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.

Postoperative bleeding usually occurs within the first 24 hours after surgery. It will occur more often in a patient who was taking aspirin but may also occur more often in a patient who has high blood pressure or who is physically active. The usual scenario for postoperative bleeding is that the patient will call the clinician and complain of blood soaking through the bandage. The patient should be instructed to apply firm pressure for 20 to 30 minutes by the clock. This will usually stop the bleeding in a majority of situations. If not, the patient may need to come into the office or go to the emergency department.

Swelling and Bruising

Patients should be warned that surgery performed around the nose or forehead can cause swelling and bruising around the eyes (Figure 36-2). It is even possible that the eyes may swell shut. The use of ice may help prevent some of this edema if it is used during the first few hours after surgery. The lips can also stay swollen for many weeks or months after surgery.

FIGURE 36-2 (A) Ecchymosis around the site of a BCC removal on the face. (Copyright Richard P. Usatine, MD.) (B) Ecchymosis around the site of an island pedicle flap.

(Courtesy of Ryan O’Quinn, MD.)

Bruising and swelling are common adverse effects of surgery on the face, especially around the eyes. The best prevention for excessive bruising and swelling after facial surgery is to have the patient sleep with the head elevated for the first 2 to 3 days. A reclining chair can be helpful and propping the head and shoulders up with pillows on the bed is an alternative.

Infection

Everyone is disappointed when the site of a skin procedure becomes infected. The highest risk for infection of skin procedures is for the larger elliptical excisions and flap procedures. The more cutting, undermining, and sewing that is done, the higher the risk of infection. Shave biopsies and intralesional injections are very low risk for infections and these procedures can be performed as clean procedures without sterile gloves. All elliptical excisions and flaps should be performed with sterile technique. Unfortunately, there is little evidence-based information to guide how sterile these procedures should be. The spectrum ranges from sterile gloves and sterile equipment only to the use of hair caps, face masks, sterile gowns, and full surgical scrubs before putting on the gloves. We all need to monitor infection rates in our practice and decide how much prevention and cost we want to assume.

The highest risks for infections involve procedures below the knee or in the groin, wedge excisions of the lip and ear, and all skin flaps and grafts.³ Patients who smoke and those taking oral corticosteroids are at higher risk of infection.⁴ The 2008 AAD advisory statement states that prophylactic antibiotics may be indicated for:

One study describes the use of intraoperative injectable clindamycin to prevent wound infections. In a total of 1030 consecutive patients who underwent Mohs surgery, prior to reconstruction, patients were randomly assigned to receive either intraincisional buffered lidocaine with epinephrine containing clindamycin or buffered lidocaine with epinephrine without clindamycin.⁷ The surgical wounds that received the clindamycin had a lower rate of infection than those that did not. The authors concluded that the results of their study support the efficacy of single-dose preoperative intraincisional antibiotic treatment for dermatologic surgery.⁷

Wound infections may initially be subtle and appear like the erythema seen around a healing incision. If you are uncertain about a possible infection, pressure applied with the gloved hand can be used to express pus hidden below the skin (Figure 36-3). If no pus is expressed but the suspicion for infection is great, consider removing a few stitches early and applying some pressure with a cotton-tipped applicator to detect pus. Send all purulent exudates for culture in this time when methicillin-resistant Staphylococcus aureus (MRSA) is so prevalent (Figure 36-3). The choice of antibiotic should consider MRSA as a possible cause of any wound infection.

FIGURE 36-3 Erythema and swelling at the site of a wound infection caused by MRSA.

(Courtesy of Richard P. Usatine, MD.)

A wound infection may present with the classic signs of redness, warmth, and pain. The patient may have a slight fever, and pus may be expressed from the wound. These symptoms usually become obvious around 5 to 7 days postoperatively or at the time of suture removal (Figure 36-4). Infections can manifest at postoperative day 2 to 4. If a patient has any complaints, it is best to examine the wound for evidence of infection. If the wound is tender and fluctuant, removal of one or more sutures to allow drainage will speed up resolution of the infection. Empirical antibiotic treatment in adults may start with cephalexin 500 mg tid–qid or clindamycin 300 mg tid in the penicillin-allergic patient. If the patient has a known history of MRSA infections, consider starting with trimethoprim/sulfamethoxazole or clindamycin. Of course, culture results in the coming days should be reviewed and may necessitate changing antibiotics.

FIGURE 36-4 Purulence and erythema at the site of a wound infection near the groin.

(Courtesy of Richard P. Usatine, MD.)

Suture Reactions

Suture reactions are frequently mistaken for infections and must be differentiated from them. These may arise in areas where buried sutures have been placed and can present as a small pustule or erosion in the suture line (Figure 36-5). The patient can complain of a “pimple” on the suture line or a piece of suture extruding from the incision line. This can occur when a buried suture is placed too close to the skin surface. Purulent material from these sites is sterile.

FIGURE 36-5 Spitting sutures along a facial repair.

(Courtesy of Richard P. Usatine, MD.)

Suture reactions can range from mild, with only a spicule of suture “spitting,” to more severe reactions in which the entire wound gets warm and boggy. These reactions are self-limited and can be calmed with intralesional injections of triamcinolone 2.5 mg/mL and warm compresses. Removal of reacting and spitting sutures can speed up resolution. Antibiotics are frequently given with severe reactions to cover the chance that there is also an element of infection. Suture reactions rarely affect the ultimate cosmetic outcome.

Scarring

Scarring can occur in any patient operated on by any clinician. In some situations scarring is predictable and cannot be prevented. The deltoid area, the chest, and the back are prone to scarring because of either the skin tension in these areas, the thicker skin in these areas, or some unknown factor. Surgery on sebaceous skin, such as the type that appears on the nose, often leads to obvious incisional scars. The most important point is to warn the patient that in these areas excisional surgery will often result in scarring no matter who does the surgery. Therefore, on the back, chest, and deltoid areas, a shave technique should be used when it is an acceptable alternative because it can offer a better cosmetic result than an excision with sutures. If a patient is overly concerned about a scar or expresses the unrealistic desire to have absolutely no scar, it is better to recommend a plastic surgeon before the procedure than after.

Excessive or increased skin tension leads to a widened scar. This is the reason why buried sutures that decrease tension can improve cosmetic results. The increased skin tension in younger patients probably contributes to the widened scars seen in young patients compared with the narrow, fine scars seen in older patients. In Figure 36-6A, a widened scar is seen on a young woman’s arm years after the wide excision of a melanoma.

FIGURE 36-6 (A) Widened scar on the upper arm of a young woman with a melanoma excised years before. (B) Scarring that occurred after a wound infection. Note the milia seen at the wound edge, which can occur at sites of wound healing.

(Courtesy of Richard P. Usatine, MD.)

Allowing sutures to remain in place for too long can also increase scarring. Complications such as infection, necrosis, or dehiscence can increase scarring (Figure 36-6B). Excessive skin tension often leads to dehiscence and scarring. Infection or necrosis often leads to dehiscence. Dehiscence may be prevented by using good excision planning, undermining when necessary, and using deep absorbable sutures to decrease skin tension across a wound. Tying sutures too tightly can also cause scarring.

Depressed scars may result from a deep shave biopsy or scarring within the dermal layer of the skin. Depressed scars can be excised or dermal fillers may be used.

The most important point when discussing potential scarring after surgery is to warn the patient about the risk of scarring or highly visible incision lines. The patient should understand that if scarring does occur, it can be treated with dermabrasion, intralesional steroids, laser resurfacing, or the yellow light laser used to treat persistent redness. See the cosmetic chapters in this book for the specifics of scar treatment.

Wound Dehiscence

If a wound dehiscence occurs without evidence of infection, it might be advisable to resuture the wound with interrupted sutures and start the patient on antibiotics. The sutures may only have to be left in place for half the normal time because the fibroblasts have already initiated the wound site and the wound is partially healed. The cause of the dehiscence may need to be addressed if significant wound tension exists. A buried absorbable suture may decrease the wound tension.

If infection or a hematoma is the cause of dehiscence, the wound should be opened and irrigated, and the patient should be started on antibiotics. The wound should be cleansed daily and left to heal naturally. It will usually take at least 3 to 4 weeks before the wound healing is complete. The patient should be informed that a scar revision may be performed at a later time if desired.

Hypopigmentation

Hypopigmentation is most likely to occur with the following procedures: cryosurgery, ED&C, and shave biopsies. Although it may be cosmetically worse in darker skinned persons, it can occur in anyone. Patients must be warned of this complication, which can be permanent. Cryotherapy to treat nonmelanoma skin cancers is likely to cause hypopigmentation because of the long freeze times that are used (Figure 36-7A). Even a simple shave excision can lead to hypopigmentation (Figure 36-7B).

FIGURE 36-7 (A) Hypopigmentation that occurred after cryosurgery of a superficial BCC. (B) Hypopigmentation after the shave excision of a basal cell carcinoma on sun-damaged skin.

(Courtesy of Richard P. Usatine, MD.)

Flap Necrosis

A long, thin advancement flap in violation of the 3 : 1 ratio runs a high risk of distal flap tip necrosis (Figure 36-8). Patients who smoke excessively experience a much higher risk of flap tip necrosis and flap failure, and encouraging smoking cessation in the perioperative and postoperative course is helpful to achieve the best healing. The use of flaps must also be carefully weighed in those patients who may have underlying skin conditions that can lead to increased complications. Decreased flexibility and therefore impaired movement of skin can be seen in patients with extensive scarring from burns or other injuries, previous radiotherapy, or an underlying skin disease such as scleroderma. Decreased perfusion of skin leading to flap failure or infection can be seen in conditions such as diabetes mellitus, lung disease, or poor circulation secondary to atherosclerosis, especially in peripheral areas. Finally, the use of a flap may not be possible in patients with extremely thin skin that will not bear the stresses of flap movement such as elderly patients with extreme photodamage or long-term users of corticosteroids.

FIGURE 36-8 (A, B) Flap necrosis in a patient unable to quit smoking.

(Courtesy of Ryan O’Quinn, MD.)

Nerve Damage

Numbness is a common complaint from patients after cutaneous surgery. It usually resolves in about 6 to 12 months after the nerves have regrown and arborized. The concern from cutaneous surgery is damaging a superficial motor nerve. The three motor nerves that are most vulnerable to damage are the temporal branch of the facial nerve, the spinal accessory nerve, and the marginal branch of the mandibular nerve.

The temporal branch of the facial nerve can be damaged by surgery to the temple area. The nerve lies just below the superficial musculoaponeurotic system (SMAS). It can be difficult to see, and there is enough anatomic variation that it can be unpredictable in its location. One way to locate the nerve is to draw an imaginary line from the tragus to the eyebrow and another imaginary line from the tragus to the upper forehead wrinkle area (Figure 36-9). The area between these two lines within the temple area is where the temporal branch of the facial nerve is most superficial. If this nerve is cut, the patient will not be able to wrinkle the forehead because the innervation to the frontalis muscle is lost. The patient will also have a permanent inability to raise the upper eyelid (Figure 36-10). If any surgery is performed in this area, it is important to discuss this risk with the patient in the informed consent process. Also explain that the anesthesia after surgery alone can cause a temporary paralysis of this nerve (See Figure 11-2B in Chapter 11, The Elliptical Excision). When electrodesiccation and curettage is an option for a superficial skin cancer in this area, it may be a good choice. Mohs surgery is also an appropriate technique in this area because the tissue is removed layer by layer by an experienced surgeon.

FIGURE 36-9 Drawing of the temporal branch of the facial nerve.

(From Usatine RP. Skin Surgery: A Practical Guide. St. Louis, MO: Mosby; 1998.)

FIGURE 36-10 (A) BCC in the region of the temporal branch of the facial nerve. (B) Permanent inability to raise the eyebrow after the temporal branch of the facial nerve was cut during surgical excision of the BCC.

(From Usatine RP. Skin Surgery: A Practical Guide. St. Louis, MO: Mosby; 1998.)

The spinal accessory nerve lies within the posterior triangle posterior to the sternocleidomastoid muscle (Figure 36-11). The nerve can lie very superficially posterior to the sternocleidomastoid muscle at the level of the thyroid cartilage notch. If this nerve is cut, the patient will lose major innervation to the trapezius muscle, resulting in impaired mobility of the scapula and shoulder.

FIGURE 36-11 (A) Drawing of the spinal accessory nerve in the posterior triangle of the neck. (B) Recurrent BCC over the site of the spinal accessory nerve in the posterior triangle of the neck. Care must be taken to avoid cutting that nerve if possible.

(A: From Usatine RP. Skin Surgery: A Practical Guide. St. Louis, MO: Mosby; 1998.)

The marginal branch of the mandibular nerve (Figure 36-12) is the third nerve in the head and neck area that is vulnerable to injury during surgery. If it is cut then motor innervation to the depressor anguli oris and depressor labii inferioris can be lost. This results in a cosmetic deformity and imbalance in the appearance of the mouth, especially when the mouth is opened or when the patient wants to frown. Fortunately the nerve is not that superficial but each clinician operating in the area of the lower mandible should be aware of this branch of the facial nerve.

FIGURE 36-12 The branches of the facial nerve most prone to be cut during facial surgery include the temporal branches and the marginal mandibular branches.

(From Vidimos A, Ammirati C, Poblete-Lopez C. Dermatologic Surgery. London: Saunders; 2008.)

Recurrence of a Lesion or Skin Cancer

There is almost nothing in the practice of medicine that is a 100% guarantee. Mohs’ micrographic surgery for the removal of skin cancer has a cure rate of only 99% in primary skin cancers. Most other surgical techniques have cure rates of about 90%, depending on a number of factors. Lipomas, cysts, and nevi (especially if they are removed with a shave) can all recur. Although recurrent lesions may be considered a complication, the patient and clinician should both realize that recurrences will occur in a small percentage of cases. When a recurrent lesion develops, the lesion will usually need to be excised again. In Figure 36-13, a BCC recurred in the incision line after a large flap was placed on the neck.

FIGURE 36-13 Recurrent BCC at two sites along the area of a large flap repair to an extensive BCC on the neck.

(Courtesy of Richard P. Usatine, MD.)

With regards to recurrence of BCC, one study showed that Mohs surgery had significantly fewer recurrences for the treatment of facial recurrent BCC than after standard surgical excision.⁸ However, there was no significant difference in recurrence of primary BCC between Mohs surgery and surgical excision in this study.⁸

In a systematic review of treatment modalities for primary BCC, the following recurrence rates were noted:

Therefore, it is important to go over possible recurrence rates with patients before the final procedure is chosen. Even benign lesions like pyogenic granulomas can recur if all of the abnormal tissue is not removed at the time of surgery (Figure 36-14).

FIGURE 36-14 Recurrent pyogenic granuloma on the finger after previous excision.

(Courtesy of Richard P. Usatine, MD.)

Making Mistakes

As a clinician, it feels awful to make a mistake that leads to harming a patient. It may also feel bad when a patient gets a less than optimal cosmetic result after a surgical procedure. We all took the oath “First, do no harm.” In performing skin surgery it is inevitable that you will have wounds that dehisce, scars that are larger than expected, flaps that necrose, and infections and hematomas that will occur in surgical sites. These are known complications of skin surgery and may not be caused by an error on your part. However, it is also possible for all of us to make mistakes. Postoperative infections and hematomas can occur even in the most carefully performed surgery. However, if a clinician is in a rush and uses less careful sterile technique or pays less attention to bleeders, he or she may contribute to these complications. We have presented ways to minimize complications, but poor outcomes can and do happen. In all cases, the goal will be to provide the patient with the best possible outcome.

It is always important to express empathy to the patient and/or patient’s family after an adverse surgical event. “I am sorry” is an appropriate expression of empathy that does not express fault. In the book Sorry Works! the authors make a strong case for using the phrase “I’m sorry” along with disclosure, apologies, and relationships to prevent medical malpractice claims.¹⁰ They make the distinction that the phrase “I’m sorry” is an expression of empathy and “I apologize” is a communication that expresses responsibility along with empathy. They suggest to only apologize after due diligence has proven that a medical error occurred.

The authors make the case that it is better to disclose an error than to attempt to cover it up.¹⁰ They state that “people can actually live with mistakes but they do not accept or tolerate cover-ups.” They suggest the use of honesty, candor, and a real commitment to fix problems when something goes wrong. Showing empathy works by making a difficult situation a little better. To learn more about how to prevent lawsuits and improve relationships with patients during and after an adverse event, consult the book Sorry Works! and the website www.sorryworks.net.

Conclusion

Careful planning and execution of surgery can prevent most complications. Early recognition of complications and rapid treatment can minimize the potential adverse outcomes that can occur when complications are allowed to progress untreated.