DS02 Challenging dogma in dermatological surgery

Abstract Dermatological surgery training is an apprenticeship with techniques often passed down and rarely questioned. Aligning clinical practice with a robust evidence base is desirable for achieving optimal surgical outcomes. Four common dogmas in skin surgery were explored using evidence-based literature. (i) ‘Double and triple curettage and cautery is an effective treatment for basal cell carcinoma (BCC)’. Quality of evidence was low, and based mostly on historical practice using a spoon curette. Modern expert opinion is that should conservative surgical treatment be required, a one-piece tangential shave or saucerization with a flexible razor blade or scalpel is preferable. The biopsy details will influence adequacy of treatment and risk stratification. Furthermore, electrodesiccation (particularly if repeated) can lead to poor healing and increased scarring while exposing the surgeon to excessive surgical plume. Based on the evidence, we recommend that repeated curettage and electrodesiccation be abandoned for the treatment of BCC. (ii) ‘Excessive surgical garb and complete field sterility in dermatological surgery reduce surgical-site infection’. Quality of evidence was low: case series and case–control studies showed that the use of masks, head coverings, full-body drapes, theatre shoes and shoe covers did not prevent surgical-site infection. Dermatological surgery is classified as ‘clean’ where the contamination rate is low. Excessive surgical garb adds little to patient care and contributes to significant waste. (iii) ‘Mohs surgical excision of BCC leads to better cosmetic outcomes’. Quality of evidence was low and likely influenced by bias of Mohs surgeons. A prospective study comparing outcomes with standard excision showed no difference in cosmetic outcomes. Multiple different factors contribute to cosmetic outcome – both surgeon related and defect related. However, at certain sites such as the alar rim and the eyelid, tissue preservation by Mohs surgery may lead to a more straightforward reconstruction and a better cosmetic outcome. (iv) ‘A dressing should always be applied on sutured defects’. Quality of evidence was low (case series). This dogma is likely influenced by bias of specialty training. Potential benefits of postoperative dressings include reduced infection, protection from trauma, reduced bleeding, less staining of clothes and patient comfort. However, dressings can potentially cause ischaemia, dermatitis and increased infection risk. There is evidence that in clean, minimally invasive skin surgery, infection rates are similar with or without a dressing. Not using routine postoperative dressings simplifies postoperative care and reduces costs; we recommend a flexible approach including patient preference. We suggest further dermatological surgery dogma is critically appraised to balance opinion-driven practice and strive towards evidence-based dermatological surgery.