Naples, Fla. - Before you start dermatologic reconstructive surgery, know the potential adverse events well, Dr. Keyvan Nouri said.
“It is important to be aware of complications, how to prevent them, and if they do occur, how to manage them,” he said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons
Bleeding, hematoma, nerve damage, infection, and contact dermatitis are among the adverse sequelae possible after surgery, Dr. Nouri said.
Dr. Keyvan Nouri
Acute bleeding is one of the most common complications in the immediate postoperative period, for example. Patients taking medications that alter hemostasis -- including aspirin, heparin, or warfarin -- are at higher risk, as are people with hypertension. “We don’t normally check blood pressure ... but [this] may be something you want to consider before surgery,” said Dr. Nouri, director of Mohs, Dermatologic and Laser Surgery at the University of Miami Leonard M. Miller School of Medicine.
To prevent medication-related bleeding, consult the prescribing physician to suggest discontinuation of the agent(s) prior to surgery, Dr. Nouri said. “We as dermatologists really have no role for stopping aspirin, Plavix, etc., beforehand.”
Strategies dermatologic surgeons can employ to minimize bleeding include use of sutures to ligate vessels, use of meticulous hemostasis during a procedure, and use of absorbable gel sponges to collect oozing from muscle and fascia, Dr. Nouri said. Also, observe areas at risk for bleeding for 10-15 minutes prior to closure if using uninterrupted sutures.
Pressure dressings help postoperatively. “Instruct patients to keep them on at least 48 hours,” he said.
A hematoma is another possible surgical complication. This “should be managed by urgently removing sutures and draining the hematoma,” Dr. Nouri said. If the bleeding does not stop, reopen the wound until you achieve hemostasis. If you place a drain to facilitate drainage, remember to remove it within 48 hours to avoid a heightened risk of infection.
Ecchymoses, another surgical complication, can be common, Dr. Nouri said, particularly when operating around the eyes or forehead. It results from blood passing through soft tissue planes. Instruct patients to apply ice on a regular basis postoperatively to minimize this effect.
Knowing your anatomy is essential to avoid damage to nerves or vital organs during surgery, Dr. Nouri said. “Know the facial danger zones.” The temporal area and angle of the jaw are examples. If the temporal nerve is damaged, the patient might be unable to lift their eyebrow after surgery. Also, an asymmetrical smile can result from damage to the submandibular branch at the angle of the jaw, he said.
Tendons also can be cut during surgery. Keep in mind that tendons become more superficial as you go more distally on the hands or lower extremities. “If a tendon is cut, we cannot repair it,” Dr. Nouri said. “The patient needs to be referred.”
The good news regarding contact dermatitis is it “used to happen a lot more in derm surgery,” Dr. Nouri said. Topical antibiotics, tapes and wound dressings, and nickel-plated surgical instruments can cause contact allergies. Watch for red, pruritic, or occasionally, vesiculated and crusted plaques. One tip is that pruritus is common with contact dermatitis, versus tenderness associated with infection.
Acute infections are rare in most dermatologic surgery patients, although immunosuppressed patients or those with uncontrolled diabetes are at higher risk, Dr. Nouri said. Malnutrition, obesity, smoking, and chronic use of steroids are other risk factors.
Also, remember to instruct patients not to shave prior to surgery. “Shaving less than 24 hours prior to surgery increases the risk of infection many times,” he noted.
Dermatologic surgery on a lower extremity carries a higher risk for infection, Dr. Nouri said. “Whenever I operate on someone’s legs, I use prophylactic antibiotics.”
Know that these and other adverse outcomes from surgery can occur, Dr. Nouri said. “Following the principles of tissue closure and antiseptic techniques will minimize these complications.”
Disclosures: Dr. Nouri said he had no relevant financial disclosures.