36 Complications
Postprocedural Adverse Effects and Their Prevention
The incidence of complications can be decreased with good procedural techniques and early recognition of problems before they become severe. Potential adverse effects and complications of skin procedures can be categorized by the time when they occur, as listed in Box 36-1.
Box 36-1 Potential Adverse Effects and Complications of Skin Procedures
An informed consent form covering the potential complications should be discussed with and signed by the patient. The informed consent form should cover the items in the list above that pertain to the surgical procedure for the specific site and patient. No absolute guarantees of cosmetic results should be made. See Chapter 1, Preoperative Preparation, and the sample consent form titled Disclosure and Consent: Medical and Surgical Procedures in Appendix A.
Review of the Literature
In a prospective study of 3788 dermatologic surgery procedures, there were 236 complications (6%).1 Most complications were minor and bleeding was the most common (3%). Vasovagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Multivariate analysis showed that anaesthetic or hemorrhagic complications were independent factors that predicted infectious complications. Patients on anticoagulants or immunosuppressant medications, type of procedure performed and duration exceeding 24 minutes were independent factors that predicted hemorrhagic complications.1
Two years later, the same group published a study of 3491 dermatologic surgical procedures describing postoperative infections in 67 patients (1.9%), with superficial suppuration accounting for 92.5% of surgical site infections.2 The incidence was higher in the excision group with a reconstructive procedure (4.3%) than in excisions alone (1.6%). Infection control precautions varied according to the site of the procedure; multivariate analysis showed that hemorrhagic complications were an independent factor for infection in both types of surgical procedures. Male gender, immunosuppressive therapy, and not wearing sterile gloves were independent factors for infections occurring following excisions with reconstruction.2
Dixon et al. performed a prospective study of 5091 lesions (predominantly nonmelanoma skin cancer) treated on 2424 patients.3 None of the patients was given prophylactic antibiotics, and warfarin or aspirin was not stopped. The overall infection rate was 1.47%. Individual procedures had the following infection incidence:
Surgery below the knee had an infection incidence of 6.9% (31/448) and groin excisional surgery had an infection incidence of 10% (1/10). Patients with diabetes, those on warfarin and/or aspirin, and smokers showed no difference in infection incidence. In conclusion, all procedures below the knee, wedge excisions of the lip and ear, all skin grafts, and lesions in the groin had the highest rates of infection and the authors suggest considering wound infection prophylaxis in these patients.3
In a prospective study of hospitalized patients undergoing diagnostic skin biopsies, infection, dehiscence, and/or hematoma occurred in 29% of the patients.4 Complications occurred significantly more frequently when biopsies were performed below the waist, in the ward compared with the outpatient operating room, in smokers, and in those taking corticosteroids.4 In addition, elliptical incisional biopsies developed complications more frequently when subcutaneous sutures were not used.4
In one study of 1400 Mohs procedures, 25 infections were identified.5 Statistically significant higher infection rates were found in patients with cartilage fenestration with second intent healing and patients with melanoma. There was no statistical difference in infection rates with all other measured variables including the use of clean, nonsterile gloves rather than sterile gloves during the tumor removal phase of surgery.5 Sterile gloves were used by all surgeons during the repair phase.
In 2008, an advisory statement on antibiotic prophylaxis in dermatologic surgery was published.6 Expert consensus based on a small number of studies suggests that antibiotics for the prevention of surgical site infections may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease.6 Also, patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, should be given prophylactic antibiotics (to prevent bacterial endocarditis) when the surgical site is infected or when the procedure involves breach of the oral mucosa.6
Bleeding
The most likely complication of dermatologic surgery is bleeding (accounting for half of a 6% complication rate).1 Larger surgeries with more undermining are at highest risk of bleeding complications. Good intraoperative hemostasis, appropriate suturing techniques, and pressure dressings can help minimize bleeding complications. Aspirin can cause excessive bleeding during surgery if not stopped 2 weeks before surgery. NSAIDs can also cause excessive bleeding if not stopped 2 days before surgery. Warfarin (Coumadin) also increases the risk of bleeding intraoperatively and postoperatively (Figure 36-1). That said most clinicians would not postpone skin surgery because the patient has recently taken aspirin or an NSAID. Often the risk of stopping warfarin or aspirin is greater to the patient (such as stroke) than dealing with the bleeding issues. In fact, in a study of 2424 patients undergoing dermatologic surgery, the warfarin or aspirin was not stopped in any of these patients.3 For further information on the risks and benefits of anticoagulation before surgery see Chapter 1 on preoperative preparation.