In this interview, Dr Nicholas J. Golda shares practical tips and updates on perioperative management in dermatologic surgery, covering recent advancements, common challenges, effective techniques, and emerging trends. Gain valuable insights to enhance patient outcomes and stay informed about the evolving landscape of dermatologic surgery.

Nicholas Golda, MD, FAAD, FACMS, is board-certified in both dermatology and micrographic dermatologic surgery. His specializations include skin cancer and Mohs micrographic surgery, which he practices at US Dermatology Partners.

Transcript

The Dermatologist: What are some practical pearls for optimizing perioperative management in dermatologic surgery, especially concerning preoperative assessment and preparation?

There's a lot of normal, you know, everyday stuff for peri and preoperative management that I won't restate. I think the biggest changes in the last couple of years have been paying more attention to just how we don't need to give out as many preoperative antibiotics as we once thought we did. And anybody who has prescribed them, you know, more familiar in the past has probably noticed that there were quite a few adverse reactions. And I think you're more likely to end up giving someone an adverse reaction, or quite honestly, just creating difficulty for yourself in terms of, you know, people not getting their prescriptions and phone calls and callbacks where where, you know, the science is showing that you're better off for the very large contingent of the people that we work on, you don't have to give out preoperative or even postoperative antibiotics.

So I think that's a biggie. And it's hard if you're in the habit of doing that, it's hard to peel yourself away from it, 'cause none of us wants our patients to have an infection. So that's a tough one. 

I think the other big areas where you've seen some movement is managing pain control. I think, you know, the studies have shown that dermatologic surgeons in the last couple of years have done a great job of prescribing a lot less narcotic pain medications afterwards, just with study after study showing the dangers, the over prescription and also the fact that really most of our patients are well managed with the agents that are available over the counter that they already got in their medicine cabinets at home.

Further, there's been some research, you know, just demonstrating using some long -acting anesthetics to head off that pain of the past and keep people from having discomfort in the first place. So, you know, prevent the pain rather than treating the pain. So there's some great research on that using long -acting anesthetics.

And then the other big thing I think is you're seeing an increased use of agents like tranexamic acid to reduce postoperative bleeding. I mean the big three that we deal with in terms of you know postoperative problems are pain, infections, and bleeding. So you're seeing some movement on all three of those fronts in terms of what we're doing. So I think those are the biggest areas for folks to pay attention to.

The Dermatologist: Can you discuss any recent updates or advancements in perioperative care protocols that dermatologists should be aware of to enhance patient outcomes?

So I think, you know, we just addressed the big three, the antibiotic issue. I think, you know, while we all have a little bit more that we can learn, I think that's something that a lot of us have wrapped our minds around. The biggest change for me personally, and one that I'd be excited to share with my colleagues, is being a little bit more comfortable with using tranexamic acid to try to prevent postoperative bleeding.

I began, you know, I kind of inched into this using it topically. And I'm to the point where I'm using it injected into my closures where I'm more worried about bleeding. And there's a lot of data out there to support its use in in the context of people that have, you know, a propensity to clot even or at a high risk for clotting from research that's from other specialties that's showing how safe it is, even with doses that are much larger than we use in dermatologic surgery.

So I think this is an area where you're going to be seeing a lot of publication and new research, a lot more than is available now. What we rely on now is more in research like orthopedic surgery, oncologic surgery, and dermatologic surgery. I think we can kind of extrapolate safety from those, but we really need that primary research and dermatologic surgery and I've got it on good advice.

We're going to be seeing more of that coming online. So none of us wants to get a phone call at midnight with a patient who's bleeding. And quite frankly, our patients don't want to call us at midnight, right? So I think it's beneficial to, you know, dermatologic surgeons and our patients to think about ways that we can reduce the already low risk of post -operative bleeding even further, especially if we're not presenting additional risk to our patients.

I think this is one of those things that's going to be adopted by more and more surgeons in the coming years as the research matures and as we develop comfort using this age in our practices.

The Dermatologist: What are some common challenges or complications faced during the perioperative period in dermatology procedures and how do you approach them?

One of the common things that will run into perioperatively and postoperatively is pain. Perioperatively, I mean, there's no getting around the fact that the initial anesthetic injection hurts.

You know, I, along with most other dermatology experts, use buffering with my lidocaine to try to ease that discomfort. There are also quite a bit of publications on things that you can do to either distract the patient or use different tools to try to ease that injection, like vibrating kind of distraction methods or even pinching the patient's skin.

I would love if we ended up with a scenario where we were able to make that injection quite a bit less painful. I think that's the biggest problem that I run into that doesn't have a great solution is trying to get anesthetic into our patients in a more pain -free way. Even when I'm deploying all of the techniques that have been written about and I've talked to my colleagues about it's still a tough one, especially given the locations that we're having to do these injections in dermatologic surgery.

Post -operative pain, I've really had a ton of success with using long -acting anesthetics in patients that I know are going to have pain. Either patients who tell me, "Look, I've had pain after previous procedures. I want you to do something about that," or folks that we just know statistically are going to have a higher risk for pain, such as scalp closures or advanced closures on the nose. And I've been using injected long -acting anesthetic in those cases to great effect.

And that's something that I'd encourage colleagues of mine that aren't doing that already to consider it's, I don't wanna overstate it. And this is, of course, anecdotal, but I've had few to know, no calls with postoperative pain when using this agent and carefully selecting who needs it. I haven't had any adverse effects from it, and I've had a lot of really happy patients.

So I think that pains in the area that we have an opportunity for growth, but also an opportunity that's in front of us to do better for our patients the postoperative period with long -acting anesthetics.

The Dermatologist: In your experience, what are some effective techniques for minimizing patient discomfort and promoting rapid wound healing during the perioperative period?

So I want to zoom in on promoting rapid wound healing. I think a lot of that has to do with managing the patient's expectations and what their concerns are.

Some people want to be done and we'll granulate those wounds. And I think that's where I get a lot of post -operative visits and phone calls from folks is on, funny enough, it's not on the really complicated closures, it's on the wounds that we do nothing for because they do take a long time to heal up.

And oftentimes it's because those wounds are in parts of the body, such as the lower leg where healing's poor to begin with. I haven't used a ton of skin substitutes or some of these products that are available to try to speed wound healing. So I can't speak from personal experience about it, but it's something I've thought about.

I've found that I work a little harder to close these defects now than I might have earlier in my career, simply from a patient satisfaction standpoint of view. Trying to marry being a good steward of health care resources and also trying to be a good steward for my patients. And folks generally want to be closed if they can be closed. And so I've had a lot of success with that, using some techniques to try to close these lower leg defects that are a little bit bigger.

And, you know, they're simple things like using, I've written about this, but just using an adhesive strip on either side of the wound to keep the skin from tearing so I can put greater load on it to get it closed up. Or using some flat reconstructions and the legs trying to get things closed, but honestly, I've had the most luck with just using steroid strips on either side of the wound and using those to enhance the strength of the wound.

It's been amazing what I've been able to get closed using that as a technique. So, getting things closed seems to help quite a bit, as long as you're not pushing it to the point where things are gonna split open or heal poorly because of the tension you're putting on the wound.

I think that's one of my bigger changes the last couple of years is I've really tried to close lower extremity defects. That's where I get the most objection from patients in terms of the length of time required for wound healing. So yeah, that's where I've been focusing.

The Dermatologist: Considering the evolving landscape of dermatologic surgery, what emerging trends or innovations do you foresee in perioperative management, and how might they influence clinical practice in the future?

So emerging perioperative trends, I think you're going to see a continued walk away from using perioperative antibiotics and perioperative prescribed pain control. We're going to get to a point where we're just not using those except for various, you know, unique circumstances.

And I think you're going to see a lot more research coming out in terms of using basically anti -fibrinolytic agents like tranexamic acid to try to manage perioperative bleeding or post -operative bleeding in addition to other agents that might be used in the wound that we're not aware of yet that might be in the pipeline. I think, you know, bleeding or, you know, it can cause failure of grafts, failure of flaps, a lot of discomfort for patients and distress. So I think it's an area that we've done a great job with infections and pain.

I think it's kind of our last of the big three complications to really tackle in a way where I think you're going to see it become a lot more widely accepted to use agents like this. And I think you'll see the development of treatment algorithms where the people will look at side effects and safety and different surgical situations.

And I think you'll see a lot more of a proscribed way of deploying these agents. I think that's the biggest thing on the near -term horizon.