Dr Ruth Harker provides her advice to doctors and nurses involved in minor surgery in aesthetic practice, explaining ‘the good, the bad and the ugly’
I don’t know if you’ve tried to get anything removed on the NHS recently? Well, unless it’s suspicious for malignancy – the Bad – it is unlikely to be done. The strain on the NHS means that non-life-threatening procedures go to the bottom of the waiting list or, in many cases relating to cosmetic appearance, patients are refused treatment altogether.
I believe this has caused an increase in demand for private treatment for concerns such as compound or intradermal naevi (ordinary moles) as patients simply dislike having them – the Good! – and skin tags, warts, seborrhoeic keratoses, epidermoid cysts and lentigines that are unsightly – the Ugly! Seborrhoeic keratoses are common, and some people’s torso is covered in them, so they are very grateful for treatment.
Pilar or epidermoid cysts are often in conspicuous positions on the scalp, forehead, and neck or back and, again, it is a real service to the patient to remove them. Often patients can have a large collection of skin tags around the neck, the axillae and the groins that they report makes them feel ‘dirty’ and unconfident. This article aims to provide tips to doctors and nurses who have a background in surgery/minor surgery and knowledge and training in dermatology, who are involved in or considering incorporating minor surgery into their aesthetic clinic. The operating room should be fit for purpose and ideally be within a clinic that is accredited by the Care Quality Commission (CQC).1 The practitioner must be registered with the General Medical Council (GMC) or the Nursing and Midwifery Council (NMC), have adequate and correct medical indemnity to cover minor surgery. For any procedures involving incision of the skin (scalpel, punch biopsy) the practitioner will need to be CQC registered as an individual. Curettage, cautery, cryotherapy are below the remit of CQC. must be adhered to and an assistant is required.
Aesthetics vs. NHS
In aesthetic practice, the usual lesions we are dealing with are seborrheic keratosis, viral warts, skin tags, benign papillomas, benign naevi (common moles) and benign cysts/boils.2
We have a different scenario to that commonly seen in the NHS. In a skin cancer clinic on the NHS, a biopsy is taken from a suspicious lesion to confirm diagnosis and plan treatment. However, in an aesthetic clinic, the practitioner should be confident that they are dealing with a benign lesion. If there is any doubt that it is not benign, the practitioner should refer the case to a consultant dermatologist with a full history, examination of the findings and photographs with their differential diagnosis for excision at hospital. There is no place for monitoring a suspicious lesion; if in doubt cut it out!
Comparatively, in aesthetic practice, minor surgery is performed and the whole specimen is sent to a hospital pathology laboratory, with details of exact site, size, duration and provisional diagnosis for confirmation that it is benign. It is explained to the patient that the specimen will be checked at the laboratory by a histopathologist as a routine standard measure and the result will be back in a few weeks. In the rare circumstance the specimen reveals a cancer, then the practitioner must refer the patient to a skin cancer clinic.
During the consultation, a full medical history should be taken. The common patient question, “Can you have a quick look at this?” is correctly answered by saying, “No; I’ll have a careful and thorough look at the whole problem.” This is important as some skin problems are the result of a systemic disease that affects the whole patient, for example rheumatoid nodules, gouty tophi or the butterfly rash of systemic lupus erythematosus.4
The patient must be examined carefully and the practitioner should identify and detail how long the lesion has been present for, and if there has been any change over time. A blemish or mole that has been life-long or present for many years and not changed is highly likely to be benign.5 It is important to ask if the patient has any other similar lesions and examine the whole body.
The dermatological examination findings should be accurately recorded and photos should be taken using a ruler in good light. This is important for comparing the scar in later days, should there be a scar.
Scar formation should also be discussed, explaining that you will do your best to minimise scarring but cannot guarantee that there will be no scar at all. I always say to patients that they currently have a lump/lesion that they know well, but after minor surgery they will end up with a new scar they don’t know – even though the scar may be minimal – and so they need to be really sure it’s worth it for them.
Practitioners should also emphasise that patience is needed as the final result cannot be seen for some weeks and that the appearance should continue to improve. As healthcare professionals know, for the first four weeks or so, the operated area will be red, then fade to pink, then fade to its natural colour and merge in completely with the surrounding skin some months later. This simple explanation during the consultation can save a lot of questions post treatment.
Practitioners should identify if the patient has any rare risks, such as haemorrhage, nerve damage, wound infection, dehiscence, inadequate closure or removal, diabetes (infection and slow healing is common), poor healing, a history or family history of keloid or hypertrophic scars, drug history, any illness, recent surgery, allergies and, importantly, is taking anticoagulants (risk of bleeding in surgery).2 In my opinion, skin surgery in pregnancy is best avoided and patients with pacemakers and implantable defibrillators require special precautions.5
If the patient is taking psychotropic drugs, anxiolytics or antidepressants, then the practitioner should consider whether the operation is appropriate, whether the patient’s mental state has influenced their decision to have the lesion removed and if they will cope with the local anaesthetic procedure. It is worth asking the patient how they fare at the dentist, whether they tolerate the local anaesthetic or have had any side effects from it. These days it’s common practice for aesthetic practitioners to go through a body dysmorphic disorder (BDD) questionnaire to check the patient is suitable for treatment so I would also recommend this for minor surgery.6
Only when all the above has been discussed and all patient queries answered, should an informed consent be obtained for an agreed fee and a date arranged for the procedure.
A ‘cooling-off’ period is where the patient having received all the possible information about the operation can go home and reflect upon it and decide whether they still wish to go ahead with the procedure.7 Likewise, the practitioner may also decide that due to risks they do not wish to operate on this patient. In particular, this applies to substantial general anaesthetic procedures. If the patient is not in good health, is frail, is on any medication causing increased risk (for example is taking anticoagulants), has BDD or has not thought about the decision carefully, the operation should be postponed, however trivial.
Details of each type of minor surgery for lesions is beyond the remit of this article, but they include the use of radiofrequency, excision, or cryotherapy.
These days, minimally-invasive techniques such as radiofrequency surgery are common in aesthetic clinics.8 In my experience, radiofrequency is particularly successful for actinic lentigines, which are commonly referred to as ‘liver spots’ on the backs of the hands or ‘tea stains’ on the cheeks. Radiofrequency surgery uses no physical effort from the practitioner, but uses part of the electromagnetic spectrum between a laser and a microwave. The operative result is achieved with less tissue damage than conventional excision or curettage and cautery and the wound healing is usually quicker with less scarring. It also has a very high safety profile with less post-operative side effects. Also, fatty eyelid streaks (xanthelasma), spider naevi and telangectasiae (dilated blood vessels) can be dealt with radiofrequency ablation or point hyfrecation9 (focused and insulated electrocautery) can be used for these.
Curettage or shave excision are very commonly used methods with excellent wound healing in the right hands. Curettage is used to scrape off raised skin lesions using a sharp cup or ring-shaped tool, whereas shave excision is performed by drawing the flat blade of a scalpel through a raised lesion, across the skin, to remove it.5
Excision of large cysts can be challenging, especially if previously infected, and caution must be exercised as to what cases the practitioner accepts to operate on.5
Cryotherapy (freezing treatment) appeals to the public as it is a ‘quick fix’. However, it can be painful and, in my experience, blisters and atrophic scars are frequent and incomplete removal is common. There is also no histological diagnosis.6
Needless to say, all the previously mentioned techniques need to be learnt through repeated practical training under the supervision of a surgeon. A different technique is used depending on the nature of the lesion; for example, a crumbly soft seborrheic keratosis can easily be curetted, whereas a macular lesion (completely flat) may need to be excised.
Patient comfortIn my clinic, the patient journey is made as pleasant as possible with relaxing music, a stress ball for local anaesthetic injections and an empathic nurse at hand. One needs to explain to the patient that they only have to be brave for a few seconds for the local anaesthetic injection, after that they will feel cool antiseptic being applied and should suffer no pain. Extra local anaesthetic can easily be added at the slightest sign of pain. Some patients are very anxious by nature and offering a sedative anti-histamine such as chlorphenamine can be useful to avoid swelling and can also calm the patient down (providing they have a companion to take them home as it causes drowsiness).10
Following the procedure, the aftercare should be explained verbally and a patient leaflet given with the practitioner’s contact number in case of infection. Wound care varies as to whether it is a shave excision (heals like a graze and wound should be kept moist) or a wound with surface stitches (must be kept dry until stitches removed). This is explained carefully to the patient at the time.
After minor surgery, the new skin may be tender for a few weeks and so patients should be advised to avoid sun exposure on the area by keeping the scar covered with clothing or if the skin must be exposed they should use a high SPF sunscreen (30 or greater) on the area for approximately six months. This is because the area will be more sensitive to sunlight. Remember, sun avoidance is always more effective than sun protection cream.
A deferred prescription for antibiotics may be wise in some cases of increased infection risk such as diabetes, or if the patient lives far away.11 First-aid measures of how to deal with infection and bleeding should also be mentioned to the patient. From recent lectures on surgical technique, with best practice, wound infection should be 1% or under in uncomplicated cases; poor practice can lead to infection rates reaching 10% or more.11 It is well recognised that using a drying, alcohol-based antiseptic such as TCP or witch hazel can be a good preventative in the healing phase. During the post-operative days, if the wound becomes more painful, red and raised than before, pussy or weepy, this suggests infection so review and antibiotics are required. If a wound bleeds, the patient should be advised to apply a firm pressure for 10 minutes without interruption and apply a clean dressing or tissue. If there is still bleeding after this, medical help should be sought.
Minor skin operations performed carefully by an adequately trained practitioner in an aesthetic clinic offers a worthwhile and much appreciated service to the patient. In most cases the patient is unable to obtain treatment for these low priority conditions on the NHS. The practitioner must always acknowledge their limitations and refer to a plastic surgeon if the benign lesion is large, complex or in a difficult site, or refer to a dermatologist if they have any suspicion the lesion is not benign.