Medical History

A complete medical history and review of systems before minor surgery may not be necessary. Before a more complex skin procedure, however, the following information should be taken during the medical history:

For minor skin surgery under local anesthesia, blood pressure should be measured but does not need to be monitored unless the patient has a history of hypertension that is not controlled. Uncontrolled hypertension may lead to increased bleeding during surgery. If the blood pressure is significantly elevated, consider postponing the procedure or giving a dose of an appropriate antihypertensive agent prior to the start of the procedure. It is prudent to be more careful with fragile patients, such as the elderly, and to be particularly careful with the use of epinephrine-containing anesthetics in patients with a history of angina, cardiac disease, or sensitivity to epinephrine. It may help to warn these patients that they may develop an increased heart rate or a feeling of anxiety after injection of lidocaine with epinephrine.

Medical Contraindications

Skin surgery is not recommended on patients who have unstable angina because the epinephrine in the local anesthetic can precipitate angina. Although this is unlikely, it is worth having nitroglycerin in the office to deal with this potential situation. Patients who have uncontrolled diabetes mellitus may experience impaired wound healing. Closer follow-up after surgery may help avoid potential problems with these patients.

Informed Consent

Thorough discussion with patients regarding the benefits and risks of any planned surgical procedure and the alternatives to surgery is essential before surgery. It is always best to devote adequate time for this discussion so that all of the patient’s questions can be answered in an unhurried manner. Although the optimal situation is to have the clinician who will perform the procedure provide the informed consent, a well-trained assistant can start the process and the clinician can answer any questions beyond the skills of the assistant. Risks include pain, bleeding, infection, scarring, change in pigmentation, regrowth, slow healing, change in anatomic appearance, skin indentation, skin protrusion, local nerve damage/numbness, loss of muscle function, and need for further treatment. A complete list of risks is listed in Appendix A on the sample consent form titled Disclosure and Consent: Medical and Surgical Procedures.

For many routine minor procedures, such as cryotherapy, a written consent may not be needed. However, clinicians may want to consider obtaining a written consent for any procedure, even as small as cryotherapy, if the procedure is to be performed on a cosmetically sensitive area such as the face or on those for whom scarring may be more of a concern. Written consent is always obtained for procedures that may have more significant adverse consequences, such as scarring or functional effects. Feel free to use or modify the form supplied in Appendix A for your own office.

For larger surgeries, show patients the planned excision before you begin the surgery. You can show the patient and any family in attendance your surgical markings before you start. Keep a handheld mirror nearby for excisions on the face so that your patient knows what you plan to do. This is a helpful method to make sure you truly have informed consent.

Anticoagulation/Antiplatelet Therapy

The clinician needs to find out which medications the patient is taking in order to determine if there will be an increased risk of bleeding in the intraoperative or postoperative period. This includes warfarin, aspirin, NSAIDs, clopidogrel, and low-molecular-weight heparin. For larger surgeries, one might query patients about their use of any vitamin, herbal, or other over-the-counter supplements because some of these can alter the coagulation profile (see Box 1-1).

The issue of whether to stop anticoagulation/antiplatelet therapy before surgery has been controversial, but the best evidence now points toward continuing these medications. One large study of 2394 patients with 5950 lesions found four independent risk factors for postoperative bleeding:

Aspirin therapy was not an independent risk factor for bleeding. The researchers concluded that “most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin.” They recommended not to discontinue aspirin before skin surgery.¹

In a meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery, a total of six studies representing 1373 patients met criteria for inclusion. Among patients taking aspirin or warfarin, 1.3% and 5.7%, respectively, experienced a severe postoperative complication. Patients taking warfarin were nearly seven times as likely to have a moderate-to-severe complication compared to controls. Patients taking aspirin or NSAIDs were more than twice as likely to have a moderate-to-severe complication compared to controls.²

In 2326 patients operated on by a single surgeon, warfarin was used by 28 patients, 228 took aspirin, and the remainder took neither. There was no difference in the complication rate among the three groups. Researchers concluded that patients taking aspirin or warfarin do not need to discontinue these medications before minor dermatologic procedures.³

In a prospective study of 51 patients undergoing a range of minor cutaneous surgical procedures including excision biopsies, local flaps, and skin grafts, patients continued their normal warfarin regimen. The international normalized ratio (INR) was checked on the day of surgery and it ranged from 1.1 to 4.0. No problems were encountered during surgery, but two patients presented with bleeding postoperatively a few days later. The study concluded that it is not necessary to modify warfarin regimens for minor cutaneous surgery.⁴

In a prospective controlled observational study, 65 patients on warfarin underwent excision of 70 cutaneous tumors. There was no increase in bleeding tendency during surgery with those on warfarin when compared with controls. Five patients on warfarin (8%) reported moderate or severe postoperative bleeding. All patients on warfarin with bleeding complications had an INR of <2.6 at the time of surgery.⁵ Bleeding risk could not be correlated with INR. The researchers suggested that it is crucial to observe meticulous hemostasis in all patients on warfarin regardless of INR.⁵

Warfarin and medically necessary aspirin should be continued as well as clopidogrel and low-molecular-weight heparin.⁶ Exceptional care must be taken to prevent bleeding by using electrosurgery, tying off vessels, and applying handheld pressure for hemostasis. Pressure dressings can also help minimize the risk of hematoma. Lastly, patients should be made aware of the small but increased risk of postoperative bleeding and given verbal and written postoperative instructions.

Antibiotic Prophylaxis

Preoperative antibiotics such as oral cephalexin, dicloxacillin, or clindamycin may be recommended for use with patients who have a higher risk of infection.⁷ These situations might include a patient who has a contaminated or infected lesion; a lesion in an area of increased bacteria, such as the axilla, ear, or mouth; a lesion on a hand or foot, especially in patients with peripheral vascular disease; a situation in which the operation might take more than 1 hour or if the wound was open for more than 1 hour; a patient for whom complete sterile technique was not optimal; or any situation in which an infection would have serious consequences, such as in a patient with diabetes or neutropenia. See Table 1-1 for classification of wound infection risk and the need for antibiotic prophylaxis. The 2008 Advisory Statement from the American Academy of Dermatology (AAD) on antibiotic prophylaxis in dermatologic surgery stated that antibiotics may be indicated for the prevention of surgical-site infections for:

TABLE 1-1 Classification of Wound Infection Risk

Source: From Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol. 1995;32:155–176.

FIGURE 1-1 Completed repair of a wedge excision to remove a squamous cell carcinoma from the ear. Consider using prophylactic antibiotics with such a surgery because there is a higher risk of infection after a wedge excision of the ear.

(Copyright Richard P. Usatine, MD.)

Table 1-2 provides recommendations for antibiotic prophylaxis in patients at increased risk of surgical-site infection.

TABLE 1-2 Antibiotic Prophylaxis for Patients at Increased Risk of Surgical-Site Infection

IM, intramuscular; IV, intravenous; PCN, penicillin; TMP-SMX-DS, trimethoprim-sulfamethoxazole double strength.

* Give one hour before surgery.

Source: Adapted from Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008;59:464–473.

In a 5-year prospective observational study, infection incidence was significantly higher in patients with diabetes (4.2%, 23/551) than in those without (2.0%, 135/6673) (p < .001).⁸ Noninfective complications were similar. Although this study demonstrates the increased risk, it does not prove that antibiotic prophylaxis will decrease this risk. However, the choice to use antibiotic prophylaxis is a complicated decision that should be made based on all available data and known patient risks.

Endocarditis Prophylaxis

The recommendations of the American Heart Association (AHA) for the prevention of bacterial endocarditis were last published in 2007.⁹ Endocarditis prophylaxis is not needed for incision or biopsy of noninfected surgically scrubbed skin no matter what endocarditis risk factors are present. The 2007 guidelines state that antibiotic prophylaxis is indicated for patients undergoing dermatologic surgery on infected skin or surgery that involves breach of oral mucosa for patients with underlying cardiac conditions associated with the highest risk of an adverse outcome from infective endocarditis.

For individuals at highest risk for endocarditis who undergo a surgical procedure that involves infected skin or skin structures, it is reasonable for the therapeutic regimen administered for treatment of the infection to contain an agent active against staphylococci and beta-hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin (SOR C).⁹ Vancomycin or clindamycin may be administered to patients unable to tolerate a beta-lactam antibiotic or who are known or suspected to have an infection caused by methicillin-resistant Staphylococcus aureus.⁹ Suggested antibiotic prophylaxis regimens for dermatologic surgical procedures that breach the oral mucosa or involve infected skin in patients at high risk for infective endocarditis or hematogenous total joint infection are recommended in Table 1-3.⁷

One published mnemonic to help remember when and how to use prophylactic antibiotics in skin surgery is I PREVENT. This represents Immunosuppressed patients; patients with a Prosthetic valve; some patients with a joint Replacement; a history of infective Endocarditis; a Valvulopathy in cardiac transplant recipients; Endocrine disorders such as uncontrolled diabetes mellitus; Neonatal disorders including unrepaired cyanotic heart disorders (CHDs), repaired CHD with prosthetic material, or repaired CHD with residual defects; and the Tetrad of antibiotics: amoxicillin, cephalexin, clindamycin, and ciprofloxacin.¹⁰

Anxiolytics at Time of Surgery

Antianxiety medications such as alprazolam, diazepam, or lorazepam can be useful in the very anxious patient who does not respond to nonpharmacologic methods of relaxation (such as slow abdominal breathing). If these medications are administered sublingually, the onset of action can be quicker than when they are administered orally. These medications should not be given to a patient who will be driving home. All patients given intraoperative or preoperative sedatives must be accompanied by an adult, must be counseled not to drive on the day of the surgery, must be observed postoperatively until the sedative effect has sufficiently diminished, and must be counseled that their mental capacities may be diminished for a prolonged period after surgery.

Preparation of the Skin

The most common preoperative preparations to be used on the skin include alcohol, Betadine (povidone-iodine), and Hibiclens (chlorhexidine). The main advantages of using chlorhexidine are that it has a longer lasting antibacterial effect than povidone-iodine and the risk of contact sensitivity may be less. One disadvantage of using chlorhexidine, however, is that it is more toxic to the eye if it accidentally drops into it. However, if the eye is flushed immediately, no damage may be done. Caution must be taken when using alcohol to be sure that all of the alcohol has evaporated before any electrosurgery is performed in the area.

The most important part of the preoperative preparation of the skin is the mechanical rubbing of the antiseptic onto the skin with the gauze. Although the gauze may not need to be sterile for the first prep, it might help to use sterile gauze in the last prep. It is actually impossible to sterilize the skin because bacteria can extend into hair follicles. The goal of the preoperative preparation of the skin is to reduce the bacteria on the skin surface by scrubbing the skin with a good antiseptic such as povidone-iodine or chlorhexidine. Povidone-iodine must be allowed to dry on the skin for its effect to be optimal. Chlorhexidine has the advantage of not staining the skin and being easy to wash off. Povidone-iodine has the advantage of being easy to see where it was applied but should be avoided in persons with iodine allergies. However, Darouiche et al. found a greater than 40% reduction in total surgical-site infections among patients undergoing clean-contaminated surgery who had received a single chlorhexidine-alcohol scrub as compared with a povidone-iodine scrub.¹¹

An 8-oz pump bottle of chlorhexidine can be kept in each examination/procedure room and can be used repeatedly by pumping the solution onto clean or sterile gauze. Povidone-iodine swab sticks are convenient, but a bit more expensive than povidone-iodine in a bottle applied with gauze.

Preparation of Hair

The best method of hair removal over a surgical site is to use scissors to cut the hair. Using scissors to clip hair is now the preferred method for preoperative hair removal because a close shave with a razor causes minute abrasions of the skin that can increase the chance of infection.¹² A depilatory cream may also be used but this is messy and more time consuming. A chemical depilatory could be used by the patient the day before surgery if desired. The scalp is the area of the body in which the hairs can most interfere with surgery. Plastering down the hair with petrolatum or other ointment can decrease the number of hairs that interfere with surgery without causing a noticeable loss of hair during the postoperative period. Hair ties and bobby pins are invaluable items to have in the office (Figure 1-2).

Figure 1-2 A fenestrated drape is used to produce a sterile field for the surgical removal of a basal cell carcinoma.

(Copyright Richard P. Usatine, MD.)

Drapes

The use of sterile fenestrated aperture drapes (drapes with a hole) is recommended when suturing is performed so that the sutures do not drag over nonsterile skin (Figure 1-3). Sterile drapes are not necessary for small procedures, such as a shave biopsy, where suturing is not performed. Disposable or linen-quality sterile drapes are adequate for the procedures described in this book. You can create your own aperture drapes by cutting a hole in a sterile disposable drape. This allows you to customize the size of the hole you need. This should be done with sterile suture scissors and not tissue scissors to avoid dulling your more expensive instruments. You can also use the paper that is used to wrap surgical trays before sterilization for this purpose to save money. Drapes can be cut in a variety of sizes with a variety of holes and then sterilized alone or as part of a packet. Some prepackaged disposable sterile drapes come with adhesive around the aperture to stabilize the drape and isolate the field.

Figure 1-3 Hair on the scalp was cut short with clean scissors to make it easier to excise this ellipse over a pilar cyst. Note how the hairs surrounding the surgical site are held down with bobby pins. Petrolatum ointment can also be used to keep the surrounding hair out of the surgical field.

(Copyright Richard P. Usatine, MD.)

Sterilization of Instruments

Before sterilization, instruments must be cleaned of blood and debris. This can be done manually with a soft toothbrush, an ultrasonic cleaner, or a combination of these procedures.

A steam sterilizer (autoclave) is necessary to sterilize instruments and ensure that diseases such as viral hepatitis or HIV are not transmitted from patient to patient. Holding solutions should not be used to sterilize instruments. They are inadequate for proper sterilization and can only be used to temporarily hold or clean instruments. The instruments should be placed in sterilization bags with indicator strips to ensure the sterilization process is effective. These bags come in a variety of sizes to accommodate different instrument sets. Self-sealing bags cost a bit more than those that must be taped, but the convenience outweighs the cost.

Instruments can be packaged in sets for specific procedures such as punch biopsies, elliptical excisions, or nail surgery. Instruments can also be sterilized separately, but they need to be moved in a sterile manner onto the sterile surgical stand. It can be helpful to create surgical packs that contain a number of cotton-tipped applicators and gauze or just include these in the sets of instruments. This can save one the time of opening individually sterilized packets and can save money by allowing one to buy applicators and gauze in bulk.