Biopsies and procedures on the lip can be made blood-free when lip is secured with a chalazion clamp (Fig. 8.2).

Use a cotton tip applicator or dental roll gauze to buttress the nasal ala (Fig. 8.3).

For procedures on the ear or eyelid, tumescence of the area with anesthesia will aid in hemostasis by compressing smaller vessels.

Be mindful of the path of larger caliber vessels so as to avoid their transection. Vessels susceptible to injury during skin surgery include the superficial temporal artery, labial arteries, angular artery, and dorsal nasal artery.

Be aware of the depth of vessels, and use this to your advantage when undermining. For example, the plane on the scalp beneath the galea is avascular and is the preferred level of undermining when operating in this region (Fig. 8.4).

Vigorous blood flow obscures the surgical field. Non-deliberate, jerky motions to stop bleeding can result in a stick.

Have gauze ready. Immediately blot the area with continuous pressure. Upon release, assess the rate and volume of blood flow.

For less brisk bleeding, apply pressure with gauze for 5 seconds, then quickly release and work. Re-blot as needed.

Put the corner of a gauze at the wound edge to absorb blood by capillary action. This method accepts a short-term free-flow of blood.

The chosen method of hemostasis is incongruent to the amount of bleeding. For example, using a topical hemostatic agent in a field that is bleeding briskly will not be successful.

Light bleeding can be stopped with topical hemostatic agents. Moderate bleeding, characterized by rapid pooling of blood in the field, should be addressed with electrosurgery. Actively spurting vessels require suture ligation. Grip the bleeding vessel with hemostats or forceps to stop it from bleeding, then throw a figure-of-eight suture.

Electrosurgery is used excessively, causing adverse cosmetic outcomes due to excess tissue destruction.

Only use electrosurgery when it is necessary to control bleeding. Distinguish between use of electrosurgery for adjunctive surgical destruction (i.e., at the base of an excised cancer) versus merely for hemostasis.

Caustic hemostatic agents such as aluminum chloride are used near the eye. These agents can be corrosive and damage the eye.

Periocular hemostasis should be performed with manual pressure or electrosurgery. If aluminum chloride must be used, the cotton tip should be wet but not dripping. This is often achieved by blotting the freshly wet applicator tip on the dry paper of the Mayo stand cover.

The containers of topical hemostatic liquids are left on the surgical tray or counter uncapped (Fig. 8.5). Blood can splash into the stock bottle. There is also temptation to double-dip a contaminated cotton tipped applicator.

Always recap stock bottles immediately after use.

Do not place a stock bottle on the surgical tray.

A gloved assistant should hand the cotton tip applicators to the surgeon (Fig. 8.6).

A cotton tip applicator, soaked with hemostatic agent, is applied to unsplayed skin. Slack wounds shelter capillaries in the dermal papillae resulting in persistent bleeding.

Splay the skin to maximize contact of the agent with the dermal capillaries.

A suboptimal electrosurgical device is used to gain hemostasis.

If bleeding vessels are visualized, indirect electrocoagulation (e.g., Bovie™) with forceps is a highly efficient method of gaining hemostasis (Fig. 8.7a). Direct electrodesiccation with a Hyfrecator™ is efficient and effective for most cutaneous procedures (Fig. 8.7b).

Failing to identify patients with implantable electronic devices (IED). Electrosurgical devices cause inappropriate functioning of IEDs (e.g., pacemakers, defibrillators) due to: (1) Use of high amperage; (2) Use of an electrosurgical device too close to the IED; or (3) Use of a device for long bursts (e.g., more than 5 seconds).

Preoperatively identify IEDs via standardized patient intake forms.

Heat electrocautery is the only true method to avoid electromagnetic interference (EI) with IEDs (Fig. 8.8). This modality does not use an electric current and poses no risk of EI.

If heat electrocautery is not available and a topical hemostatic agent would not create effective hemostasis then an electrosurgical device with a bipolar electrode tip should be used (Fig. 8.9).

Many outpatient offices have monoterminal, monopolar electrosurgical units (e.g., Hyfrecator) (Fig. 8.10). Limit Hyfrecator current flows to short bursts of 5 seconds or less, and place the settings on the lowest power possible to attain hemostasis. Finally, the surgical site should not be within 15 cm of the IED.