How to practice dermatosurgery safely?

Dermatosurgery has become an integral and essential component of current dermatology practice. No surgery can be totally risk free, only the level of risk varies. Patient safety has to be ensured by following standard protocols and taking appropriate precautions to prevent complications and mishaps. Mismatch between patient's expectations and outcome can lead to litigation. A dermatosurgeon should take care of his legal safety by obtaining informed consent and meticulously documenting and preserving medical records. Importance of communication and maintaining of fiduciary relationship with the patient cannot be overemphasized.

INTRODUCTION

Dermatosurgery has been defined as the practice of dermatology that specializes in surgical procedures and minimally invasive treatments to improve the health, function and appearance of skin.[1] Any surgical intervention is necessarily entwined with risk of complications, but the level of risk is low in case of dermatosurgery.

Patients or clients undergoing dermatosurgery not only expect 100% safety but also fulfilment of their imagined expectations as to the outcome. On the other hand, a dermatosurgeon cannot provide any kind of guarantee with respect to the results.[2] This article looks at the issue of safety of dermatosurgery from both patient's angle as well as that of the dermatosurgeon.

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.

PROCEDURE

Dermatosurgeons should follow standard protocol and procedures and avoid experimenting. Guidelines published by the local professional associations for various procedures are very useful in this connection.[10] All precautions must be taken to avoid mishaps. For example, use of eye shields while performing facial procedures, safe handling of sharps, avoiding use of spirit swabs during electrosurgery, use of protective glasses by patient and caregiver during laser procedures. World Health Organisation has suggested a checklist[11] to ensure surgical safety, and it can be easily adapted to dermatosurgery.

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

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

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

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]

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.

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.

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

CONCLUSION

Patients undergoing dermatosurgery, especially aesthetic procedures, expect great results without risk or complications. Dermatosurgeons cannot give any such guarantee but can only ensure standard care and best possible improvement. The potential risk of malpractice litigation is there but they can be minimized if standards of care are followed. However, even today, most patients faithfully believe that their doctor will keep their best interest in mind. Although litigations are rare, a prudent dermatosurgeon should insure himself and his clinic separately under professional indemnity insurance for malpractice.