Optimizing Dermatologic Surgery Care
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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.
The Dermatologist: What are some practical pearls for optimizing perioperative management in dermatologic surgery?
Dr Golda: The big 3 that we deal with in terms of postoperative problems are infections, pain, and bleeding, and we are seeing some movement on all these fronts. I think the biggest change in the last couple of years has been paying more attention to how we do not need to give out as many preoperative antibiotics as we once thought we did. And anybody who has prescribed them in the past has probably noticed that there were quite a few adverse reactions. I think you are more likely to end up giving someone an adverse reaction or, quite honestly, just creating difficulty for yourself in terms of people not getting their prescriptions and phone calls and callbacks. The science is showing that you do not have to give out preoperative or even postoperative antibiotics for a large contingent of the people who we work on. It is hard, though, to peel yourself away from prescribing antibiotics because none of us wants our patients to have an infection.
I think another big area where we have seen some movement is pain control. Studies have shown that dermatologic surgeons in the last couple of years have done a great job of prescribing a lot less postoperative opioid pain medication. We have study after study showing the dangers of over prescription and most of our patients are well managed with over-the-counter agents. Further, there has been some research demonstrating that we can use long-acting anesthetics to head off pain and keep people from having discomfort in the first place.
The other big thing is that we are seeing an increase in the use of agents like tranexamic acid to reduce or prevent postoperative bleeding. This is the biggest change for me personally, and one I am excited to share with my colleagues. I kind of inched into this using it topically. Now I am to the point that I am using it injected into my closures where I am more worried about bleeding. There is research from other specialties to support the use of tranexamic acid, even with doses that are much larger than we use in dermatologic surgery, for patients who have a propensity to clot or are at a high risk for clotting. I think this is an area where we are going to be seeing more primary research being done in dermatologic surgery. None of us wants to get a phone call at midnight from a patient who is bleeding. And, quite frankly, our patients do not want to call us at midnight. So, I think it is beneficial for dermatologic surgeons and our patients to think about ways that we can reduce the already low risk of postoperative bleeding even further, especially if we are not presenting additional risk to our patients. I think the use of tranexamic acid is going to be adopted by more and more surgeons in the coming years as the research matures and we develop comfort using it in our practices.
The Dermatologist: What are some common challenges or complications faced during the perioperative period and how do you approach them?
Dr Golda: One of the common things that we run into peri-operatively and postoperatively is pain. Perioperatively, there is no getting around the fact that the initial anesthetic injection hurts. I, along with most other dermatologists, use buffering with my lidocaine to try to ease that discomfort. There are also several publications on things that you can do to either distract the patient or use different tools to try to ease the injection, such as vibration distraction methods or even pinching the patient’s skin. I would love it if we ended up with a scenario where we are able to make the injection quite a bit less painful. I think the biggest problem I run into that does not have a great solution is trying to get anesthetic into our patients in a more pain-free way. Even when I am deploying all the techniques that have been written about and I have talked to my colleagues about, it is still a tough one, especially given the locations of these injections in dermatologic surgery.
In terms of postoperative pain, I have had a ton of success with using long-acting anesthetics for patients who I know are going to have pain, either those who tell me, “I’ve had pain after previous procedures and I want you to do something about it,” or folks who we know statistically are going to have a higher risk of pain, such as scalp closures or advanced closures on the nose. I have been using injected long-acting anesthetic in those cases to great effect. This is something that I would encourage colleagues of mine to consider if they are not doing it already. It is, of course, anecdotal, but I have had few to no calls from patients with postoperative pain when using this agent and carefully selecting who needs it. I have not had any adverse effects from it, and I have had a lot of happy patients.
The Dermatologist: In your experience, what are some effective techniques for promoting rapid wound healing during the perioperative period?
Dr Golda: I think a lot of promoting wound healing has to do with managing the patient’s expectations and what their concerns are. Some people want to be done and we will granulate those wounds. This is where I get a lot of postoperative visits and phone calls, not from patients with complicated closures, but from those with wounds that we do nothing for because they take a long time to heal up. Often, it is because those wounds are in parts of the body, such as the lower leg, where healing is poor to begin with. I have 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 point of view. I try to marry being a good steward of health care resources and being a good steward for my patients who generally want to be closed if they can be closed. I have had a lot of success using some techniques to close lower leg defects that are a bit bigger.
There are simple things like using adhesive strips on either side of the wound to keep the skin from tearing so I can put a greater load on it to get it closed. It has been amazing what I have been able to get closed using this technique, as long as you are not pushing it to the point where things are going to split open or heal poorly because of the tension you are putting on the wound. I think one of my bigger changes in the last couple of years is that I have really tried to close lower extremity defects. That is where I get the most objection from patients in terms of the length of time required for wound healing, so it is where I have been focusing.
The Dermatologist: What emerging trends or innovations do you foresee in perioperative management, and how might they influence clinical practice in the future?
Dr Golda: I think we are going to see a continued walk away from using perioperative antibiotics and perioperative prescription pain control. And I think we are going to see a lot more research coming out in terms of using antifibrinolytic agents like tranexamic acid to try to manage perioperative or postoperative bleeding, which can cause failure of grafts and flaps and lot of discomfort and distress for patients. We are going to see it become a lot more widely accepted to use agents like this and treatment algorithms where we will look at side effects and safety for different surgical situations to develop a more prescribed way of deploying these agents.
