Management of Complications in the Acute Healing Stage

Summary

Postoperative bleeding and hematoma are an ever-present risk given the current preference to perform Mohs excisions and repairs with no regard to patient’s anticoagulation status.
Although gratifyingly rare, appropriate treatment of soft-tissue infections on the face requires accurate identification of the involved pathogen.
Although nearly universal in use, prolonged application of topical antibiotic ointment results in a very high incidence of dermatitis.
The early identification and effective treatment of chondritis is necessary to prevent long-term ear deformity.

21.1 General Principles

Management of complications in the early healing stage requires a degree of diligence and enthusiasm than the initial procedure requires. ¹^, ²^, ³ So often, early wound complications that can put the entire procedure at risk are attempted to be managed in a clinic setting when they require an operating room or are not approached with appropriate diligence in what could have been an easy return to the operating room and procession to final healing turns into a late complication requiring revision and reoperation anyway.

21.1.1 Hematoma

Currently, the standard of care is for dermatologists to not alter the coagulation status of patients undergoing Mohs resection. In this patient population, hematomas can be a frequent complication. The reconstructive surgeon needs to be adept at identifying which patients and procedures can be managed with anticoagulation. Additionally, the surgeon should be well versed with the use of a wide range of intraoperative techniques for safe hemostasis during awake anesthesia, including wide infiltration with epinephrine containing local anesthetics, and the use of topical oxidized cellulose. ⁴^, ⁵

Again, most hematomas can be prevented by attention to intraoperative hemostasis and awake anesthesia. If a hematoma occurs in the initial postoperative period, there can be little downside to immediately returning to the operating room, identifying the bleeding source, and evacuating the hematoma. If a hematoma occurs in the immediate perioperative period but after patient discharge, the criteria for returning to the operating room for evacuation is similar but not as urgent. Few hematomas will resolve completely and spontaneously. There is almost always some negative impact on the final repair appearance whether it is a color mismatch or contour irregularity, but it always carries with it an increased risk of postoperative infection if left undrained. ⁶

The routine use of compressive dressings are surgeon dependent and in a series of over 200 cheek reconstructions, no compressive dressings were used with no increase in bleeding complications. It seems prudent to place a drain routinely on take backs for bleeding. This can be removed in the initial postoperative period.

21.1.2 Infection

Fortunately due to the favorable vascularity of the face, soft-tissue infections in facial reconstruction are gratifyingly rare even in the patient population with frequent comorbid disease including diabetes and steroid dependence (▶ Fig. 21.1). ⁷ With soft-tissue infections in the face, management can be based on the general classification of purulent and nonpurulent infections and each can be categorized as mild, moderate, or severe. ⁷^, ⁸^, ⁹^, ¹⁰ Mild nonpurulent skin infections include impetigo and cellulitis. ⁷^, ⁸^, ⁹^, ¹⁰ Impetigo is most frequently caused by Staphylococcus aureus or Streptococcus pyogenes and can be managed with topical antibiotics and oral cephalexin if required. ⁷^, ⁸^, ⁹^, ¹⁰ For purulent skin soft-tissue infections, wound culture is mandatory for appropriate antibiotics selection and therapy. Antibiotic therapy for mild to moderate cases can be initiated with trimethoprim/sulfamethoxazole or doxycycline pending culture results, while severe purulent and moderate to severe nonpurulent cellulitis requires admission with intravenous antibiotics. ⁷^, ⁸^, ⁹^, ¹⁰ All cases of purulent skin soft-tissue infections require wound debridement and washout with concomitant culture for appropriate antibiotic selection. ⁷^, ⁸^, ⁹^, ¹⁰ Severe purulent and moderate to severe nonpurulent cellulitis requires admission with intravenous antibiotics. ⁷^, ⁸^, ⁹^, ¹⁰ In all cases, outpatient management requires careful and frequent postoperative visits to ascertain the effectiveness of the chosen antibiotic therapy. There should be no hesitation regarding repeated surgical debridement until clear signs of improvement are seen (▶ Fig. 21.2 and ▶ Fig. 21.3).

Fig. 21.1 Hematoma requiring re-operation and evacuation.

Fig. 21.2 A 75-year-old male 1 month status post meshed Integra placement for scalp wound with exposed bone. Fibrinous exudate illustrated is consistent with characteristic of normal wound healing with Integra and is not an infectious process. Exudate is removed and split-thickness skin graft is performed as planned with 100% graft take. Results shown at 2 weeks.

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