A Surgeon’s Approach to Non-Invasive Dermatology

Dr. Jennifer Chwalek has practiced Mohs micrographic surgeon for more than 10 years and is a Clinical Instructor of Dermatology at Mount Sinai Medical Center where she teaches the latest surgical techniques to dermatology residents. We were curious to find out how a practicing surgeon looks at non-invasive and minimally invasive cosmetic dermatology procedures.

What is Mohs surgery?

Mohs surgery is a highly specialized technique for treating skin cancer which was developed by Dr. Frederic Mohs in 1938.  It is used as a tissue sparing method for removing skin cancer in cosmetically sensitive areas such as the head and neck. During the procedure the skin cancer is removed in stages, one tissue layer at a time and examined under a microscope until the margins are clear and there is no remaining skin cancer.  Mohs surgery yields high cure rates (in the range of 94-99% compared to traditional excision cure rates of approximately 80-90%) as well as superior cosmetic outcomes. Recent studies comparing different treatment modalities have confirmed that mohs surgery often results in the best cosmetic outcomes. 

Why are you passionate about skin cancer prevention?

Despite the success of mohs surgery in treating skin cancer, surgery still has risks associated with it and is stressful for most people.  For this reason, it is important we do everything we can to prevent skin cancer. I use every office visit as an opportunity to educate patients about the importance of daily sun protection and the warning signs of skin cancer.  Most skin cancers, when diagnosed early have an excellent prognosis.

How does Mohs impact your cosmetic dermatology practice?

Mohs surgery requires an in-depth understanding of facial anatomy, precise surgical skills as well as training in facial reconstruction.  This is important during cosmetic procedures, such as dermal fillers, cutaneous lasers, radiofrequency microneedling, and thread lifts where every millimeter counts for obtaining superior cosmetic results.  My surgical practice has taught me how to optimize normal wound healing and avoid abnormal scarring. Mohs also bridges didactic knowledge with ongoing clinical practice. Often I have to think outside of the box when determining the best way to reconstruct a wound.  Likewise, each cosmetic patient requires an individual approach and I often have to adapt techniques to best serve the patient.  

Do the two worlds ever collide?

While cosmetic dermatology and skin cancer treatments don’t usually overlap, I constantly consider the cosmetic repercussions and outcomes for my surgical patients. 

Laser resurfacing, in particular, Fraxel, can help to treat pre-cancer lesions (actinic keratoses or AKs) and possibly prevent early skin cancers.  AKs are a common pre-cancerous condition affecting up to 58 million Americans, according to the Skin Cancer Foundation.  AKs appear as rough, red, scaly patches, and is caused entirely by sun exposure and UV damage (insert friendly reminder to wear sunscreen here). That’s why it most commonly develops on sun-exposed areas such as the face, scalp, ears, chest, arms, and upper back. Left untreated, AK can turn into a type of skin cancer known as squamous cell carcinoma. 

Fraxel creates microscopic zones of injury in the skin, stimulating a wound-healing cascade that ultimately results in increased collagen production and photorejuvenation. That’s why it’s a great choice for those looking for less wrinkled, more youthful skin, though that healing response is also what helps treat the AK.

A 2013 study published in the Journal of the American Academy of Dermatology found that participants had over an 86 percent reduction in facial AK lesions six months after treatment.  One of the benefits of fraxel is that it not only treats existing spots, but may also prevent new ones from forming. 

I recommend one to two treatments initially, then yearly treatments afterward. It’s important the laser treatment is performed by a board-certified physician with an expertise in laser surgery in order to get optimal results.  If it is performed too aggressively or with poor technique, it may result in scarring and dyspigmentation. 

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