f a n e s t h e s i a in d e r m a t o l o g i c s u r g e r y 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19, 20.

Fink 8R. Leaves and needles: the introduction of surgical local anesthesia. Anesthesiology 1985;63:77-83. Wildsmith JA, Strichartz, GR. Local anesthetic drugs: a historical perspective. Br J Anaesth 1984;56:937-9. Dinehart SM.Topical, local, and regional anesthesia. In:Wheeland RG, editor. Cutaneous surgery. Philadelphia:W8 Saunders; 1994. p 102-12. Bennett RG. Fundamentals of cutaneous surgery. St Louis: Mosby; 1988. p 194-239. Carroll MJ.Tissue necrosis following a buccal infiltration. Br Dent J 1980;149:209-10. Roser-Maass E. Necrosis of the fingertips after local anesthesia for nail extraction. Hautarzt 1981;32:39-41. Garolock JH. Gangrene of the finger following digital nerve block anesthesia. Ann Su rg 1931 ;94:1103. Kaufman PA. Gangrene following digital nerve block anesthesia. Arch Surg 1941;42:929. La Rossa B, Riccio R. Epinephrine in local anesthesia. Paris Med 1925;2:341. Pelner LoGangrene of the toe following local anesthesia with procaine-epinephrine solution. N Y State J Med 1944;42:544. Ruben JA. Sloughing in local anesthetics: its causes and prevention. Penn Med 1920;123:713. Serafin FJ. A precaution in the uses of procaine-epinephrine for regional anesthesia. JAMA 1928;91:43. Grekin RC, Auletta MJ. Local anesthesia in dermatologic surgery.J Am Acad Dermato11988;19:599-614. Miller HC, Dick PG, Stuart CW. Clinical and electrocardiographic findings following the use of various local anesthetic solutions. Anesth Analg 1938;17:207-10. Klein JA.The tumescent technique for liposuction surgery.Am J Cosmet Surg 1987;4:263-7. Klein JA. Tumescent technique for regional anesthesia permits lidocaine dose of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248-63. Klein JA.The tumescent technique: anesthesia and modified liposuction technique. Dermatol Clin 1990;8:425-37. Lawrence N, Coleman WR Liposuction. Adv Dermatol 1995;11:19-49. Hanke CW, Bernstein G, Bullock S. Safety and tumescent liposuction in 15,336 patients: national survey results. Dermatol Surg 1995;21:45962. Ostad A, Kageyama N, Moy RL.Tumescent anesthesia with a lidocaine dose of 55mg/kg is safe for liposuction. Dermatol Surg 1996;22:9217