Aluminum chloride comes in strengths from 20% to 70% available in water- or alcohol-based solutions (Figure 4-1). Alcohol alone (anhydrous alcohol) will support a solution of up to 20%, so the stronger concentrations are either in water or a mixture of water and alcohol. I prefer to use aluminum chloride in an aqueous solution because it can be used safely with electrosurgery and comes in higher concentrations. With an alcohol-based solution, it is possible to ignite the alcohol when electrosurgery is performed in the same field. However, drying the field after applying the alcohol-based solution makes it safe to use with electrosurgery.

FIGURE 4-1 70% aluminum chloride in purified water is a useful topical hemostatic agent.

(Copyright Richard P. Usatine, MD.)

Aqueous aluminum chloride can be ordered as a 35% or 70% solution from Delasco (see the Resources section at the end of the chapter for ordering information). Both are inexpensive and excellent for hemostasis. No studies are available to determine whether one percentage is better than another. I use 70% with good results. These solutions have a 3-year shelf life. Drysol, the brand name of 20% aluminum chloride in anhydrous ethyl alcohol that is sold by prescription to treat hyperhidrosis, also produces hemostasis but is more expensive to purchase and messier to use.

The major advantage of aluminum chloride is that it is a clear solution that does not stain or tattoo the tissue. It does not cause tissue necrosis and does not damage the normal skin surrounding the wound. Aluminum chloride should not be used in deep wounds that will be sutured because it can delay healing and increase scarring.¹

When using aluminum chloride after a shave or punch biopsy, first dry the field with a cotton-tipped applicator or gauze. The aluminum chloride should then be applied to the dry field by rolling or twisting the moist applicator against the open wound (Figure 4-2). Although light pressure may work, it often helps to use heavier pressure while twisting the applicator clockwise and counterclockwise against the area. After a 2- to 4-mm punch biopsy, a dry cotton-tipped applicator can be held with downward pressure against the open hole to dry the field. If sutures are not to be used, the aluminum chloride should be applied with downward pressure and held against the wound until hemostasis is achieved (Figure 4-3).

FIGURE 4-2 Clear aluminum chloride on a cotton-tipped applicator being used to stop bleeding after shave excision of a seborrheic keratosis.

(Copyright Richard P. Usatine, MD.)

FIGURE 4-3 A 4-mm punch biopsy being left open to heal by secondary intention. Hemostasis was achieved using aluminum chloride.

(Copyright Richard P. Usatine, MD.)

Monsel’s Solution

Monsel’s solution consists of 20% ferric subsulfate. It is used to produce hemostasis after biopsies of the skin and cervix. It is applied to the skin in the same manner as aluminum chloride. There is a small risk of tattooing the skin through iron deposition. One major nuisance in using Monsel’s solution is that the iron precipitates around the top of the container, making it difficult to open. Aluminum chloride containers are always easy to open.

Monsel’s solution can leave a histologic artifact in the skin. Therefore, when a repeat biopsy is performed in an area where Monsel’s solution was previously used, it helps to warn the pathologist.¹

Silver Nitrate

Silver nitrate comes in easy-to-use sticks. Its hemostatic action is slower and the response to it is more variable. Silver nitrate may tattoo the skin black with silver. Silver nitrate has been used to treat umbilical granulomas in infants, but there are better and safer options.²

Electrocoagulation

Electrocoagulation is an ideal method for controlling bleeding during surgery. This is especially true with an excision that will be closed with sutures. Electrocoagulation is essential in most elliptical excisions and all flaps. During surgery, electrocoagulation helps to produce a relatively bloodless field (Figure 4-4). This helps to see the landmarks for placing both deep and superficial sutures. Electrocoagulation can prevent postoperative bleeding and hematoma formation. Patients should, however, still be given information on what to do if postoperative bleeding occurs and a number to call if help is needed.

FIGURE 4-4 An electrosurgical instrument is being used to stop bleeders after undermining the wound edges. Note that the surgical assistant is using two skin hooks to hold open the undermined skin while the clinician is using the Hyfrecator to stop the bleeding.

(Copyright Richard P. Usatine, MD.)

Electrosurgery is an alternative method of hemostasis after a shave biopsy. It can also be used as a backup in the rare instance in which chemical agents fail to provide hemostasis after a shave. First dry the surgical field with a cotton-tipped applicator or gauze before using electrosurgery, especially after a chemical agent in an alcohol solution has been used.

Electrosurgery is an ideal method for hemostasis when tissue destruction is desired. This is true when shaving off a pyogenic granuloma or hemangioma. The electrodestruction diminishes the likelihood of regrowth of vascular tissue while achieving hemostasis. Another example of this is during electrodesiccation and curettage of a basal cell carcinoma (BCC). The electrodesiccation simultaneously destroys malignant tissue and produces hemostasis. (See Chapter 14, Electrosurgery, for further information on this procedure.)

In surgical wounds that need closure, it is important not to use so much electrocoagulation that it produces large areas of char and tissue necrosis. This can increase the risk of wound infection. When a vessel is not responding to electrocoagulation, use a suture. One easy method is to use an absorbable suture with a small figure-of-eight suture around the vessel (Figure 4-5). For example, if you are already using Vicryl for your deep sutures, just use this for the hemostatic stitch. The U-suture (square suture) is another method of obtaining hemostasis with a deep absorbable suture (Figure 4-6).

FIGURE 4-5 The figure-of-eight suture can be used to stop bleeding with absorbable suture below the epidermis or nonabsorbable suture on the surface. (A) A figure-of-eight suture pulls tissue together to tamponade bleeding vessels. (B) Start the figure-of-eight suture by clamping the bleeding vessel or tissue with one or two hemostats. The bleeding should stop before proceeding with the suture. Insert the needle with absorbable suture at #1 going under the hemostat and exiting the tissue at #2. Reload the needle and insert the needle at #3 and exit at #4 with the second stitch parallel to the first. Then tie the suture between points #1 and #4, creating the crossover figure-of-eight suture. The hemostat may be released once the first or second tie is in place.

(A: From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010; B: Copyright Richard P. Usatine, MD.)

FIGURE 4-6 The U-suture (square suture) is one way to stop bleeding at the edge of an incision similar to the horizontal mattress suture. It can also be placed deep with an absorbable suture.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

Electrosurgical Equipment and Its Use

Modern electrosurgical equipment uses an alternating current transferred to the patient through cold electrodes. The tissue is heated through tissue resistance to the current. The current used can range from 0.5 to 4 MHz (radio-frequency). The various types of electrosurgical units are covered in detail in Chapter 14.

Regardless of the type of unit used, there are four major ways to produce electrocoagulation:

1. The electrode comes in direct contact with the bleeding site or vessel.

2. The electrode is touched to a hemostat or forceps that is grasping the bleeding tissue or vessel and then activated.

3. Special bipolar forceps are used to grasp the tissue and are activated with a foot peddle (Figure 4-7).

4. Use “cut and coagulation” with an electrosurgical unit that can cut tissue and produce hemostasis simultaneously (see Chapter 14).

FIGURE 4-7 Bipolar forceps are useful for focused hemostasis and safer when the patient has a pacemaker.

(Copyright Richard P. Usatine, MD.)

Working in a Bloody Field

Bipolar forceps have the advantage of working in a bloody field that is not entirely dry (Figure 4-7). It is still best to dry the field as much as possible, but the current can still pass through the bleeding tissue despite the presence of blood. The ball electrode on the Surgitron can also work in a bloody field (Figure 4-8). When a standard electrode is not working because the field has too much blood, it may help to grasp the bleeding tissue with a hemostat or forceps and direct the current through the instrument to stop the bleeding. The bipolar forceps is the safest method to use in a patient with a pacemaker or implantable defibrillator (see Chapter 14, Electrosurgery).

FIGURE 4-8 Ball electrode used on a radio-frequency electrosurgery device for electrocoagulation in a wet field.

(Copyright Richard P. Usatine, MD.)

In Figure 4-9, a pyogenic granuloma was just shaved off the lip of a postpartum woman. A dry cotton-tipped applicator was rolled ahead of the electrode with pressure to dry the field for electrocoagulation with a Hyfrecator electrode. Because this was a very vascular lesion, the electrocoagulation was applied as the cotton-tipped applicator was lifted from the bleeding site.

FIGURE 4-9 After excising a pyogenic granuloma from the lip, a Hyfrecator is used to destroy any remaining abnormal tissue and to achieve hemostasis. Note that the cotton-tipped applicator is being rolled just ahead of the electrosurgical electrode.

(Copyright Richard P. Usatine, MD.)

Because a shave excision does not need to be a sterile procedure, the handpiece and the electrode should be clean but do not have to be sterile. However, when doing an excision in which sutures will be placed, the electrode must be sterile and the handpiece needs to be sterile or covered in a sterile sheath. Most cutting units have a handpiece that can be sterilized in an autoclave. Con-Med, which manufactures the Hyfrecator Plus, produces sterile handpiece sheaths to be used in sterile surgical procedures. A sterile surgical glove may also be used as a sterile sheath. Just drop the handpiece through one of the longer fingers on the glove.

To summarize, electrocoagulation should be used in the following situations:

• In a wound that will be closed with sutures

• To obtain a bloodless field during surgery

• To prevent postoperative bleeding and hematomas

• When the chemical hemostatic agent fails after a shave or punch biopsy

• When tissue destruction is desired (e.g., with removal of a BCC or a pyogenic granuloma).

When using electrocoagulation near the eye, the physician should be aware that the spark will arc to the area closest to the electrode. Make sure that the treatment area is closer to the electrode than the globe. A spark to the globe is potentially damaging to the eye.

Mechanical Hemostasis: Pressure and Sutures

The direct application of pressure works to slow and stop bleeding in many surgical procedures. A large blood vessel that does not stop bleeding with electrocoagulation can be ligated. Suturing a wound is a form of pressure application that brings the two open sides in direct opposition to each other. Packing an open wound (such as a drained abscess) also is a form of direct application of internal pressure.

After suturing an elliptical excision, it is wise to apply a pressure dressing to decrease the risk of hematoma formation. This can be left in place for 24 hours and is described further in Chapter 35, Wound Care. We recommend that patients apply direct pressure for 5 to 10 minutes by the clock if postoperative bleeding occurs at home. Increasingly longer periods of time can be attempted as needed. Of course, if the bleeding continues patients will need to access direct care.

In skin surgery, blood vessels may require tying off. It is usually quicker to use the electrosurgery unit for small blood vessels, with the exception of superficial large arteries such as labial or temporal arteries. These vessels can be clamped with a small hemostat and tied off with absorbable sutures. The figure-of-eight suture and U-shaped suture are useful in this setting (Figures 4-5 and 4-6). Horizontal mattress sutures can be used to stop oozing on the edges of the wound and achieve wound eversion (Figure 4-10).

FIGURE 4-10 A horizontal mattress suture can be used to minimize oozing at the cut edges.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

Purse String Stitch

The purse string stitch is depicted in Figure 4-11. A single purse-string suture may be tried at first. A double purse-string suture can be used when other methods fail (Figure 4-11). A 3-0 or 4-0 Prolene suture with at least a 16-mm needle is useful for this technique. The first purse string is placed around the central lesion, with both ends of the suture terminating on one side of the lesion. The second purse string is begun on the opposite end of the first suture and placed around the central lesion. Hemostasis is achieved as both purse-string ends are cinched tight, tamponading the vessels peripheral to the centrally excised lesion.³

FIGURE 4-11 A double purse-string suture can be used when other methods fail. A 3-0 or 4-0 Prolene suture with PS-2 needle is useful for this technique. (A) The first purse string is placed around the central lesion, with both ends of suture terminating on one side of the lesion. (B) The second purse string is begun on the opposite end of the first suture and placed around the central lesion. (C) Hemostasis is achieved as both purse-string ends are cinched tight, tamponading the vessels peripheral to the centrally excised lesion.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

Locked Stitch

A running locked suture (Figure 4-12) provides more hemostasis than a running suture that is not locked. In most skin surgery the locking is not needed and increases the risk of necrosis of the wound edges. When bleeding is continuing despite other methods, the benefits outweigh the risks of locking the sutures.

FIGURE 4-12 A running locked suture provides more hemostasis than a running suture that is not locked.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

Using Tourniquets and Clamps to Prevent Bleeding

A chalazion clamp was designed to keep a bloodless field on the eyelid when removing a chalazion. It also can be used on the lip to provide hemostasis during surgery (Figure 4-13). A finger tourniquet can be made with a surgical glove to create a bloodless field for finger surgery (Figure 4-14).

FIGURE 4-13 A chalazion clamp was designed to keep a bloodless field on the eyelid when removing a chalazion. It also can be used on the lip to provide hemostasis during surgery.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

FIGURE 4-14 A finger tourniquet can be made with a surgical glove to create a bloodless field for finger surgery. (A) The middle finger from a surgical glove is severed at both its base and its tip. (B) The finger glove is placed over the treated digit and rolled back proximally, forming the tourniquet. (C) A curved hemostat grasps the ring tourniquet with the loops facing away from the surgical field (optional step—provides additional compression and ensures tourniquet is not forgotten and left in place).

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

Physical Agents (Gelating Sponge)

A number of gelatin sponges are sold to produce hemostasis. These include Gelfoam, Helistat, Oxycel, and Avitene. A piece of Gelfoam can be placed into the hole of a punch biopsy that is not sutured. Absorbable hemostats (e.g., Surgicel, Collastat, and Instat) are also available. All of these products are expensive and have no proven advantage over the less expensive chemical agents.

Conclusion

Many techniques are available to control bleeding during and after surgery. Judicious application of these hemostatic methods can save time, minimize complications, and maximize the cosmetic outcome of surgery by reducing unnecessary tissue destruction. A summary of recommended hemostasis methods for various procedures is given in Table 4-1.

TABLE 4-1 Recommended Hemostasis Methods for Various Procedures

Procedure	Hemostasis Method
Shave biopsy	Aluminum chloride; light electrocoagulation if this fails.
Punch biopsy	If sutured: suturing usually stops bleeding but pressure and/or electrocoagulation may also be needed.
Elliptical excision	If not sutured: pressure, aluminum chloride, and electrosurgery if needed.
	External pressure and electrocoagulation to produce dry field.
	Tying off of vessels and bleeding areas as needed.
	Closing with sutures.
	Applying external pressure dressing.
	Note: Chemical agents should not be used.
Curettage	Aluminum chloride or electrocoagulation.
Scissor surgery	Aluminum chloride or electrocoagulation (snip surgery).
Incision and drainage	Packing of the wound, which produces hemostasis by pressure.