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Dermatologic Surgery
with Radiofrequency
Art of Successful Practice
http://taylorandfrancis.com
Dermatologic Surgery
with Radiofrequency
Art of Successful Practice

Bipin Deshpande
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

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Library of Congress Cataloging‑in‑Publication Data

Names: Deshpande, Bipin, author.

Title: Dermatologic surgery with radiofrequency : art of successful practice / Bipin Deshpande.
Description: Boca Raton, FL : CRC Press/Taylor & Francis Group, 2018. | Includes bibliographical
references and index.
Identifiers: LCCN 2017057558| ISBN 9781138301146 (hardback : alk. paper) | ISBN 9780203732182
(ebook : alk. paper)
Subjects: | MESH: Dermatologic Surgical Procedures--methods | Pulsed Radiofrequency
Treatment--methods | Ambulatory Surgical Procedures--methods
Classification: LCC RD655 | NLM WR 670 | DDC 617.4/77--dc23
LC record available at https://lccn.loc.gov/2017057558

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com

and the CRC Press Web site atW

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I dedicate this book to the “inspiring memories” of my late father Shri Bhaskar Shripad Deshpande,
who had always inspired me throughout my childhood and career to be a compassionate and helpful
medical practitioner.

Bipin Deshpande

v
http://taylorandfrancis.com
Contents

Foreword xi
Preface xiii
Acknowledgments xv
Authorxvii

1 Introduction 1
2 Office dermatologic surgery 5
Reference 7
3 Prerequisites of office dermatologic surgery 9
Preoperative clinical assessment 9
The ideal dermatologic surgeon 9
Staff or assistants 10
Role of patient’s accompaniment 10
Preoperative sterilization 10
Sensitivity testing 10
Intraoperative requirements 10
Postoperative care 10
4 Selection of surgical modality 11
5 Why radiofrequency? 15
Reference 17
6 Practical tips for switching over to radiofrequency surgery 19
From scalpel to radiofrequency (RF) surgery 19
From electrocautery to RF surgery 20
From cryosurgery to RF surgery 20
From ablative lasers to RF surgery 21
7 Fundamental features of radiofrequency surgery 23
Physical characteristics 23
Biological characteristics 24
Equipment details 26
Functionality 26
References 28
8 Radiofrequency surgery operative skills: Tips and tricks to master the technique 29
Reference 32
9 Precautions and safety measures 33
Patient safety issues 33
Practitioner safety issues 34
References 34

vii
viii Contents

10 Radiofrequency surgery rehearsal or practice sessions 35

Practice session suggestions and tips 35
Applications of waveforms 36
Reference 40
11 Patient assessment and counseling 41
Patient consultation and assessment 41
Informed consent 42
12 Applications 43
Therapeutic applications 44
Diagnostic applications 44
13 Specific applications: Radiofrequency commonality 45
Moles or intradermal nevi or melanocytic nevi 45
Warts (verruca plana, verruca vulgaris, digitate, or filiform warts) 50
Skin tags 53
Dermatosis papulosa nigra (DPN) 54
Milia 55
Corns and calluses 55
Keratoses (seborrheic and actinic) 56
Sebaceous cysts 60
14 Expanding the applications of radiofrequency dermatologic surgery 63
Molluscum contagiosum 63
Syringomas 65
Senile comedones 65
Closed comedones 67
Xanthelasma 67
Cherry angiomas 68
Earlobe repair 68
Mucoceles (submucous cysts) 68
Capillary hemangiomas and pyogenic granulomas 69
Trichoepitheliomas, neurofibromas, and keratoacanthomas (cutaneous horns) 70
Freckles 71
Mucosal lesions 72
Hypertrophic scars and keloids 73
Condyloma acuminata and genital lesions 74
Periungual and subungual lesions 75
Ingrown toenails 75
Rhinophyma 76
Facial gray hair 77
Chronic lichenified eczema, prurigo nodularis, hypertrophic lichen planus, and papular
or nodular lesion of unknown etiology 78
Telangiectasia 81
Basal cell carcinoma 81
Reference 82
15 Gems and jewels of radiofrequency surgery 83
Radiofrequency resurfacing technique for depressed facial scars 85
Radiofrequency resurfacing technique for hypertrophic scars on face 87
Radiovaporization and its applications 87
References 88
16 Biopsy using radiofrequency surgery 89
References 92
 Contents ix

17 Postoperative recovery and care 93

General postoperative care (excision wounds) 93
General postoperative care (desiccation wounds) 94
Aftercare 94
18 Tips and tricks to minimize complications 95
Complications due to anesthetics 95
Complications due to equipment, electrical inappropriateness, and electrode problems 95
Complications due to inappropriate technique, lack of experience, or overzealous
approach 96
Complications due to patient’s noncompliance 96
Tips and tricks to avoid or minimize complications 97
Conditions to avoid in office surgery 98
19 Postradiofrequency surgery outcome 99
Postoperative outcomes 99
Final results 101
20 Achieving aesthetically superior results: Tips and tricks 103
Tips for aesthetically superior results 103
Tricks of blending technique 104
21 Noteworthy cases 105
Case 1: Multiple tongue papilloma (papillomatosis) 105
Case 2: Giant condyloma acuminata on perianal area 106
Case 3: Posttraumatic punched out scar on tip of nose 108
22 From fantasy to factuality 111

Index 115
http://taylorandfrancis.com
Foreword
In the early 1980s, CO2 lasers were adopted by
dermatologic surgeons and were widely featured in
medical journal articles. A few years later, I had the
privilege of participating in a formal debate held
as a plenary session at the scientific meeting of the
American Society for Dermatologic Surgery. In the
debate, an expert in CO2 laser surgery (Dr. Philip
Bailin) and I, representing radiosurgery (then
“electrosurgery”), were given the opportunity to
convince the audience as to which modality was
superior. At the conclusion of this session, attend-
ees voted and were found to favor electrosurgery
over laser, by a margin of 7 to 1! Factors relating
to cost, ease of training, mobility of the equip-
ment, and versatility were all determinants of that
decision. These positive attributes of radiosurgery
remain today.
I have adopted many new technologies, includ-
ing laser, over the years, but radiofrequency
remains an irreplaceable modality in my cosmetic
dermatologic surgery practice. Although radiosur-
gery is performed thousands of times around the
globe each day, it has been many years since a new
text highlighting its use has appeared. Despite the
emergence of many modern energy-based tech-
nologies, utilizing a variety of laser, ultrasonic, and
other concussive and thermal formats, radiofre-
quency remains a readily available and inexpen-
sive solution to many dermatologic surgical needs,
particularly in less developed countries.
Dr. Bipin Deshpande has been a devoted prac-
titioner and educator on this subject for nearly
two decades, and his book, Dermatologic Surgery
with Radiofrequency, is the culmination of his
explorations and the insights that he has garnered.
The monograph not only provides detailed treat-
ment information but, in addition, illustrates how
radiofrequency fits into the overall setting of der-
matologic surgery. Moreover, the reader has an
opportunity to explore and hone new skills by
using the included practice sessions. I applaud
Dr. Deshpande for his tireless efforts to keep the
importance of radiofrequency alive in the next
generation of practitioners.
Sheldon V. Pollack, MD
Associate Professor of Medicine (Dermatology)
University of Toronto
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Preface
Medical practice is an art that is learned through
experience built up over decades of hard work. This
can never be taught in medical colleges. Art has no
boundaries or limits, so much so that any good and
learned practitioner not only can be a successful
practitioner, but with devotion and effort can spe­
cialize in a novel field.
I remember a practicing anesthesiologist in
India who after 10 years began specializing in the
field of dermatologic surgery and cosmetic derma­
tology. He successfully transformed himself into
an (an)aesthetic practitioner.
I started my practice as a family physician in
the metropolitan city of Pune, India, in 1988. I
had done my specialization in dermatology but
only practiced it occasionally. I always like to be
off the beaten track, and even in family practice
I presented many novel studies at local confer­
ences. Simultaneously, I studied light and its
effects on skin (photobiomodulation) way back
in 1996 and am still doing these treatments. I
have presented many studies on photobiomod­
ulation at various national and international
conferences.
I find the field of dermatology very challenging;
many skin diseases have recurrences, which can
be frustrating to patients as well as doctors. The
therapy angle is very narrow and with side effects.
Managing skin diseases with limited medicines is
an art. After years of managing the same patients
with the same problems or new patients with the
same problems, when one day you experience
the “one shot treatment” of dermatologic surgery
where a patient is cleared of his or her skin prob­
lem, it is really like a refreshing drink after toiling
in the hot sun.
Radiofrequency surgery was to me a “refresh­
ing drink.” It refreshed me so much when I
experienced its results that it became my passion.
The happiness that came along with the successful
results and the great patient satisfaction because
of no recurrence was itself a great inspiration to
explore and do more.
I introduced radiofrequency surgery in Indian
dermatology at the National Dermatology Confer­
ence in 2000. Since then, radiofrequency surgery
has received an overwhelming response in all der­
matology societies. I have spoken on many national
and international podiums, conducted teaching
workshops, and written many articles.
Believe me, I have never marketed my ser­
vices. My patients are my best walking and talking
advertisements.
Many doctors from faculties other than derma­
tology have shown great interest in radiofrequency
surgery. Some have learned from me, but there are
many more who would still like to learn the tech­
nique. For them and purely clinical dermatologists
and all the new budding dermatologists, this book
will be of great assistance not only as a guide but as
a step-by-step learning book to practice radiofre­
quency surgery at their bests in their own clinics
or offices.
There was no valuable publication on the use of
radiofrequency surgery in dermatologic surgery
for more than a decade. There are numerous publi­
cations on lasers and radiofrequency for skin tight­
ening and body contouring, as well as fractional
radiofrequency for acne scars. While conducting
workshops, the attending doctors expressed the
need of a publication on uses of radiofrequency for
dermatologic surgery. Hence, I have made an effort
to compile my data and personal experiences to
write this book.
I have written this book as a “storybook” that
slowly and steadily unravels the basic as well as
xiii
xiv Preface
the “gems and jewels” of radiofrequency surgery.
I have tried to use simple language to cover almost
all aspects of the surgery required for clinic-based
practice. I have also made it very practical with
a large collection of my case study photos and
schematic illustrations. Most of the after photos
are given to show the immediate postoperative
appearance of wound, which can result in least or
negligible scarring. It is for the readers to under­
stand that if they can achieve such a postoperative
wound on the operating table, they are assured a
best result.
The book’s final chapter takes readers to an
imaginary world but emphasizes the importance of
scientific knowledge and the limits of technology.
My sincere and best wishes to you!
Acknowledgments
It was my real dream to write a book on radiofre-
quency surgery since the time I started in the field.
It has been a very interesting 18 years and it is now a
passion. All these tireless years, I have been through
practical research of my own and education with
the help of thousands of photographs and numer-
ous lectures and workshops for the budding and
already practicing dermatologists. Over this period
there have been many good people who have helped
me with kind advice without expecting any returns.
I must thank Dr. Jon Garito, former president of
Ellman International Inc., New York, for his very
friendly advice and help in the initial period.
I thank Dr. Dileep Mane, chairman cum man-
aging director, Noble Hospital, Pune, India, for
his kind help in allowing me to organize so many
radiofrequency surgery teaching workshops.
A special word of thanks and my love and grati-
tude for my wife, Anjali, and son, Dr. Ruchir, who
have very patiently supported me and inspired me
throughout these tireless 18 years always with a
smile. It is their sacrifice that has helped me to rise
to such a height on this academic front.
I express my love and special gratitude to my
mother, Sushanta, who was always a driving force
to me in my early childhood, without which I
would never have seen these days.
Finally, I thank Mr. Bharat Ketkar, a profes-
sional artist who has done such wonderful line
drawings and illustrations for my book.
xv
http://taylorandfrancis.com
Author
Dr. Bipin Deshpande, MBBS, DVD, FAAD, has
been a practicing dermatologist for 29 years. He
is the head of the Department of Cosmetology at
Noble Hospital, a leading hospital in Pune, India.
He attended St. Vincent’s High School and B. J.
Medical College, Pune.
Dr. Deshpande has been an International
Fellow of the American Academy of Dermatology
for 12 years. He is also a life member of the Indian
Association of Dermatologists, Venereologists and
Leprologists; Cosmetic Dermatology Society of
India; and Indian Medical Association.
He specializes in cosmetic dermatology, der­
matologic surgery, and laser therapy. He has been a
pioneer in India in the fields of radiofrequency sur­
gery and photobiomodulation, and he introduced
radiofrequency surgery in Indian dermatology in
2000 at the National Dermatology Conference.
He also introduced photobiomodulation with
the help of the case study article “Diabe­tic Ulcer
Treated by BioBeam 660 Phototherapy” in the
Indian Journal of Dermatology, Venereology and
Leprology in 1996.
He has presented more than 40 original
research papers at national dermatology confer­
ences and national cutaneous surgery confer­
ences. He has also presented more than 30 original
research papers at various international dermatol­
ogy conferences including the World Congress of
Dermatology, American Academy of Dermatology,
World Congress of Family Physi­cians, International
League of Dermatology with Egyptian Women’s
Dermatology Society joint conference, DASIL
(Dermatologic and Aesthetic Surgery International
League), and IMCAS (Internal Master Course on
Aging Skin).
He has conducted more than 50 teaching work­
shops in India for radiofrequency surgery and one
workshop in Cairo, Egypt. He has been a guest
speaker at many local, regional, and national
conferences.
His chapter contributions include “Radiofre­­
quency Surgery: Ablative and Non-Ablative”
in the Manual of Cosmetic Dermato­ logy and
Surgery published in 2009, and “Radiofre­quency
and Electrocautery” in the book Procedures in
Dermatosurgery: Step by Step Approach to be pub­
lished in early 2018.
He was conferred in Who’s Who in Medicine
and Healthcare in 2007 and 2009, Who’s Who in
Asia in 2007, and Who’s Who in World in 2008 by
Marquis Who’s Who.
Deshpande has an Indian patent for designing
an instrument for facial scar management.
xvii
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Introduction
Dermatologic surgery, or cutaneous surgery, is an
ever-expanding and sought after field. The ever-
increasing demand for surgery in dermatology is
not the only reason for it. There is a growing demand
for dermatologic surgery from many fields of medi-
cine, including general surgery, otorhinolaryngol-
ogy, ophthalmology, plastic and reconstructive
surgery, and family practice. Dermatologic surgery
was and is still being performed quite commonly
using the “gold standard” scalpel or the favorite
modalities of contemporary clinical dermatologists
like electrocautery and cryosurgery.
Dermatologic surgery generally fits into the
category of minor surgery. For decades general
practitioners or family physicians performed
these surgeries in their small setups. Dermatologic
surgery in family practice started dwindling in
the last three decades as more specialized surgical
care became available with advanced technology.
Technological advances and availability of differ-
ent medical specialties even made family practice
a specialty of its own. The dermatologic surgery
also became specialized with the development
of electrosurgery, radiofrequency surgery, and
lasers. The development of punches facilitated
doing skin biopsy.
Dermatologic surgery involves surgery related
to all skin diseases for diagnostic and therapeutic
purposes. Skin diseases include cutaneous, vene-
real, and leprologic diseases.
Decades earlier, before the advent of electro-
surgery and lasers, lesions were removed using the
modalities of a scalpel, hyfrecator, electrocautery,
cryosurgery, or chemical cautery. Here, the final
result involved complete removal of lesion where
the residual scar hardly mattered.
In the modern era, there is an additional demand
from patients due to cosmetic concern of facial
1
skin and other body parts. This has expanded the
scope of dermatologic surgery to the present stage
where it involves giving more specialized surgical
services to reduce the operative time and postop-
erative downtime as well as resulting in minimum
complications and negligible residual scarring.
In the early 20th century the methods of der-
matologic surgery were very crude. Some of these
small skin surgeries were performed by licensed
medical practitioners. But, I recall that in rural or
semiurban areas such surgical work was carried
out by unlicensed practitioners or quacks with
complications. Though the scalpel and cryosur-
gery or electrocautery were used, most of the skin
lesions on bodily skin and genitalia were removed
leaving obvious scarring or suture marks (Figures
1.1 and 1.2). These were accepted without prejudice
or mistrust.
The better knowledge and applications of elec-
tric current, electromagnetism, laser physics and
their connections as well as applications on the
biological tissues made huge progress in the later
part of the 20th century. The development of good
quality electrosurgery equipment dates back to
1926 and is credited to Harvard physicist William
Bovie. This was preceded by many earlier experi-
ments to develop equipment using electric current
for skin surgery. The Bovie electrosurgery equip-
ment was reasonably complete comprising of both
cutting and coagulation currents. This was further
improvised to include more facilities for better
removal of superficial as well as deep lesions. Thus
the newer equipment using higher frequencies
allowed electrosection, electrocoagulation, elec-
trodesiccation, and fulguration, which led to more
precise and effective dermatologic surgery. Lasers,
which became available after 1960, have been a
favorite of modern-day dermatologists.
1
2 Introduction
Figure 1.1 Postchemical cautery scabs and burnt
skin.
Figure 1.2 Postelectrocautery scars.
The educational curriculum of dermatology
at many institutions has yet to include modern
electrosurgery and lasers. In fact, there is a need
to update the educational curriculum to include
these and modern radiofrequency surgery uni-
versally. Because of this drawback, dermatologists
were hardly well equipped to surgically deal with
skin lesions. This lack of confidence among derma-
tologists led to many skin lesions being tackled by
surgeon colleagues. There was also a lack of aware-
ness among the general public as to the best surgi-
cal treatment for skin lesions.
Dermatologic surgical care given by surgeons
from any faculty, whether general surgery or oth-
ers, appeared to lack in the dexterity compared to
their dermatology colleagues. This lack is likely
due to either use of their favorite scalpel or surgi-
cal diathermy or due to lack of awareness of the
histopathology of the concerned d ­ ermatological
lesions. The advantage dermatologists have in doing
dermatologic surgery is that they are well aware of
the histopathology of the concerned skin lesions.
They know the best level to reach in order for com-
plete removal with minimal or no scarring.
The dermatologic surgery described in this
book is confined to the minor operating theater
or office surgery, which is performed in a clinic-
based setup. While performing such procedures,
one must be perfectly clear in the scope and limi-
tations of them. One must be fully confident in
performing these procedures totally in the office
with or without the help of staff. One must also
be absolutely clear with the criteria of performing
dermatologic surgical procedures in the hospital
operation theater. Although these criteria may
vary between professionals, the overall accepted
ones are mentioned in Table 1.1.
Office dermatologic surgery has advantages
and disadvantages, which are mentioned in Tables
1.2 and 1.3. Office dermatologic surgery can be
Table 1.1 Criteria for doing hospital-based
dermatologic surgery
• Pediatric patients under 6 years of age
• Geriatric patients: No age limit, but patients
have cardiac or other major risk factors
• Patients with bleeding disorders
• Patients with lesions that are likely to bleed
significantly during surgery
• Patients with lesions close to sensitive areas
of body such as the eyes, inside nostrils, or
in the oral cavity
• Very anxious and noncooperative patients
• Immunocompromised patients
• Cancer patients
• Patients with HIV and HBV infection
Table 1.2 Advantages of office dermatologic
surgery
• Patient is more comfortable
• Less time-consuming
• Easy to plan and perform
• Minimum investigations
• Fewer restrictions
• Rapid biopsy
• Financial saving
• Instant surgical treatment possible

Table 1.3 Disadvantages of office dermatologic
surgery
• All skin lesions cannot be tackled effectively
• Limitation of space, disinfection facilities
• Limitations of surgical time
• Likely to miss serious pathology
• Limitations of anesthesia (general anesthesia
cannot be given)
• Lack of sufficient staff
• Fear of medicolegal implications if any
serious complications occur
performed effectively using a scalpel, electrocau-
tery, cryosurgery, electrosurgery, radiofrequency
surgery, or lasers. I used the first three modalities
early in my career. Once I started using radiofre-
quency surgery I found that it had potential to
replace not only all the earlier ones but also could
be a better alternative to ablative lasers.
A survey was conducted among dermatolo-
gists (young and budding as well as those having
10 years or more experience) to find the choice of
modality for dermatologic surgery. The survey
was done using a small, easy-to-complete ques-
tionnaire circulated in semiurban areas and met-
ropolitan cities in India. The survey was sent to
100 dermatologists having practice experience
between 4 and 20 years. Eighty-five dermatolo-
gists completed the survey. The first part of the
survey contained questions related to dermato-
logic surgery in practice and the second part con-
tained questions related to radiofrequency surgery
in practice. The results of this survey revealed
that a majority of dermatologists preferred using
Introduction 3
radiofrequency surgery for office dermatologic
surgery.
The results of the first part of the survey are as
follows:
ll All dermatologists performed dermatologic
surgery.
ll Most (more than 80%) had electrocautery and
radiofrequency surgery.
ll Only a few (less than 20%) had all modalities of
electrocautery, scalpel, cryosurgery, lasers and
radiofrequency surgery.
ll Most (more than 80%) agree that 10% to 25% of
practice is contributed by dermatologic surgery;
only few have less than 10% or more than 25%.
ll All agree that “dermatologic surgery is an
indispensable part of dermatology practice”
today.
The results of the second part of the survey are
given in Chapter 5.
Office dermatologic surgery has the clear
advantage of an “instant organization within prac-
tice.” This makes it possible to make immediate or
on-the-spot decisions for quick consultation and
surgery. This is time-saving for patients and quick
revenue-building for doctors. The clinic or office
should be predesigned or modified to suit this
advantage. Additional staff or assistant help should
be planned for proper implementation of this ser-
vice. It is always possible for any medical profes-
sional, whether dermatologist or surgeon from any
faculty, to give this service during routine consult-
ing practice hours as time-gap adjustments or pre-
planned hours on particular days of the week.
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Office dermatologic surgery
Clinic-based dermatologic surgery is performed in
the office or clinic of a clinician. Any clinician hav-
ing reasonable knowledge and confidence can per-
form the surgery. Any clinician who has a routine
clinical practice as a physician can later modify his
or her practice to perform dermatologic surgery
after acquiring sufficient knowledge and skills.
Here, my advice is to have full inclination and
intention to do so.
A clinician or practitioner from any faculty of
medicine can develop and establish an office der-
matologic surgery. Following are some of my sug-
gestions before developing this practice:
ll Total inclination and devotion
ll Sufficient space in clinic to devote to this
activity
ll Minimum requirements of minor operating
theater
ll Quiet and clean surroundings
ll Sufficient operating skills
ll Reasonably trained staff
ll Investment in reasonably good and advanced
surgical technology considering the array of
various dermatological conditions one needs to
deal with
I will next expand on these suggestions.
Total inclination and devotion. Dermatologic
surgery on facial or bodily skin requires good
understanding of the histopathology of the rel-
evant skin lesions to be tackled. In today’s world,
cosmesis is of primary concern, hence all such sur-
geries need to be given sufficient time and care for
best results. Best results will be delivered only with
total inclination and devotion. One should avoid
any interruption or disturbance of phone calls or
other activities of the clinic.
2
Sufficient space in clinic. Office-based derma-
tologic surgery requires a minimum of 140 square
feet floor area. It is always desirable to have a sepa-
rate room for this area rather than assigning a
small cubicle in a large consulting room.
Minimum requirements of minor operating the-
ater.1 The room delegated for dermatologic surgery
should be properly designed and equipped for the
job (Figure 2.1). The requirements are described in
brief next:
ll Room color should be light or pale white/yellow
for good illumination.
ll Flooring can be of light-colored tiles or carpet
(nonslippery).
ll LED tube lights are best for good illumination.
ll Electrical fixtures in the form of ceiling and
wall-mounted fans, exhaust fans, air condi-
tioner, sufficient sockets for connecting differ-
ent equipment, and extension boards.
ll Inverter with sufficient battery backup for
covering at least 3 hours in case of unexpected
electricity failure.
ll An operating magnifying lens with a circu-
lar tube light fitted around the lens, which is
sufficient for any surgeries to be performed in
the clinic (Figure 2.2). It has the advantage of
giving a magnified view for clean and clear dis-
section as well as good cosmesis.
ll Surgical trolleys (one or two) for keeping surgi-
cal equipment, syringes, dressing material,
bandages, paper tapes, tissue papers, surface
and local anesthetics, emergency medicine,
sphygmomanometer, alcohol-based antiseptic,
povidone-iodine, normal saline, sterilized cot-
ton, forceps (plain, toothed, and artery), kidney
trays, and formal saline-filled plain bulbs for
biopsy materials (Figure 2.3).
5
6 Office dermatologic surgery
Figure 2.1 Minor operating theater (office dermatologic surgery), Noble Hospital, Pune, India.
Figure 2.2 Operating bed with magnifying lens.
ll Washbasin and two waste bins (one for
surgery-related materials and the second for
routine waste).
ll Wall-mounted mirror and hand-held mirror
(for patient to use postsurgery).
ll Music player with speakers for playing soft,
soothing music in the background for reliev-
ing anxiety of patients thus creating a relaxing
environment in the operating room.
Quiet and clean surroundings. An office for
dermatologic surgery needs a clean dust-free
environment and quiet surroundings for efficient
surgical procedures (Figure 2.4).
Sufficient operating skills. All clinicians, derma-
tologists or otherwise, ought to acquire sufficient
operating skills with their preferred modality
before going into full-fledged dermatologic sur-
gery. They must always be up to date and try to
employ the latest techniques with minimum down-
time and negligible scarring.
Reasonably trained staff. A staff is usually
preferred to assist during office dermatologic
surgery. An effort must be made to train such a

Figure 2.3 Surgical trolley containing radiofre-
quency equipment and other requisites for office
surgery.
staff to assist while giving local anesthetic injec-
tion and calming patients if they are panicky.
The staff should also help in preparing patients
for minor surgery, helping with instruments dur-
ing surgery, and modifying the power or other
Figure 2.4 Consulting room with adjoining operating theater and laser room.
Reference 7
parameters of the operating equipment. The staff
should also be trained for handling situations of
vasovagal shock or helping during emergencies.
A close relative of the patient can be allowed to
sit inside the operating room to further boost the
confidence of the patient as well as relieve anxiety
of the relative in the case of a child, the elderly, or
pregnant woman.
Investment in good, effective surgical technology.
A judicious investment in the best surgical tech-
nology will always give unlimited returns in the
form of name, fame, and monetary returns. This
decision is very critical, as such investment has to
be done considering one’s budget, aim of surgical
practice, easy operability, best results, space occu-
pancy, maintenance, and recurring costs.
It is much easier to learn radiofrequency sur-
gery though it requires proper training to under-
stand the functioning of this technique. All details
regarding this are covered at length in the relevant
chapters in the later part of this book. In fact, any
clinician or surgeon using other surgical modali-
ties can also specialize in the use of radiofrequency
surgery for dermatologic surgery. Switchover tips
are explained in detail later.
REFERENCE
1. Brown JS. Minor operating theater, In: Minor
Surgery: A Text and Atlas, 4th e
­ dition, London,
Arnold Publishers, 2000.
http://taylorandfrancis.com

Prerequisites of office dermatologic
surgery
Prerequisites of office dermatologic surgery done
using any surgical modality remain the same. This
chapter considers more issues that are an integral
part of this surgery.
PREOPERATIVE CLINICAL
ASSESSMENT
All patients posted for dermatologic surgery need to
be counseled about the procedure. The counseling
may take 15 to 30 minutes. The assessment centers
upon two main concerns: (1) the ideal patient and
(2) frequently asked questions and patient counseling.
The ideal patient
The patient is the center of the whole show of office
dermatologic surgery. The patient posted for sur-
gery must be in a stable mental state. He or she
should also be fully prepared for the planned sur-
gery, its final result, and its possible side effects
and shortcomings. All doubts and fears about sur-
gery or its postoperative cosmesis must be totally
cleared from the patient’s mind. The patient should
not have unrealistic expectations.
Frequently asked questions
and patient counseling
All patients, whether stable or anxious, have basic
questions they will ask before any surgery, including:
ll How much pain during and postsurgery?
ll Will surgery fully clear the concerned
problem?
3
ll Will surgery worsen my facial appearance (in
case of facial lesion)?
ll How much time is needed for full recovery?
ll Will there be a need for me to take leave from
work for recovery?
ll Will there be any scars?
These frequently asked questions and many
more should be satisfactorily answered and all
other doubts of the patient must be effectively
cleared through a very candid and clear discus-
sion. This positive counseling should lead to boost-
ing the patient’s confidence and building of a good
relationship of mutual trust between patient and
surgeon.
THE IDEAL DERMATOLOGIC
SURGEON
All dermatologic surgeons are expected to possess
certain qualities, including the following:
ll Depth of knowledge and understanding of the
skin lesions to be removed
ll Adequate training and experience to handle
such cases
ll Technical aptitude and dexterity to use radio-
frequency surgery to deliver the best results
ll Adequate patience to understand patient’s
expectations and work systematically to
achieve promised results
ll Never overpromise results, always be patient
during surgery using radiofrequency, and
never be overzealous in order to avoid
complications
9
10 Prerequisites of office dermatologic surgery
STAFF OR ASSISTANTS
Dermatologic surgery usually requires only one
to two assistants. Generally, a single assistant
is good enough for radiofrequency surgery. An
assistant helps with preoperative preparation of
the patient and making all requirements ready
beforehand, including preoperative sterilization
and minimum required documentation. They can
also assist with simple tasks during the procedure
like holding forceps, during hemorrhage, alleviat-
ing fears of anxious patients, and postoperative
dressing. An assistant need not be a paramedic
(though a trained nurse always makes a differ-
ence) but should be stable minded and have good
endurance. Good experience is a must for such a
job. Preoperative and postoperative documen-
tation, histopathology specimen handling, and
record keeping should be responsibly carried out
by an assistant. The assistant staff does not need to
be fully scrubbed and wearing sterile gloves dur-
ing operation unless their active participation is
required.
ROLE OF PATIENT’S
ACCOMPANIMENT
Any patient who is posted for dermatologic surgery
is always a bit uncomfortable, anxious, or appre-
hensive before start of the surgical procedure. I
always allow the patient’s accompaniment (spouse,
friend, parent, guardian) inside the operating
room to alleviate this feeling. The patient is always
more comfortable having the accompanying per-
son close inside the operating room than without,
because the patient is in an unfamiliar environment
during the procedure. The accompanying person is
not required to be scrubbed; they can just wear the
footwear meant for an operating room and sit at a
specified comfortable distance in the room. Their
presence makes the operating environment more
relaxed. In fact, even the accompanying person
feels more comfortable than sitting outside waiting
anxiously. I have seen that this simple allowance
reflects a good gesture on the part of the surgeon as
far as confidence and transparency is concerned.
However, I always take precaution not to allow
any qualmy accompanying person, for example,
someone who cannot stand the sight of blood or
seeing the patient being injected or operated upon,
who may spoil the situation.
PREOPERATIVE STERILIZATION
Sterilization of all materials used for office surgery
should be carried out with the authentic methods
of sterilization such as the autoclave or hot air
ovens. The materials include all the instruments
used in operation, that is, the forceps, needle hold-
ers, scalpels, blades, electrodes, and other relevant
tools. If any office surgeries are to be performed
with the radiofrequency method on an urgent
basis, I steam-sterilize the electrodes.
SENSITIVITY TESTING
Lignocaine sensitivity, though very low (<1%),
should be included in the protocol for all patients
for safety purposes. I have encountered sensitivity
to topical surface anesthetic cream in my practice,
though very rarely.
INTRAOPERATIVE REQUIREMENTS
All operations are planned beforehand. The plan-
ning includes the selection of instrument, elec-
trodes, good illumination, and magnifying lens.
Patient skin preparation is always done with stan-
dard protocol using povidone-iodine followed by
absolute alcohol. Normal saline, sterilized gauze
pieces, cotton balls, dressing materials, paper
tape, and postoperative soothing gels (for patients
treated with electrodessication) are also part of
these requirements. A hand mirror is essential for
all patients to see themselves immediately after
office surgery done on the face.
POSTOPERATIVE CARE
All patients in office surgery are conscious and
aware of all the events taking place during surgery.
Postoperative care consists of dressings and advice
to be followed regarding medicines, soap use dur-
ing baths, and other relevant matters. Follow-up
visits are advised as well. Specific care pertaining
to radiofrequency surgery is covered later.
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 CHAPTER XLI.
DECISION OF THE UMPIRES.

A.H. XXXVII. A.D. 658.

The interval passed uneasily. Muâvia

ruled in Syria; Aly, over the rest of the The interregnum.
Moslem world. Neither, for the moment,
interfered with the other. The empire held itself in suspense.
Within the time appointed, Amru
appeared at Dûma, and, shortly after, Abu The Umpires meet.
Mûsa. Each was followed, according to Ramadhân, a.h. XXXVII.
Feb. a.d. 658.
agreement, by a retinue of four hundred
horsemen.[543] Thither also, to the neutral spot, flocked multitudes
from Irâc and from Syria, from Mecca and Medîna. With intense
interest they watched the strange proceeding, which (as they
expected) was about to decide the future of Islam. The leading chiefs
of the Coreish were also there; some, we are told, with the distant
hope that haply the choice might fall on one of themselves.[544]
The Umpires met in a pavilion pitched
for the occasion; and beneath it, a private And confer with each other.
conference was held between the two
alone. The account given by our authorities of what passed between
them, is very brief. The result we must accept, but the colloquy which
led to it is altogether of an uncertain kind. The gist of it is as follows.
Abu Mûsa, pressed by his astute colleague, admitted that the putting
of Othmân to death was a wicked and unjustifiable thing. ‘Then why,’
rejoined Amru, ‘wilt thou not take Muâvia, the avenger of blood, for
his successor?’ ‘If it were a mere question of blood-feud or
kinsmanship,’ Abu Mûsa answered, ‘there were Othmân’s sons with
a nearer claim. Succession to the throne, however, was a matter to
be determined, not by such considerations, but by the vote of the
chief Companions of the Prophet.’ Amru (so the story runs) then
proposed his own son: ‘A just and good man,’ replied Abu Mûsa, ‘but
one whom thou hast already made to take sides in the civil war; and,
Amru! we must above all things beware of kindling mutiny again
amongst the Arab tribes.’ A similar objection shut out Abdallah son of
Zobeir; and the son of Omar was put aside as not having qualities
fitting him for command. ‘Then,’ asked Amru, after all the possible
candidates had been named and negatived, ‘what may be the
judgment that thou wouldest give?’ ‘My judgment,’ answered Abu
Mûsa, ‘would be to depose both Aly and Muâvia, and then leave the
people free to choose whom they will.’ ‘Thy judgment is also mine,’
said Amru promptly; ‘let us go forth.’
The people, in breathless expectation
of the impending announcement, crowded The judgment.
round the pavilion as the Umpires issued
from it. ‘Let them know,’ said Amru to his fellow, ‘that we are agreed.’
Abu Mûsa advanced, and with voice loud and clear,[545] said: ‘We
are agreed upon a decision such as, we trust, will reconcile the
people, and reunite the empire.’ ‘He speaketh true,’ said Amru: ‘step
forth, O Abu Mûsa, and pronounce thy judgment.’[546] Then spoke
Abu Mûsa: ‘Ye people! we have considered the matter well. We see
no other course so likely to restore peace and concord amongst the
people, as to depose Aly and Muâvia, both the one and the other.
After that, ye shall choose a fit man in their room. This is my
judgment.’ He stepped aside, and Amru
advancing said: ‘Ye have heard the Deposing Aly.
sentence of Abu Mûsa. He hath deposed
his fellow; and so do I too depose him. But as for my Chief, Muâvia,
him do I confirm. He is the heir of Othmân, and as avenger of his
blood, the best entitled to succeed.’
The assembly was thunderstruck. Even
the Syrians had never dreamed of Muâvia The people thunderstruck.
achieving such a triumph; nor had it
entered the minds of those on Aly’s side, that their Umpire could be
overreached thus shamefully. ‘What could I do?’ cried Abu Mûsa,
assailed on every hand; ‘he agreed with me, then swerved aside.’
‘No fault of thine,’ said the son of Abbâs: ‘it was the fault of those
who put thee in the place.’ Overwhelmed with reproaches, Abu Mûsa
made his escape and fled to Mecca, where he thenceforward lived in
obscurity.[547] In the heat of his indignation,
the commander of the Kûfa body-guard Muâvia saluted Caliph by the
Syrians.
made an onset upon Amru, and was
roughly handling him, when the people interposed to set him free.
Amru returned forthwith to Damascus, where by acclamation Muâvia
was saluted Caliph by the Syrians.
How the startling intelligence affected
Aly, may be judged by the fact that to the The two Caliphs curse each
other in the daily service.
prescribed daily service he added a
petition cursing by their names, Muâvia, Amru, and several of their
chief adherents. Muâvia was nothing loth to follow his example. And
so the world was edified by the spectacle, in the cathedral temples of
Islam, of the rival Commanders of the Faithful uttering maledictions
in their daily prayers, the one against the other.[548]
 CHAPTER XLII.
THE KHAREJITES, OR THEOCRATIC SEPARATISTS, DEFEATED
AT NEHRWAN.

A.H. XXXVII. A.D. 658.

Aly, as the reader will suppose, was not

content with heaping imprecations on his Aly’s designs against Syria.
antagonist. He resolved on the immediate
renewal of hostilities. But he had other work before him first in
dealing with the fanatics nearer home.
Ever since they had broken up their
camp at Harôra, these, instead of settling Hostile attitude of the
down in sentiments of loyalty and peace, theocractic faction.
Ramadhân, a.h. XXXVII.
had been gaining in aggressive force and Jan. a.d. 658.
stubbornness. There should (such was
their cry) be no oath of fealty but to the Lord alone, the Mighty and
the Glorious. To swear allegiance either to Aly or Muâvia was in
derogation of that great name. ‘Ye are both of you,’ they would say,
‘coursing along, neck and neck, in the race of apostasy: the Syrians
run after Muâvia whether the way be right or wrong, and ye swear for
Aly through black and white. It is nought but blasphemy.’ So they
formulated their creed into one short sentence: No judgment, but the
Lord’s alone; and this they insolently flung in Aly’s teeth.[549] In vain
the Caliph argued, as he had done before, that the Arbitration had
been forced upon him by themselves. ‘It is true,’ they would readily
reply; ‘but we have repented of that lapse; and thou must repent of it
likewise, or else we shall fight against thee; and if so be that we are
slain, we shall meet our Lord with joy.’ Aly
yet hoped to gain them over. He bore with Aly’s forbearance.
their seditious talk; and in a public address
in the Great Mosque at Kûfa, he declared his intention of treating
them with forbearance. ‘They should have free access to the
mosques for prayer. If they joined his army, they should share the
booty like the rest. So long as they refrained themselves from any
overt act of disloyalty, he would use no force of arms against them.’
Instead of softening the fanatics, this
moderation only tended to embolden them. The Khârejites march to
Nehrwân. Shawwâl, a.h.
When the Umpires’ judgment was XXXVII. March, a.d. 658.
announced, they were elated at a result
which in their eyes amply justified their secession at Siffîn. They held
frequent meetings in secret, and resolved on raising the Divine
standard. They looked for heavenly interposition; but even if they
perished, it would be in a righteous cause, sure to triumph in the
end; they would, at any rate, be protesting against a wicked world,
and become inheritors of a blessed futurity. In the month following
the Arbitration, they began accordingly, in concert with the brethren
who sympathised with them at Bussorah, to leave their homes by
stealth. The party from Bussorah, five hundred strong, was pursued
by the governor, Ibn Abbâs; but they effected their escape, and
joined the bands which in greater force had issued forth from Kûfa.
Secular power, and the dignity and pomp of this life, were abhorrent
from these Covenanters’ creed; and it was only after many had
declined the dangerous pre-eminence, and then simply as a
temporary expedient to meet the present necessity, that a chief was
prevailed on to accept the supreme command. The design was to
occupy the city of Medâin, upon the Tigris, and there, under a
Council of Representatives, establish theocratic rule as a model to
the ungodly cities around. But the governor had timely warning, and
repulsed the attempt. They passed on, and crossed the river farther
up in various bodies, and, appointing Nehrwân as their rendezvous,
assembled there to the number of 4,000.
Aly did not at first recognise the serious
character and bearing of the movement. Aly orders levy for Syrian
campaign.
The number of the fanatics was
comparatively insignificant; and he hoped that, when they saw their
former comrades in arms marching against the graceless Syrians,
they would not hesitate again to join his standard. So he mounted
the pulpit and harangued the men of Kûfa. He reprobated the
Umpires, because they had cast the Book of the Lord, equally with
the precedent of the Prophet, behind their backs. Both were
apostates, rejected of the Lord, of his Prophet, and of all good men.
‘Wherefore,’ he concluded, ‘we must begin to fight our battle again at
the point where, on the eve of victory, we were forced to leave it off.
Prepare then to march for Syria, and be ready in your camp without
the city, by the second day of the coming week.’ Then he indited a
despatch to the fanatics at Nehrwân. It was
couched in terms similar to his address, And summons the theocrats,
and ended thus: ‘Now, therefore, when ye who refuse to join him.
have read this, return forthwith and join the army. I am marching
against the common enemy, yours and ours alike; and we have
come back again to the state of things when aforetime at Siffîn ye
were fighting by my side.’ In reply Aly received an insulting message:
‘If he acknowledged his apostasy and repented thereof, then they
would see whether anything could be arranged between them;
otherwise they cast him off as an ungodly heretic.’ The stiff-necked
theocrats were thereupon, for the present, left to their own devices,
and the business of raising levies for Syria proceeded with. But little
enthusiasm was anywhere displayed in the
cause of Aly. Of the 60,000 fighting men Aly marches for Syria.
drawing stipendiary allowances in
Bussorah, 3,000 were with difficulty got together. At Kûfa, after vain
appeal to the loyalty of the city, a conscription was ordered through
the heads of clans; and thus at length an army of threescore and five
thousand men of every rank and class was brought into the field.[550]
With this imposing force, Aly had
already commenced his march on Syria, But is diverted by the
when tidings reached him that the fanatics excesses of the fanatic host.
were committing horrid and cold-blooded outrages in the country
round about their camp.[551] A messenger was sent to make inquiry;
but he too was put to death by the insurgents. The tidings of their
proceedings became more and more alarming, and the men of Kûfa
demanded to be led against them; ‘for how,’ said they, ‘can we leave
such outlaws unpunished and at large behind us, and our homes
exposed to their unlicensed cruelties?’ Aly himself, seeing that this
must be done, changed his course eastward, crossed the Tigris, and
marched against the fanatics. When now near to Nehrwân, he sent a
messenger forward, to demand that the murderers should be
delivered up. ‘Surrender these to justice,’ he said, ‘and ye shall be
left alone, until the Lord grant us victory in Syria, and then haply He
shall have turned your hearts again toward us.’ They replied that
‘they were all equally responsible for what had passed, and that the
blood of the ungodly heretics they had slain was lawful to them.’ A
parley ensued, in which the Caliph through his captains expostulated
with the misguided fanatics, and offered quarter to all who should
come over to his army, or retire peaceably to their homes. Some
obeyed the call and came over; 500 went
off to a neighbouring Persian town, and The fanatics at Nehrwân
many more dispersed in other directions to dispersed and slain.
their homes at Kûfa or elsewhere. Eighteen hundred remained upon
the field, martyrs to the theocratic creed. With the wild battle cry, On
to Paradise! they rushed upon the Kûfa lances, and were slain to a
man. Aly’s loss was trifling.[552]
It would have been better for the peace
of Islam if none of the four thousand had The Khârejites again appear
escaped. The snake was scotched, not in the field. a.h. XXXVII. a.d.
658.
killed. The fanatic spirit was strangely
catching; and the theocratic cause continued to be canvassed
vigorously and unceasingly, but in secret, at Bussorah and at Kûfa.
However hopeless the attainment of their object might appear, the
fanatics were nerved, if not by the expectation of Divine aid, at the
least by the sure hope of a Martyr’s crown. In the following year
armed bodies once and again appeared unexpectedly in the field,
denouncing Aly, and proclaiming that the Kingdom of the Lord was at
hand. One after another these bands of insurgent fanatics were cut
to pieces, or put to flight with ease. But the effect was unsettling; and
it could not but endamage the name and power of Aly, who now
reaped the fruit of his weak compromise with the enemies of
Othmân, and his neglect to bring them to justice. Fanatical in their
extravagant doctrine, they were too sincere
to combine with any of the political sects, They become a thorn in the
and hence they never came near to Moslem empire.
leaving any permanent mark of their theocratic creed behind them.
But both at this period and in succeeding reigns, we find them at
intervals gathering up their strength to assail the empire, and as
often beaten back. Ever and anon, for years, and even for ages,
these Khârejites still ‘went forth’[553] on their desperate errand, a
thorn in the side of the Caliphate, and a terror to the well-disposed.
 CHAPTER XLIII.
REVOLT OF EGYPT.

A.H. XXXVIII. A.D. 658.

Having thus disposed of the fanatics at

Nehrwân, and recrossed the Tigris, Aly, at Aly abandons the war
the head of his army, turned his face again against Syria. End of XXXVII.
April, a.d. 658.
towards Syria. But the soldiers urged that,
before setting out upon so long a campaign, their armour needed
refitting. ‘Let us return for a little to our homes,’ they said, ‘to furbish
up our swords and lances, and to replenish our quivers.’ Aly
consenting, they marched back and pitched their camp at Nokheila.
This being close to Kûfa, the soldiers dropped off in small parties
thither; and so it came to pass that, in a short time, excepting
commanding officers, the camp was left almost empty. Aly, finding
that no man returned, became impatient, and himself re-entering
Kûfa, again harangued the people on the obligation to go forth with
him and make war on Syria. But exhortation and reproach fell
equally on listless ears. There was no response. Aly lost heart. The
Syrian expedition fell through; and no attempt was made to resume it
further.
Thus closed the thirty-seventh year of
the Hegira. The situation was unchanged. Position of Aly and Muâvia.
Muâvia, with now a colourable title to the
Caliphate, remained undisturbed in his position virtual monarch of
Syria, strong in the loyalty and affections of the province; while Aly,
mortified by an indifferent and partly alienated people, was now to
experience a severer trial.
We turn to Egypt. Before the Syrian war, as already stated, there
was a powerful faction in that dependency of Aly’s Caliphate,
especially at Kharanba, siding with those who demanded satisfaction
for the blood of Othmân; and Cays, having been recalled for leaving
these dissentients alone, Mohammed son of Abu Bekr had been
appointed in his room. Casting aside the
waiting policy of his wiser predecessor, Egypt revolts. a.h. XXXVIII.
Mohammed at once summoned the a.d. 658.
recusants, either to submit themselves to him, or to be gone from
Egypt. They refused, but masking for the present their hostile
designs, watched the issue of the struggle at Siffîn. When the armies
separated from that battle-field, leaving Muâvia still master of Syria,
they gained heart and began to assume the offensive. A party sent
against them was defeated, and the leader slain; and a second
attempt at retrieving the loss met with a like fate. The slumbering
elements of revolt were everywhere aroused.
Aly saw now the mistake which he had
made, but too late. He would have Ashtar, appointed governor,
is poisoned.
reappointed Cays; but Cays declined again
to take the post. The only other fitted for the emergency was Ashtar
the regicide, whom he summoned from his command at Nisibîn, and
sent off in haste to Egypt. But on the way he met with an untimely
death, having been poisoned, at the instigation (it is said) of Muâvia,
by a chief on the Egyptian border with whom he rested.[554] There
was joy at the death of the arch-regicide throughout the land of
Syria, where he had been greatly feared. Aly was equally cast down
by the untoward event. His only resource was now to bid
Mohammed son of Abu Bekr hold on, and do what he could to
retrieve his position. But the faction which
favoured Muâvia gained ground daily; and Mohammed killed and Egypt
when, shortly after, Amru, at the head of a conquered by Amru for
Muâvia. Safar, a.h. XXXVIII.
few thousand men, crossed the border, he July, a.d. 658.
was joined by an overwhelming body of
insurgents. Mohammed, after a vain attempt to meet his enemy in
the field, was easily put to flight. In the struggle he was killed, and his
body ignominiously burned in an ass’s skin.[555] Thus Egypt was lost
to Aly; and Amru, as the lieutenant of the rival Caliph, again became
its governor.
The loss of Egypt was the harder for
Aly to bear, as undoubtedly it might have Mortification of Aly at the
loss, and at the
been averted but for his removal of Cays; lukewarmness of Kûfa.
and even now it might have been retrieved
if the men of Kûfa had not been heartless in his cause. Over and
again he implored them to hasten to the defence of Egypt. With
difficulty two thousand men were got together; but after so long a
delay that they had hardly marched before news of the defeat made
it necessary to recall them. Aly thereupon ascended the pulpit, and
upbraided the people for their spiritless and disloyal attitude. For fifty
days, he had been urging them to go forth, to avenge their fallen
brethren, and to help those who were still struggling for him in the
field. Like a restive wayward camel, that refused its burden, they had
held back. ‘And now,’ he said, in grief and bitterness of spirit, ‘the
son of Abu Bekr is fallen a martyr, and Egypt hath departed from us.’
 CHAPTER XLIV.
THE REMAINDER OF ALY’S REIGN.

A.H. XXXVIII.–XL. A.D. 658–660.

No gleam of fortune lighted up the

remaining days of Aly’s reign. What with Remainder of Aly’s reign.
the rising of fanatics at home, and the
threats of the rival Caliphate abroad, his life was one continual
struggle. And, moreover, the daily exhibition of indifference and
disloyalty in Kûfa, the city of his choice, was a burden and
mortification hard to bear.
The loss of Egypt, and the cruel death
of Mohammed son of Abu Bekr, preyed Insurrection at Bussorah
upon his mind. He withdrew into the suppressed.a.d. 658.
a.h. XXXVIII.

strictest privacy. Ibn Abbâs, fearful lest his

cousin should resign the Caliphate, or do some other rash and
unadvised thing, set out from Bussorah to visit and comfort him. This
becoming known to Muâvia, he took the opportunity, during the
absence of Ibn Abbâs, to send an emissary with the view of stirring
up the disaffected elements at Bussorah. Among certain of the clans,
he was sure of finding many who, equally with himself, sought to
avenge the blood of Othmân; few were zealously attached to the
cause of Aly; the remainder were mostly Khârejites, of the theocratic
faction, now as hostile to Aly as to Muâvia himself. Abdallah, the
Syrian agent, carrying a letter to the citizens of Bussorah, was so
well received, that Ziâd, who held temporary charge of the city, was
forced to retire with the treasures and the gubernatorial pulpit into
the stronghold of a loyal clan, from whence he wrote for help to Kûfa.
Aly at once despatched a chief of influence among the Beni Rabia,
the leading tribe at Bussorah, who were by his persuasion induced to
rally round Ziâd. After severe and bloody fighting in the city, attended
by various success, the rebels were at last defeated, and driven for
refuge to a neighbouring castle. There they were surrounded, and
the castle having been set on fire, Abdallah, with seventy of his
followers, perished in the flames. The victory was decisive for the
time; but the insurrection had brought to light the alarming spread of
disaffection, and showed how precarious was Aly’s grasp upon the
Bedouin races of this factious city.
The spirit of disturbance and unrest
was not confined to Egypt and to Khârejite émeutes.
Bussorah. During the year, we read of five
or six occasions on which considerable bands of Khârejites were
impelled by their theocratic creed to go forth and raise the standard
of rebellion. One after another they met the common fate of
slaughter and dispersion. But though crushed, the frequent repetition
of such desperate enterprises, the fruit of a wild and reckless
fanaticism, had a disturbing effect on the capital and the empire at
large. The most serious of these risings
was that led by Khirrît; and it is the more Rebellion of Khirrît in
remarkable, because this chief had with his Southern Persia,
XXXXVIII. a.d. 658.
a.h.

tribe, the Beni Nâjia, fought bravely by the

side of Aly in the battles both of the Camel and Siffîn. He was now
driven, like many others, by his strong convictions to rebel. Boldly
approaching the throne, he told Aly that since he, as Caliph, had
referred a Divine issue to the arbitration of man, he could obey him
no more, neither stand up behind him in the Mosque at prayer; but
henceforth was sworn to be his enemy. Aly, with his usual patience,
said that he would argue out the matter with him, and arranged a
meeting for the purpose. But the night before the appointed day,
Khirrît stole away from the city with all his following. ‘Gone,’ said Aly,
‘to the devil; lost, like the doomed Thâmudites!’ They were pursued,
but by so small a party that they held it at bay, and in the end
effected their escape to Ahwâz and Râm Hormuz. There they raised
the Persians, Kurds, and Christian mountaineers, by the specious
and inflammatory cry that the payment of taxes to an ungodly Caliph
must be renounced. With a band of apostate Arabs, they kindled
revolt throughout the province of Fars, and put the governor to flight.
A force from Bussorah drove them to the
shores of the Indian Ocean. But luring the suppressed, and Khirrît slain.
people by delusive arguments and
promises, they still gained head; and it was not till after a bloody
battle, in which Khirrît lost his life, that the supremacy of the
Caliphate was re-established in Southern Persia. The Mussulman
prisoners in this campaign were set at
liberty on their taking afresh the oath of Christian captives.
allegiance; but the Christians, five hundred
in number, were all marched away to be sold into captivity. The
women and children, as they were torn from their protectors, wailed
with loud and bitter cries. The hearts of many were softened.
Mascala, Governor of Ardshîr, touched by the scene, took upon
himself the cost of ransoming these Christian captives, and set them
free. Aly, hearing of it, demanded from him immediate payment at a
thousand pieces for each captive; and Mascala, unable to pay down
so great a sum, fled and joined Muâvia.[556]
The defeat of the Khârejites did not at
once restore peace to Persia; for Fars and Ziâd suppresses rebellion in
Kermân threw off their allegiance, and Persia, a.h. XXXIX. a.d. 659,
expelled their governors. To quell the spreading insurrection, Aly was
happy in the selection of Ziâd, the Chancellor of Bussorah, a man,
as we have seen, of conspicuous administrative ability. He carried
with him a great court and retinue; but it was mainly by his ready tact
in setting one rebellious prince against another, and by well-
appointed promises and favours, that he succeeded in restoring
peace. Aly recognised his service by
conferring on him the government of Fars; and is appointed Governor of
and his administration there became so Fars.
famous as to recall to Persian memories the happy age of
Nushirwân. He fixed his court at Istakhr (Persepolis), and built a
castle there, in connection with which his name was remembered for
many ages following.
Though successful thus in Persia, Aly
was still subject to trouble and molestation Expeditions from Syria
against Irâc. a.h. XXXVIII-IX.
nearer home. Muâvia, relieved now from a.d. 658–9.
apprehension on the side of Egypt, began
to annoy his rival by frequent raids on Arabia and the cities beyond
the Syrian desert. The object was various—now to ravage a province
or surprise a citadel, now to exact the tithe from the Bedouin tribes,
or, again, to force upon them allegiance to the Syrian Caliphate.
Such inroads, though not always successful, inspired a sense of
insecurity; and, what was worse than that, they betrayed more
clearly than ever the lukewarmness of the people in the cause of Aly.
These would stir neither hand nor foot to repel the Syrians invading
cities so close to them even as Ain Tamr, Anbâr, and Hît. To show his
displeasure at their listlessness and
disobedience, Aly went forth himself into Safar, a.h. XXXIX. June, a.d.
the field almost unattended. On this, the 659.
men of Kûfa, partly through shame, partly lured by the promise of
increased stipends, marched to the defence of their frontier. During
the year there were eight or ten inroads of this kind from Syria.
Though eventually repelled, it was not always without loss in
prisoners, plunder, and prestige. On one occasion, however, Aly’s
commander, with a flying column, pursued the raiders back into the
heart of Syria as far as Baalbek; and thence, turning northward,
escaped by Ricca again into Irâc. On the
other hand, Muâvia, to show his contempt Muâvia visits Mosul.
for the power of Aly, made an incursion
right across the plain of Upper Mesopotamia. For some days he
remained encamped on the banks of the Tigris; and, after leisurely
inspecting Mosul, which he had never seen before, made his way
back again to Damascus unmolested.
The fortieth year of the Hegira opened
with a new grief for Aly. At the close of the Raid of Bosor on Medîna,
year preceding, as the annual pilgrimage Mecca, and Yemen. a.h. XL.
a.d. 660.
drew near, Muâvia sent Bosor, a brave but
cruel captain of his host, with three thousand men into Arabia, to
secure for him the allegiance of the sacred cities. As he drew nigh to
Medîna, Abu Ayûb, the governor, fled to Kûfa, and Bosor entered
unopposed. Proceeding to the Great Mosque, he mounted the
sacred steps of the Prophet’s pulpit, and, recalling Othmân to mind,
thus addressed the people: ‘O citizens of Medîna! The Aged Man!
Where is the aged, grey-haired man whom, but as yesterday, and in
this very place, I swore allegiance to? Verily, but for my promise to
Muâvia, who bade me stay the sword, I had not left here a soul
alive!’ Then he threatened the leading citizens with death if they
refused to acknowledge Muâvia as their Caliph; and so, fearing for
their lives, all took the oath of allegiance to the Omeyyad ruler.
Passing on to Mecca, the same scene was enacted by the imperious
envoy there, and with the same result.[557] Then he marched south
to Yemen, where he committed great atrocities upon the adherents
of Aly. The governor, Obeidallah son of
Abbâs, escaped to his cousin at Kûfa. But He slays the infant children of
two of his little children, falling into the Aly’s cousin.
tyrant’s hands, were put to death in cold blood, as well as their
Bedouin attendant, who ventured to protest against the cruel act. An
army of four thousand men was despatched in haste from Kûfa, but
too late to stop these outrages; and Bosor made good his escape to
Syria. The wretched peninsula fared no better at the hands of the
relieving army. Many of the inhabitants of Najrân were put to death,
because they belonged to the party of Othmân. The men of Mecca
were forced to recall the oath they had just taken, and again do
homage to Aly. Similarly, the citizens of Medîna swore allegiance to
Hasan, son of Aly, at the point of the sword;[558] but no sooner were
the troops gone, than Abu Horeira, of the opposite faction, resumed
his functions as leader of the daily prayers. The cruel death of his
cousin’s infant children preyed on Aly more, perhaps, than all his
other troubles put together; and he cursed Bosor in the daily service
with a new and bitter imprecation. The disconsolate mother poured
forth her sorrow in plaintive verse, some touching couplets of which
still survive.[559]
Yet another grief was in store for Aly.
He had promoted his cousins, the sons of Abdallah son of Abbâs
Abbâs, to great dignity, giving the chief retires to Mecca.
command in Yemen to one, in Mecca to another, in Medîna to a third;
while Abdallah, the eldest, held the government of Bussorah, the
second city in his Caliphate. Complaints having reached the Court of
certain irregularities in the administration of Bussorah, Aly called
upon his cousin to render an account. Scorning to answer the
demand, Abdallah threw up his office, and, carrying his treasures
with him, retired to Mecca. Aly was much mortified at this unfriendly
act; and still more so by the desertion of his own brother, Ackîl, who
went over to Muâvia.[560]
These troubles, crowding rapidly one
upon another, entirely broke the spirit of Aly, broken in spirit,
Aly. He had no longer the heart to carry on concludes truce with Muâvia.
a.h. XL. a.d. 660.
hostilities with Syria. If he might secure the
Eastern provinces in peaceful subjection to himself, it was all that he
could hope for now. Accordingly, after lengthened correspondence,
an armistice was concluded between Aly and Muâvia, by which they
agreed to lay aside their arms, respect the territory of each other,
and maintain a friendly attitude.
It is possible that a double Caliphate
thus recognised, in two separate and The double Caliphate.
independent empires, by the Rulers of the
East and of the West, might have been prolonged indefinitely, or
even handed down in perpetuity, had not the tragical event occurred
which will be narrated in the following chapter.