A Guide To Addressing Complications In Dermatologic Surgery

Dermatologic surgical procedures in the lower extremity may lead to complications for podiatric patients. Sharing insights from their experience and the literature, these authors discuss how to prevent complications including infection, coagulation issues, wound dehiscence, scarring and pain.

Complications during dermatologic surgery are not uncommon events and taking the correct steps early in management can prevent significant morbidity for the patient. Although there are stringent postoperative protocols to combat improper wound healing, it is important to be aware of the potential surgical complications that may arise with patients.

Surgical complications may range from life-threatening to acute with potential complications including cardiorespiratory arrest, anaphylaxis and cardiac arrhythmias. Complications also may be limited to improper wound healing due to superinfection, wound dehiscence and necrosis, or an undesirable aesthetic outcome of a scar. Proper patient history gathering prior to any surgical procedure is fundamental to minimizing serious complications. Adhering to proper sterile technique during surgical procedures in combination with thorough postoperative instructions is key to preventing complications from dermatologic surgeries.¹ Conducting dermatologic surgeries with careful consideration of the potential complications that may arise is an effective prevention measure.

Dermatologic surgery in the lower extremity consists of minor procedures such as electrosurgery, biopsies and minor excisions of both benign and malignant tumors.² More complicated techniques and reconstruction carry higher risks of complications but when there is appropriate management, these procedures still have relatively low complication rates.³ One may use local anesthetics such as lidocaine in most dermatologic procedures when no patient-related contraindications prohibit their use. Lidocaine is the most commonly used local anesthetic agent in dermatologic procedures due to its low allergenicity, rapid onset and one- to two-hour duration of action. One may use bupivacaine or prilocaine for longer procedures or for particularly pain-sensitive patients.⁴ Lidocaine allergy, although uncommon, does exist and clinicians should rule allergy out prior to its use.

An Overview Of Common Dermatologic Procedures

Electrodessication and curettage. One scrapes skin growths with a curette and then performs electrodessication. There are one to two more cycles of curettage and electrodessication to eradicate a cutaneous malignancy.

Shave biopsy. The clinician uses a blade to perform the shave biopsy, sampling a portion of the concerning lesion for histological evaluation. Shave biopsies are not typically full-thickness biopsies.Therefore, the blade does not reach the subcutaneous fat.

Punch biopsy. A punch biopsy tool operates as a cylindrical cookie cutter that allows for a full-thickness sampling of tissue. One often closes the defect left by the cylindrical blade with sutures but surgeons have used alternative modalities such as gel foam.

Mohs surgery. Mohs surgery is a surgical technique used to treat skin malignancies. The treating physician progressively excises thin layers of the tumor and evaluates the borders. This procedure may take many hours and stages until the treating physician reaches clear borders. Mohs surgeries can lead to significant surgical defects that may require subsequent reconstructive surgery.

Pointers On Proper Pre-Op Evaluation

Preventing potential complications from dermatologic surgery begins with proper history gathering. This includes a thorough review of past and present illnesses, surgical history and medication history, including prescribed and non-prescribed medications, family history and allergies.⁵

Evaluation of cardiac abnormalities is important for dermatologic surgical procedures due to the risk of developing endocarditis. Although this complication is rare in cutaneous surgery, the risk increases in those with underlying or past cardiac abnormalities such as congenital heart malformations, hypertrophic cardiomyopathy and a prior history of endocarditis. To minimize this risk, consider preoperative antibiotics and use them primarily in high-risk patients. Assessing the current criteria established by cardiology associations is important in determining patient risk.⁶

Patients with diabetes mellitus are more vulnerable to postoperative complications. This patient population is susceptible to the development of acute non-healing ulcers due to a disrupted wound healing process. Ulcer formation is a result of hypoxic conditions, epidermal cell and fibroblast dysfunction, and an impairment in angiogenesis, all of which are exacerbated by diabetes. It is important for physicians to monitor wound healing closely in patients with diabetes postoperatively and ensure that proper wound care is in place to avoid serious complications.⁷

Handling Pain After Derm Surgery

Pain management is an important part of patient care pre- and post-surgery. Minor dermatologic surgeries require local anesthetics to manage pain intraoperatively. Analgesic use is procedure-specific and often requires an open discussion between the physician and the patient. Certain procedures, such as nail surgery, are more likely to be followed by considerable postoperative pain and may require analgesics with narcotics for optimal pain control.

It is important for physicians to follow proper guidelines in the assessment of postoperative pain. This includes assessing pain onset, location and quality as well as provocative and palliative factors. Physicians usually recommend over-the-counter analgesics for post-op pain after minor dermatologic surgeries. In cases of excessive pain, patients should present to the office and get an assessment for infection or other potential complications.

What You Should Know About Coagulation Complications

Making a proper assessment of factors that may interrupt the normal coagulation process is important in dermatologic surgery to minimize the risk of hemorrhage. Defects in the coagulation cascade or a decreased platelet count may contribute to failure in the overall outcome of surgical treatment. Many patients who are on medications that disrupt platelet function may need to continue these medications regardless of their dermatologic procedure. One may take several measures to manage bleeding complications in these patients, such as mixing the local anesthetic with epinephrine, and applying pressure with sterile gauze and electrocautery intraoperatively.

Consider using simple blood tests detecting the platelet and prothrombin count primarily in more extensive dermatologic surgeries such as skin flaps and grafts used in traumatic accidental loss of skin.¹

A potential complication of postoperative bleeding is the formation of a hematoma, which increases the risk of wound infection and delays healing. Hematoma formation is mainly due to a coagulation of blood within a cavity and presents as painful swelling. One extracts clots by incision and administers antibiotics.¹ Prevention is key. Apply a pressure bandage immediately postoperatively and instruct the patient to keep it in place for at least 24 hours to reduce the risk of hematoma formation.

Preventing Post-Op Infections

From the moment a dermatologic procedure compromises the epidermis, microorganisms on the surface of the skin and within the hair follicles may colonize the open wound. This colonization may progress to a wound infection.

There are a variety of factors that may lead to infection. Environmental factors include poor sterile technique and hand washing practices. Washing both hands with antiseptic/antimicrobials such as chlorhexidine and properly disinfecting the surgical site are of paramount importance.^2,8,9

There are additional methods that procedure room staff can take, such as the use of proper surgical attire by physician and assistants. This includes the use of scrubs, surgical caps and shoe covers in order to decrease the overall level of microorganisms in the procedure room, and thereby reduce the risk of infection.¹⁰

Which Patient Factors Can Increase Infection Risk?

Patient factors that may influence the risk of infection include comorbid conditions such as diabetes mellitus, autoimmune disease, age, obesity and smoking.

Age. Increased age is a major risk factor in wound healing. This delay in wound healing in the elderly population can be due to an alteration in the inflammatory response, decreased chemokine production and a reduction in the phagocytic capacity of macrophages. These factors slow the wound healing process and may also increase the risk of postoperative infection.⁷ For this reason, one needs to review proper wound care measures in detail in this population and advise these patients to return to the office for re-evaluation at the first sign of infection.

Obesity. Obese individuals are at an increased risk for cutaneous surgical complications for a variety of reasons. This patient population suffers from poor perfusion and hypovascularity, both of which lead to slow wound healing. Microorganisms that inhabit skin folds also pose a risk for infection.⁷

Smoking. Patients who smoke have a delay in wound healing postoperatively and researchers think this is due to the effects of smoking on the microvasculature.¹¹ Smokers are at an additional increased risk for infection, wound necrosis and rupture. The vasoconstrictive effects of nicotine may lead to tissue ischemia. Smoke exposure leads to a decrease in migration and growth of fibroblasts, reducing wound contraction.⁷

When Are Prophylactic Antibiotics And Medications Appropriate?

Prophylactic oral antibiotics are generally not routinely indicated in dermatologic surgery, except in immunosuppressed patients or those with artificial heart valves or prosthetic joints.12 When there is a patient who meets the criteria, selecting the appropriate prophylactic medication is key to making sure skin flora is covered.

Staphylococcus epidermidis colonizes the upper body and is the primary bacteria in endocarditis of non-cutaneous infection. Staphylococcus aureus is present in the perineal area and nares in a small percentage of the population, and is a common bacteria leading to infective endocarditis postoperatively. Choosing an antibiotic that covers both species decreases the likelihood of infection. Therefore, cephalexin (Keflex), a first-generation cephalosporin, is the treatment of choice with amoxicillin (Moxatag, Vernalis Therapeutics) being a second choice. Patients with penicillin allergies receive clindamycin, azithromycin or clarithromycin (Biaxin) orally.^1,2

Physicians use nonsteroidal anti-inflammatory drugs (NSAIDs) as anti-inflammatory medications but they have the potential to impair wound healing. Ascertaining a thorough medication history is important and the literature recommends discontinuing NSAIDs prior to surgery.⁷

Glucocorticoids decrease fibroblast proliferation, collagen synthesis and interfere with reepithelialization, all of which are key components of the wound healing process.¹ Chemotherapeutic medications disrupt the proliferative phase of the wound healing process, and inhibit DNA, RNA and protein synthesis. They also may increase susceptibility to infection given their effects on the immune system.

Keys To Preventing Or Mitigating Scar Formation

The final appearance of a wound may pose as an aesthetic complication to the patient. Patients need to be prepared for all the potential cosmetic outcomes prior to surgery. Hypertrophic scarring and keloid formation are not a result of poor surgical technique, but rather result from predisposing host factors in the patient such as family history.¹ Tight suturing or sutures left in place for an extended period of time may also lead to scarring. Therefore, adequate incision and suturing styles as well as timely suture removal are all important in avoiding scar formation.

In addition, tension at the surgical site may also lead to wound dehiscence. The use of subcutaneous sutures prior to placing superficial sutures has helped in preventing such tension.¹ If the wound is large enough or suturing is not a possibility, healing by second intention is another option.

Dermatologic surgery also encompasses nail surgery procedures. Biopsies, nail surgeries and excisions of the nail matrix can result in scarring of the matrix, leading to the formation of an abnormal nail plate. De Berker and colleagues performed a study of nail procedures and cited a 22 percent rate of residual scarring and nail dystrophy.¹³ Potential scarring of the nail includes pincer nails, split nails, hooked nails or misaligned nails.¹⁴ Nail dystrophy reportedly causes psychological distress, which underscores the importance of a thorough preoperative discussion of risks and patient expectations of outcomes for nail procedures and dermatologic procedures in general.^13,15

A Guide To Post-Op Care After A Dermatologic Surgery

After a dermatologic surgical procedure, physicians often place a pressure bandage over the surgical site in order to provide hemostasis and usually instruct patients to keep this on for 24 hours. Not only does this immobilize the wound, allowing critical first steps in the wound healing process to occur, it prevents hemorrhage and hematoma formation as well. First, one would apply petrolatum or antibiotic ointment to the wound site, and then add a non-adherent dressing and gauze for support.

Provide the patient with both vocal and written instructions on wound care, including washing instructions, decreased motion and friction of the surgical site and elevation.⁵

In Conclusion

Dermatologic surgery complications most often include pain, bleeding and infection. There are measures that surgeons can take either to prevent these complications or recognize and treat them early to prevent more serious consequences. In general, rigorous patient education, thorough history taking and proper sterile technique practiced by the surgeon and staff can prevent the most serious consequences with dermatologic surgery complications.

Dr. Adigun is a Fellow of the American Academy of Dermatology. She practices at the Dermatology & Laser Center of Chapel Hill in Chapel Hill, NC.

Omobola Onikoyi is a student at Touro College of Osteopathic Medicine in Middletown, NY.

References

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