How to Practice Dermatosurgery Safely?

Patient selection

Patient selection depends on various factors such as age, co-morbidities, medical indications and contraindications, patient's desire for a cosmetic procedure, their expectations, etc. Patients with depression and dysmorphophobia need psychiatric opinion and thorough counselling before subjecting them to aesthetic procedures.[2]

History

It is important to elicit patients' history of allergies, smoking, drug intake, keloidal tendency, bleeding diathesis, herpes simplex infection, implantation of cardiac pacemaker (in case of electrosurgery) and procedures in the past.

Counseling[3] and consent[4]

Signing of the specific consent form should not be a ritual but should be preceded by a process of information exchange between the patient and the dermatosurgeon. Patient has to be given adequate information to enable him/her to take the decision to undergo the procedure. For ease of recall of what is considered “adequate”, a mnemonic “PARCODE” has been suggested. [See Table 1].[5]

Table 1 Information to be given before seeking consent

Workup

Preparatory work up includes basic laboratory tests, use of tretinoin before certain procedures like chemical peels, testing for lignocaine allergy, test procedures or patches in some cases, antibiotic prophylaxis, fitness for anaesthesia, etc. Stopping aspirin and clopidogrel has not been reported to make a significant difference in complication rates.[67]

Derma OT

Dermatosurgery operation theatre[8], whether office-based or hospital-attached, must be well-equipped with standard instruments including those for emergency resuscitation and drugs. Aseptic conditions must be ensured.[9] Following universal precautions, use of protective gloves, gown, mask and glasses is important. Safe handling and disposal of biomedical waste is mandatory. Documented proof of maintenance of equipment should be preserved so that possible machine malfunction causing harm to patient can be defended.

Documentation

Medical records must be accurate, clear, chronological and legible. They must be kept confidential and preserved for at least three years.[2] Before and after photographs are vital in case of aesthetic procedures. Ideally electronic records should be maintained.

Follow up

Clear instructions must be given about post-procedure care including dressings, medication, sun protection and follow-up visits. In case of unexpected development or complication, patient must have access to expert advice.

Dermatosurgeon's safety

1. The physician must make sure that the postgraduate qualification is registered under the state medical council.

2. One should not attempt to perform procedures beyond one's competency and skill.

3. Standard care must be ensured but no guarantee of any kind should be given to the patient. It must be noted that in a malpractice case, whether “standard care” was rendered or not is decided by the court based on expert testimony.[12]

4. As a dermatosurgeon is vicariously liable for the negligent actions of his/her assistant or staff, only qualified and trained personnel must be employed. If however unqualified trained staff are employed, their names should be included in your professional indemnity insurance policy with small additional extra premium.

5. In spite of taking all possible precautions, things can go wrong. Risk of malpractice litigation can be covered by professional indemnity insurance being offered by professional bodies or insurance companies.

6. Communication is the key. Dermatosurgeons should use this art to gain and maintain the relationship of trust with the patient.