Dermatologic Surgery 26  (1), 5-11
 

BACKGROUND.Dermatologic surgery has a long and distinguished history in the United States.

OBJECTIVE.To examine the specific contributions of American dermatologic surgeons.

METHOD.The medical literature on cutaneous reconstructive and cosmetic surgery for the last century and a half was researched.

RESULTS.Numerous American dermatologic surgeons have had a major impact on scientific and technological discoveries in cutaneous surgery. Dermatologic surgeons have been significantly involved in cutaneous surgery since the second half of the 19th century. Dermatologic surgeons have contributed many important advances to the fields of chemical peeling, cryosurgery, dermabrasion, electrosurgery, hair transplantation, soft tissue augmentation, tumescent liposuction, laser surgery, phlebology, Mohs chemosurgery, cutaneous reconstruction, wound healing, botulium toxin, blepharoplasty, and rhytidectomy.

CONCLUSION.Dermatologic surgeons in the United States have contributed significantly to the history of reconstructive and cosmetic surgery. Dermatologic surgeons have been leaders in advancing this field and are poised to continue in the future.

AS LONG AGO as 50,000 B.C., needles were used by prehistoric man to pass a variety of suture materials through the skin.¹ Physicians in ancient Egypt, Babylonia, India, Greece, and Rome performed a vast array of cutaneous surgical procedures and some even specialized exclusively in this pursuit.² In the modern era, however, dermatology was not recognized as a “formal” specialty until the second half of the 19th century. Many early American dermatologists received their training in Europe and returned here to practice and teach dermatology. In the United States many early dermatologists were originally trained as surgeons and later became interested in skin diseases.

When the American Dermatologic Association (ADA), the first national U.S. dermatological society, was established in 1876 a number of the founding members were quite experienced in surgery. T. Brown was a professor of clinical and operative surgery at the College of Physicians and Surgeons in Baltimore; he also served as president of the Medical and Surgical Society of Baltimore.³ L. Bulkley founded the New York Skin and Cancer Hospital in 1883; he also helped to form the Section on Cutaneous Medicine and Surgery of the American Medical Association and was its first chairman in 1888.³ H. Piffard, an ADA founder and president, introduced the dermal curette in 1870; he served as surgeon to the City Hospital in New York (1871–96) and invented flash photography.^4,5 E. Wigglesworth, another ADA founder and president, reported in 1876 on using the curette for treating psoriasis, eczema, and even condylomata lata.⁶ G. Fox, another ADA founder and president, introduced a variation on the Piffard curette with a more delicate handle in 1902 that is still used today.⁷ E. Keyes was an ADA founder and the first professor of dermatology at Belleview Hospital Medical College in New York, where he also was a professor of urology.³ He modified the cutaneous punch for skin biopsies and removal of small lesions and scars in 1879.⁸

Many physicians were jointly interested in genitourinary disease as well as cutaneous disease because of the impact of syphilis on these two organ systems. The Journal of Cutaneous and Genito-Urinary Diseases was published from 1882–1902 and featured many articles on dermatologic surgery. The journal was taken over by the ADA in 1902 and eventually by the AMA in 1920 when its name was changed to the Archives of Dermatology and Syphilology. Today the Archives of Dermatology is the modern continuation of that century-old journal.

The Medical Dermatology Era

By the 1920s, dermatologists were the practitioners of a wide variety of cutaneous surgical procedures. S. Noel, a French dermatologist, was world famous for her work in facelifting and blepharoplasty and published a book on aesthetic surgery.⁹ At the same time, dentists and surgeons interested in head and neck reconstruction were beginning to pioneer the specialty of plastic surgery.¹⁰

Meanwhile more effective medical treatments for skin disorders began to appear. Surgical treatments for syphilis, such as curettage of condylomata lata, were replaced by medical approaches. Dermatologist W. Pusey, president of the AMA in 1923, was one of the first U.S. physicians (1900) to use roentgenotherapy for skin diseases and tumors.¹¹ A wide variety of skin disorders were now treated with X-ray.

In the 1930s dermatologists had two national organizations, the ADA and the AMA's section on dermatology and syphilology. These two organizations joined together in 1932 to cosponsor the formation of the American Board of Dermatology and Syphilology. The ADA was quite exclusive in membership and had only about one-fifth of the active U.S. dermatologists as members. There was obviously a need for a truly representative national dermatology society. In 1937, 14 dermatologists met in Chicago to form the American Academy of Dermatology and Syphilology. These physicians were primarily medical dermatologists, in contrast to the medical-surgical founders of the ADA 60 years earlier.

Gradually dermatologists in the 1930s and 1940s concentrated more and more on medical and radiologic solutions to skin disease. Although the curette and the punch remained important tools, more sophisticated skin surgery was largely abandoned. Plastic surgeons meanwhile had begun to perform most of the soft tissue reconstruction in the United States.¹⁰

The Rebirth of Surgical Dermatology

After World War II, dermatologists resumed their interest in cutaneous surgery. Returning from battlefield assignments, many had broad experience in surgical techniques. At the same time, public interest in appearance surgery was growing. In the 1950s, American dermatologists popularized dermabrasion, introduced hair transplantation, and resumed interest in chemical peeling.¹² Silicone was pioneered for soft tissue augmentation by dermatologists. In the 1960s, dermatologists invented cutaneous laser surgery and developed several laser systems.¹² Some began teaching skin grafting and local flap repair at the AAD annual meeting. In 1970 a group of surgically oriented dermatologists met at the annual AAD meeting and established the American Society for Dermatologic Surgery (ASDS) (Table 1). The ASDS rapidly grew into the premier organization in the world dedicated to advancement of dermatologic surgery. The 1970s were a time of numerous specialized symposia on skin surgery sponsored by the ASDS, and interest in dermatologic surgery grew rapidly. The Journal of Dermatologic Surgery was founded in 1975 by P. Robins and G. Popkin. Soon after, in 1976, the International Society for Dermatologic Surgery was also founded by P. Robins. In that same year, the American College of Chemosurgery, later the American College of Mohs Micrographic Surgery and Cutaneous Oncology, was founded. L. Field established the International Traveling Chair of Dermatologic Surgery in 1988, which spawned the formation of numerous national dermatologic surgery societies throughout the world.

By the end of the 1970s, dermatology had evolved into a medical-surgical specialty much like otolaryngology or ophthalmology. Through the 1980s and 1990s the ASDS has remained the principal source of postgraduate educational programs in dermatologic surgery. The ASDS has also been active in representing the interests of dermatologic surgeons to the AMA and to state medical and legislative bodies.

For more than 100 years, dermatologic surgeons have played a prominent role in the development of cutaneous surgical procedures. Following is a brief comment on many of these. In the months that follow, expanded articles on the history of dermatologic surgical procedures will appear in Dermatologic Surgery.

Chemical Peeling

In the late 1800s, dermatologists used a variety of chemicals to smooth wrinkles and facial scarring. Resorcinol, salicylic acid, trichloroacetic acid, and phenol were all employed.¹³ G. Mackee, who was chairman of dermatology at the Skin and Cancer Hospital in New York, used phenol for treating facial scars beginning in 1903. He reported on his more than 50-year series in the British Journal of Dermatology in 1952.¹⁴

Dermatologists continued to be involved in chemical peeling throughout the 20th century. J. Urkov described removal of skin defects by controlled exfoliation with phenol.¹⁵ S. Ayres added to the scientific knowledge of trichloracetic acid through his studies in the 1950s and 1960s.¹⁶ J. Stagnone described chemabrasion (dermabrasion immediately following a chemical peel) in 1977.¹⁷ S. Stegman defined the depth of injuries produced by chemical peeling and dermabrasion in scientific studies in the 1970s and 1980s.¹⁸ E. Van Scott's seminal work on a-hydroxy acids spawned the widespread use of these agents in the 1980s and 1990s.¹⁹ H. Brody, G. Monheit, and M. Rubin led the research in trichloroacetic acid and combination peeling in the 1990s.²⁰

Cryosurgery
A. White first used cryogens to remove skin lesions in 1899.²¹ White and H. Whitehouse independently pioneered the use of cryogens for malignant tumors in 1907.²² Later W. Pusey pioneered the use of solid carbon dioxide snow for destruction of superficial cutaneous lesions.²³ Although dermatologists used cryosurgery extensively throughout the 20th century, it was S. Zacarian in the 1960s who first studied the biology of cutaneous responses to cryogenic stimulation. He carefully defined the parameters for treatment of cutaneous malignancies with cryosurgery.²⁴ Cotton swabs were replaced by more efficient cryospray devices. Cryobiology research was furthered by the work of D. Torre, E. Kuflik, G. Graham, A. Gage, R. Lubritz, and others.

Dermabrasion

The German E. Kromeyer,²⁵ in 1905, introduced machine-powered abrasion using rotating metal burrs and cylindrical knives. The lack of uniform results, excessive bleeding, and pain caused the procedure to fall into disfavor. It was almost 50 years later that A. Kurtin²⁶ was able to overcome these limitations by freezing the skin, creating an anesthetized, rigid, bloodless field, allowing for the use of a rotary wire brush to achieve a controlled abrasion. Originally called “plastic planing,” it was later that the term “dermabrasion” was used.²⁷

J. Burks, N. Orentreich, R. Luikart, and S. Ayres helped refine this procedure throughout the 1950s and 1960s.^28,29 Although Kromayer had used the Keyes punch to remove minute scars 50 years earlier, this method was rediscovered by L. Lowenthal as well as Burks, who in the 1950s popularized the use of punch scar removal with autologous graft replacement followed by dermabrasion.^28,30 J. Yarborough introduced the concept of scar revision using dermabrasion within 6–8 weeks after traumatic or surgical skin injury.³¹ Yarborough became world renowned as the champion of the wire brush for dermabrasion.³² T. Alt favored the diamond fraise and popularize this instrument in the 1980s.³³ S. Mandy proposed preconditioning the skin with topical retinoids before dermabrasion to enhance healing.³⁴ H. Roenigk, J. Pinski, J. Robinson and C. W. Hanke suggested that the complex effects of systemic retinoids on the skin prior to dermabrasion might lead to scarring.³⁵ D. Harris reintroduced manual dermabrasion combined with chemical peeling in 1994.³⁶ J. B. Pinski pioneered the use of new dressings for postdermabrasion healing.³⁷ W. Coleman and J. Klein adapted tumescent anesthesia to dermabrasion in 1991.³⁸

Electrosurgery
Dermatologists have used electrosurgical devices for removal of skin lesions for more than a century. G. Mackee reported on electrosurgical fulguration of skin lesions in 1909.³⁹ Dermatologists have continued to pioneer research in electrosurgery throughout the 20th century.⁴⁰

Modern devices allow more precise delivery of electrical energy to skin lesions without scarring. North American dermatologists including J. Sebben and S. Pollack have been prominent in developing safe and effective electrosurgical techniques. More recently, “cold” electrosurgery or coblation has been pioneered by A. Carruthers, R. Grekin, W. Tope, and S. Pollack for cutaneous resurfacing.⁴¹

Hair Transplantation
Although Japanese dermatologists reported transplantation of hair-bearing grafts to areas of alopecia in the 1930s, language problems and World War II prevented the dissemination of this technique to the United States.² N. Orentreich developed the theory of donor dominance in 1959, demonstrating that nonbalding scalp grafted into balding areas retained all of its original donor characteristics.⁴² A number of dermatologists helped to refine Orentreich's technique throughout the 1960s. J. Burks, T. Tromovitch, L. Lewis, B. Stough, O. Norwood, S. Ayres III, and others were early hair transplantation pioneers.^43–45

The technique was refined and widely taught by J. Yarborough, T. Alt, W. Unger, and J. B. Pinski in the 1970s.⁴⁶ In the 1980s and 1990s a variety of other surgical specialists became interested in hair transplantation. Dermatologists, however, continue to play a leading role in this procedure. R. Limmer, R. Bernstein, and D. Stough have been instrumental in the development of micro- and minigrafts and microscopic follicular graft techniques in recent years.⁴⁷

Soft Tissue Augmentation

Although fat transplantation and dermal grafts were used sporadically throughout this century, the first material used widely for filling cutaneous defects was liquid silicone. The technique of microdroplet silicone was pioneered by N. Orentreich.⁴⁸ With formal approval by the U.S. Food and Drug Administration (FDA) Zyderm Collagen™ became the preferred tissue filler in the 1980s.⁴⁹ S. Stegman, T. Tromovitch, M. Elson, F. Brandt, A. Klein, and W. Hanke lead the effort to develop proper surgical techniques for use of bovine collagen materials. Recently, injectable human collagen has become available, and it remains to be seen whether this will decrease the use of bovine collagen in dermatology.

The American dermatologist S. Gottlieb developed Fibrel™ in the 1980s.⁵⁰ His approach involved an improvement over A. Spangler's original concept of using fibrin foam, developed in the 1950s.⁵¹ Dermatologists have led the research into hyaluronic acid, hylan B gel, and human collagen as injectables for soft tissue augmentation.⁵²

Fat transplantation was repopularized with the development of liposuction in the 1980s. Instead of the 19th century enbloc transplantation of fat, tissue could be aspirated and reinjected without major incisions or scars. P. Fournier introduced the new procedure of microlipoinjection at the annual meeting of the ASDS in May 1986. This technique was immediately embraced and refined by a number of dermatologists including S. Asken, W. Coleman, E. Griffin, R. Glogau, and J. Skouge.^52,53 Lipocytic dermal augmentation, a method of processing fat into a less viscous form which could be injected into the dermis as an alternative to collagen, was developed by Fournier and refined by American dermatologists W. Coleman, N. Lawrence, and K. Pinski.⁵⁴

Modern permanent implants include polytetrafluoroethylene, a suturelike material that can be implanted subdermally to correct contour abnormalities. Softform™ is a tubular form of polytetrafluoroethylene manufactured by the Collagen Corporation which has been promoted as a more effective alternative. The use of these materials has been pioneered by a number of dermatologists including R. Glogau, F. Brandt, S. Cox, and N. Lawrence.⁵²

Dermatologists continue to lead research in soft tissue augmentation.⁵² E. Griffin and J. Swinehart reintroduced and refined techniques in dermal grafting. D. Orentreich developed the concept of subcision for scars and wrinkles. D. Piacquadio has led research into hylan B gel. The future of soft tissue augmentation appears very bright.

Tumescent Liposuction

 

Liposuction was invented by the Italian cosmetic surgeons A. Fischer and G. Fischer in the mid 1970s.² It was popularized by Y. Illouz and P. Fournier in France. L. Field, an American dermatologist, was probably the first U.S. physician to import this technique to America in 1977.⁵⁵ Dermatologists quickly became leaders in the development of this new procedure. S. Asken, R. Narins, B. Chrisman, W. Coleman, and S. Stegman were early pioneers in performing liposuction under local anesthesia.⁵⁶ In 1985 J. Klein developed the tumescent technique, which enabled large volumes of fat to be removed using only local anesthesia.⁵⁷ P. Lillis helped to refine this approach, demonstrating decreased bleeding compared to older approaches.⁵⁸ W. Hanke, G. Bernstein, and others reported on the excellent safety record of tumescent liposuction.⁵⁹ W. Cook integrated dermal laser resurfacing on the undersurface of the skin and liposuction for neck lifting.⁶⁰ The AAD was the first specialty organization to publish guidelines of care for liposuction in 1989.

Although liposuction is clearly a procedure practiced by several specialties, it continues to be a prime source of interspecialty competition between dermatologic surgeons and plastic surgeons. Studies continue to show that tumescent technique as a local anesthesia approach to liposuction is extremely safe and remains the standard of care for liposuction.^61,62

Laser Surgery

Soon after the development of the laser in the 1950s, L. Goldman, chairman of dermatology at the University of Cincinnati, became the first physician to experiment with these new instruments on the skin.⁶³ Goldman did pioneering work with the CO₂ laser and the argon laser. He also did early research with the Nd:YAG, ruby, and copper vapor lasers.⁶⁴

Goldman was followed by a second generation of innovative dermatologic laser surgeons including K. Arndt, P. Bailin, G. Brauner, E. McBurney, and R. Wheeland.^65–69 R. Anderson and J. Parrish developed the pulsed dye laser at Harvard University in the early 1980s. They also developed the theory of selective photothermolysis, that is, that selective tissue injury can be produced by using appropriate laser wavelengths and pulse duration.⁷⁰

Subsequently dermatologists developed dozens of useful laser applications and dominated this field through the 1980s and 1990s. Pigmented lesion and tattoo lasers were pioneered by R. Anderson, R. Geronemus, S. Kilmer, D. Goldberg, J. Grevelink, and others.^71,72 Pulsed dye laser research was led by J. Garden, O. Tan, T. Alster, R. Geronemus, and others.^73,74 Laser resurfacing was introduced by L. David and R. Fitzpatrick and taught widely by C. Weinstein, M. Goldman, N. Lowe, A. Kauvar, and others.^75,76 Lasers for hair removal were pioneered by T. Alster, C. Nanni, R. Geronemus, M. Grossman, M. Gold, and others.⁷⁷ Dermatologic surgeons are currently involved in research on nonablative lasers for skin tightening and applications for stria ablation, laser hair transplantation, scar revision, and a variety of other conditions.

Phlebology

Although physicians first began to sclerose veins in Europe in the late 19th century, American interest was slow to develop.⁷⁸ In the 1970s dermatologists E. Bodian, D. Duffy, B. Chrisman, and N. Sadick refined the European techniques with polidocanol, saline, and other sclerosants.^79–82 R. Fitzpatrick, M. Goldman, R. Weiss, and others pioneered the use of lasers and visible light sources for destroying leg veins.⁸³ R. Weiss and M. Weiss introduced ambulatory phlebectomy, invented by Swiss dermatologists, into the United States, transforming the eradication of varicose veins into an office surgical technique.⁸⁴

Mohs Chemosurgery, Cutaneous Reconstruction, and Wound Healing

F. Mohs pioneered the unique concept of using a zinc chloride paste for the treatment of cutaneous malignancies during the 1930s.⁸⁵ This in vivo fixative was applied to the tumor and allowed to harden. Twenty-four hours later the hardened malignancy was removed layer by layer and tissue sections were prepared for histologic examination. This layer-by-layer removal of the tumor progressed until a negative margin was obtained. Mohs preferred that these wounds heal by secondary intention.

Dermatologists were the first to recognize the value of Mohs method in obtaining a high cure rate for cutaneous malignancies while preserving normal tissue. Mohs began to train dermatologists in formal fellowships. Some of these individuals themselves formed fellowship training programs throughout the United States and abroad. Early pioneers included T. Tromovitch, S. Stegman, P. Robins, R. Ammonette, H. Menn, and others.

In 1970 Tromovitch and Stegman developed a technique of using the Mohs micrographic surgical approach without the zinc chloride fixative, using frozen sections.⁸⁶ This method, called the “fresh tissue technique,” allowed similar cure rates. The chief advantage of this approach was that the defects created could be repaired immediately.

Because of the large size of many of the defects resulting from Mohs micrographic surgery, new approaches of reconstruction were required. Although plastic surgeons had up to this point been performing much of the cutaneous reconstruction in the United States, dermatologic surgeons soon took over this area nearly completely since they were usually the primary surgeon consulted. Dermatologists who did not practice Mohs surgery referred their patients with larger tumors to physicians who were trained in this technique. In most cases, the repairs after the Mohs surgery were then performed by the Mohs surgeon alone. The 1970s spawned a dramatic increase in interest in cutaneous reconstruction among dermatologists led by S. Stegman, T. Tromovitch, and P. Robins. J. Zitelli developed imaginative approaches to skin grafting and flap repair in the 1980s.⁸⁷ Dermatology residency programs integrated reconstructive surgery into their core curricula. Almost every dermatology residency program has a Mohs micrographic surgeon who teaches flaps, grafts, and dermatologic surgery. This led to the formation of the Association of Academic Dermatologic Surgeons with N. Swanson as the first president. Since dermatologists operate primarily on an ambulatory basis, they began to perform these tissue repairs in an ambulatory care setting, with tremendous cost savings over traditional hospital reconstruction.

The introduction of Mohs surgery also encouraged dermatologic interest in the science of wound healing.¹² Dermatologists such as W. Eaglestein, V. Falanga, R. Clark, and J. Zitelli have been leaders in research on the biology of healing wounded skin and have also been instrumental in developing new biological dressings based on wound healing research.⁸⁸

Botulinum Toxin
 

Dermatologists pioneered the use of botulinum toxin for facial wrinkles. A. Carruthers (a dermatologist) and J. Carruthers (an ophthalmologist) were the husband and wife team that lead the research into cosmetic applications of this toxin.⁸⁹ A. Klein, J. Fulton, F. Brandt, and others helped to refine the use of this material and teach appropriate techniques. Botulinum toxin proved to be quite popular, effective, and safe in treating wrinkles caused by facial expressions and is now used widely by dermatologists alone and in combination with other cosmetic surgical procedures. Dermatologic surgeons also pioneered its use for sweat reduction of the palms and axillae.⁹⁰

Blepharoplasty and Rhytidectomy
 

Although dermatologists such as S. Noel were quite active in blepharoplasty and facelifting in the 1920s,⁹ dermatologists largely abandoned these procedures until the early 1980s. At that time, increased sophistication in surgical techniques for facial reconstruction lead many dermatologists to begin to perform these procedures. Dermatologists such as B. Chrisman, L. David, and S. Asken have made significant contributions in traditional and oriental blepharoplasty⁹¹ and helped to develop the field of laser blepharoplasty.⁹² As laser resurfacing of the eyelids was developed by dermatologists, interest in transconjunctival blepharoplasty performed simulataneously was also popularized.⁹³

Dermatologists have also become more interested in facelifting over the last 20 years. B. Chrisman, P. Collins, and L. Field pioneered the use of liposuction techniques for facelift surgery,⁹⁴ and T. Alt and S. Asken refined and simplified rhytidectomy techniques.⁹⁵ C. Weinstein led research in brow lifting and endoscopic forehead lifting and helped to define parameters for combining these techniques with laser resurfacing.⁹⁶ J. Fulton developed techniques for the simultaneous use of laser resurfacing with facelifting.

The rich history of dermatologic surgery portends an active continuation of that strong tradition. Young dermatologists are increasingly interested in the surgical aspects of dermatology. Residency programs continue to increase the amount of surgery taught in their programs. These young, enthusiastic dermatologic surgeons are the future of the specialty. Dermatology continues to attract some of the brightest and the best medical graduates. It is clear that they will continue to add to the surgical advances of those who have gone before them. The future for our field seems very promising.

References

The Medical Dermatology Era  The Rebirth of Surgical Dermatology  Chemical Peeling  Cryosurgery  Dermabrasion  Electrosurgery  Hair Transplantation  Soft Tissue Augmentation  Tumescent Liposuction  Laser Surgery  Phlebology  Mohs Chemosurgery, Cutaneous Reconstruction, and Wound Healing  Botulinum Toxin  Blepharoplasty and Rhytidectomy  The Future