Review of the Literature

In a prospective study of 3788 dermatologic surgery procedures, there were 236 complications (6%).¹ Most complications were minor and bleeding was the most common (3%). Vasovagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Multivariate analysis showed that anaesthetic or hemorrhagic complications were independent factors that predicted infectious complications. Patients on anticoagulants or immunosuppressant medications, type of procedure performed and duration exceeding 24 minutes were independent factors that predicted hemorrhagic complications.¹

Two years later, the same group published a study of 3491 dermatologic surgical procedures describing postoperative infections in 67 patients (1.9%), with superficial suppuration accounting for 92.5% of surgical site infections.² The incidence was higher in the excision group with a reconstructive procedure (4.3%) than in excisions alone (1.6%). Infection control precautions varied according to the site of the procedure; multivariate analysis showed that hemorrhagic complications were an independent factor for infection in both types of surgical procedures. Male gender, immunosuppressive therapy, and not wearing sterile gloves were independent factors for infections occurring following excisions with reconstruction.²

Dixon et al. performed a prospective study of 5091 lesions (predominantly nonmelanoma skin cancer) treated on 2424 patients.³ None of the patients was given prophylactic antibiotics, and warfarin or aspirin was not stopped. The overall infection rate was 1.47%. Individual procedures had the following infection incidence:

Surgery below the knee had an infection incidence of 6.9% (31/448) and groin excisional surgery had an infection incidence of 10% (1/10). Patients with diabetes, those on warfarin and/or aspirin, and smokers showed no difference in infection incidence. In conclusion, all procedures below the knee, wedge excisions of the lip and ear, all skin grafts, and lesions in the groin had the highest rates of infection and the authors suggest considering wound infection prophylaxis in these patients.³

In a prospective study of hospitalized patients undergoing diagnostic skin biopsies, infection, dehiscence, and/or hematoma occurred in 29% of the patients.⁴ Complications occurred significantly more frequently when biopsies were performed below the waist, in the ward compared with the outpatient operating room, in smokers, and in those taking corticosteroids.⁴ In addition, elliptical incisional biopsies developed complications more frequently when subcutaneous sutures were not used.⁴

In one study of 1400 Mohs procedures, 25 infections were identified.⁵ Statistically significant higher infection rates were found in patients with cartilage fenestration with second intent healing and patients with melanoma. There was no statistical difference in infection rates with all other measured variables including the use of clean, nonsterile gloves rather than sterile gloves during the tumor removal phase of surgery.⁵ Sterile gloves were used by all surgeons during the repair phase.

In 2008, an advisory statement on antibiotic prophylaxis in dermatologic surgery was published.⁶ Expert consensus based on a small number of studies suggests that antibiotics for the prevention of surgical site infections may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease.⁶ Also, patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, should be given prophylactic antibiotics (to prevent bacterial endocarditis) when the surgical site is infected or when the procedure involves breach of the oral mucosa.⁶

Pain

Most skin procedures and surgeries will result in some pain when the anesthesia wears off. Explain to patients that they may safely use acetaminophen for pain relief unless they have severe liver disease or some other unusual contraindication. Ibuprofen should be safe unless the patient is anticoagulated or has another contraindication to the use of ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin should be avoided for pain control because it can increase the risk of bleeding and hematoma. Acetaminophen and hydrocodone combination products are generally not needed unless the procedure was large and particularly painful. When this is the case, it is helpful to write out that prescription before the patient leaves the office. A quick discussion about pain control can prevent unnecessary distress to the patient later and unnecessary phone calls to you at night. If a patient complains of increasing pain over time, a hematoma or infection should be considered and it is best to see the patient in the office.

Bleeding

The most likely complication of dermatologic surgery is bleeding (accounting for half of a 6% complication rate).¹ Larger surgeries with more undermining are at highest risk of bleeding complications. Good intraoperative hemostasis, appropriate suturing techniques, and pressure dressings can help minimize bleeding complications. Aspirin can cause excessive bleeding during surgery if not stopped 2 weeks before surgery. NSAIDs can also cause excessive bleeding if not stopped 2 days before surgery. Warfarin (Coumadin) also increases the risk of bleeding intraoperatively and postoperatively (Figure 36-1). That said most clinicians would not postpone skin surgery because the patient has recently taken aspirin or an NSAID. Often the risk of stopping warfarin or aspirin is greater to the patient (such as stroke) than dealing with the bleeding issues. In fact, in a study of 2424 patients undergoing dermatologic surgery, the warfarin or aspirin was not stopped in any of these patients.³ For further information on the risks and benefits of anticoagulation before surgery see Chapter 1 on preoperative preparation.

FIGURE 36-1 Bleeding and ecchymosis after the removal of a large squamous cell carcinoma on the face of a woman on Coumadin. Although this looked bad at this point in time, all healed well over time and by continuing the Coumadin, she never had a stroke.

(Courtesy of Richard P. Usatine, MD.)

The risk of intraoperative bleeding can be decreased by waiting 10 minutes after injecting lidocaine and epinephrine to allow the epinephrine to have maximal vasoconstrictive effect before beginning the procedure. The risk of hematoma can be lessened with careful attention to hemostasis using appropriate electrocoagulation and tying off larger vessels. However, excessive electrocoagulation can cause unnecessary tissue damage, leading to impaired wound healing. Although sutures that are placed tightly can cause suture marks, they can also stop bleeding. Tighter sutures might be used in a situation where the patient seems to be oozing or bleeding excessively. If the patient has a bleeding diathesis, undermining should be kept to the absolute minimum necessary.

Pressure dressings are helpful following most skin surgeries except the majority of shave biopsies, which have little risk of bleeding. A good, firm pressure dressing will prevent many after-hour bleeding episodes. The pressure dressing may be constructed with gauze that is doubled up (or dental roll) and tape applied on top using firm pressure during the first 24 hours. Blood on the dressing is better than blood in the wound. Sending the patient home with gauze in hand along with instructions about what to do if bleeding occurs is also helpful. Although blood-soaked bandages can be one manifestation of excessive bleeding, internal bleeding can result in hematoma formation and/or ecchymosis.