Dermatologic Surgery and Dermatologic Oncology as an Essential Part of the Modern Dermatology in Bulgaria

Abstract

Dermatosurgery and dermatooncology are an integral part of dermatology as a speciality, and this postulate is strictly respected in a high percentage of European dermatological units. Due to the fact that a number of other specialties interweave with the subject of therapy - the surgical treatment of the patient with skin tumors, the positioning of dermatosurgery as part of dermatology is generally controversial (according to some), and at the same time is often the subject of a number of debates and conflicts. These include maxillofacial surgeons, plastic surgeons, regenerative and reconstructive surgeons, surgical and medical oncologist, etc. The advantages of these specialities are mainly based on good medical practice and good surgical techniques that are applied. In contrast, their disadvantages are based on the lack of good awareness of the initial surgical approach as well as the need for time-adjusted and accurately performed additional surgical interventions which should befurthermore careful scheduled with the relevant oncology units. Losing this thread, in practice, it turns out that we are losing the patients themselves or, looking laconically, we are working with reduced efficiency and effectiveness. Although for the last 15 years the positions of these sub-sectors in Bulgaria had been underdeveloped, a certain ascent has been observed nowadays or from a couple of years ago. This advance is undoubtedly due to the influence of the German Dermatological School, presented by Prof. Dr. Uwe Wollina, Head of Department of Dermatology, Venereology and Allergology in Dresden, Germany, as well as due to other respected representative of the Italian Dermatological School - in the face of Prof. Dr. Torello Lotti, Head of the Dermatology Unit at G Marconi University of Rome, Italy.

Introduction

Attested in English in 1819, the word dermatology derives from the Greek δέρματος (dermatosis) [1], genitive of δέρμα (derma), “skin” [2] (itself from δέρω dero, “to flay”) and -λογΊα -logia. Readily visible alterations of the skin surface have been recognised since the dawn of history, with some being treated, and some not. In 1801 the first great school of dermatology became a reality at the famous Hôpital Saint-Louis in Paris, while the first textbooks (Willan’s, 1798–1808) and atlases (Alibert’s, 1806–1814) appeared in print during the same period [3].

Dermatosurgery and dermatooncology are an integral part of dermatology as a speciality, and this postulate is strictly respected in a high percentage of European dermatological units. Due to the fact that a number of other specialties interweave with the subject of therapy - the surgical treatment of the patient with skin tumors, the positioning of dermatosurgery as part of dermatology is generally controversial (according to some), and at the same time is often the subject of a number of debates and conflicts. These include maxillofacial surgeons, plastic surgeons, regenerative and reconstructive surgeons, surgical and medical oncologist, etc. The advantages of these specialities are mainly based on good medical practice and good surgical techniques that are applied. In contrast, their disadvantages are based on the lack of good awareness of the initial surgical approach as well as the need for time-adjusted and accurately performed additional surgical interventions which should be furthermore careful scheduled with the relevant oncology units.

Figure 1.

1a) Island flap. Patient with keratoacanthoma (histopathologically verified after the surgical excision), located in the area of the left cheek, Medical Institute of the Ministry of Interior, Department of Dermatology, Venereology and Dermatological Surgery, 2017, Sofia, Bulgaria; 1b) Oval excision of the primary tumor; 1c) Extension of the wound edges in the shape of triangle peripherally. Preparation of the distal and proximal part of the created skin island; 1d) Transposition of the skin island in the proximal direction followed by careful adaptation of the wound edges; 1e) Adaptation of the distal part of the island; 1f) Post operative clinical finding

Losing this thread, in practice, it turns out that we are losing the patients themselves or, looking laconically, we are working with reduced efficiency and effectiveness.

Figure 2.

2a) Patient with basal cell carcinoma of the cheek, preoperative clinical finding. Marking of the resection fields; 2b) Oval excision of the primary tumour with island flap plastic planning. Step by step dissection; 2c) VY flap. Oval excision of the primary tumour and island flap plastic planning. Clinical status immediately after the excision; 2d) Gradual extension of the defect in the shape of a triangle at both of the ends and changing of the primary idea for island flap performance. Medical Institute of the Ministry of Interior, Clinic of Dermatology, Venereology and Dermatological Surgery, 2017, Sofia, Bulgaria; 2e) Gradual extension of the defect in the form of a triangle. Electrocoagulation; 2f) Defect closing from distal to proximal direction. Gradual adaptation of the wound edges by single skin stiches; 2g) Intraoperative finding with minimising the size of the defect by gradually adapting of the wound edges; 2h) Expansion of the defect forward the pre-auricular area, leading to better adaptation of the wound edges; 2i) Post-operative findings; 2j) Post-operative findings. VY flap

Although for the last 15 years the positions of these sub-sectors in Bulgaria had been underdeveloped, a certain ascent has been observed nowadays or from a couple of years ago.

This advance is undoubtedly due to the influence of the German Dermatological School, presented by Prof. Dr. Uwe Wollina, Head of Department of Dermatology, Venereology and Allergology in Dresden, Germany, as well as due to other respected representative of the Italian Dermatological School - in the face of Prof. Dr. Torello Lotti, Head of the Dermatology Unit at G Marconi University of Rome, Italy.

A number of specialists from Bulgaria benefit from the advice and teaching from these already established and internationally respected dermatosurgical and oncological units in Europe (in particular Germany and Italy) within the framework of the international collaboration, currently mediated by the Onkoderma / ADCRSTR cooperation group, the Association for Dermatohistopathological Control, Reevaluation and Subsequent Therapeutic Recommendations.

Figure 3.

3a) Intraoperative findings in a patient with a small squamous cell carcinoma of the ear. Triangular excision. Medical Institute of the Ministry of Interior, Clinic of Dermatology, Venereology and Dermatological Surgery, 2017, Sofia, Bulgaria; 3b) Intraoperative defect; 3c) Adaption of the wound edges; 3d) Post-operative findings

The Association for dermatohistopathologic control and subsequent therapeutic recommendations was created, guided by the idea to provide adequate medical care at the European and global level, which is supported basically at national but also at international German and Italian dermatological schools. Among the objectives of the association is to support young physicians in their professional development as dermatologists and oncologists, integrating international quality of education and training. Despite being a controlling institution for histopathological samples (at the national level) and accurate diagnosis, ADCRTSR.com plays a key and regulatory role in international collaboration and the realisation of numerous innovative projects, namely - projects with the dermatosurgical and dermatooncological division. The influence of the German dermatological school in Dresden, Germany, represented by Prof. Dr. Uwe Wolina and the Italian Dermatological School in Rome, Italy, represented by Prof. Dr. Torello Lotti, is helping in profiling the activity of one of the first non-private clinics with a dermatosurgical and dermatooncological division – the Dermatology unit of the Ministry of Interior Medical Institute, where such a type of skin surgery is performed today in the everyday clinical practice. The international collaboration with renowned international experts is essential for the improvement of both of the primary and specialized national medical care, The Association’s members support international collaboration in science, while working hard for the improvement of their knowledge and medical science as a whole, participating in several research projects and publications, as well as in integration of new theories on the etiology and pathogenesis of known diseases and unsolved mysteries in the field of pathogenesis and manifestation of certain diseases. The innovative thinking and dedicated work of our partners cooperate in combating a variety of medical problems.

More than 100 projects have been carried out within the framework of this collaboration over the last 3-4 years, concerning basically the good medical practices and dermatological science, resulting in the maximum of the possible effectiveness regarding the observance of the international standards for dermatologic surgery and oncology. Optimal conditions for the development of the young scientist have also been created meanwhile, in the above-mentioned sub-units as this realisation is still in the stage of everyday improvement. The initial creation of (currently) a small group of specialists, with interest in dermatologic surgery and dermatologic oncology in Bulgaria, leads to increased competitiveness, which inevitably requires also higher qualification - the qualification which is essential as for our survival, as well as the same in patients. Sooner or later the desired effect of the increased effectiveness of the specialised medical assistance, as well as the improved overall survival rate of the patients has been achieved, as a result from the established international relationships and cooperation group.