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MANAGEMENT OF SURGICAL COMPLICATIONS

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SUMMARY

  • Dermatologists perform approximately 9.5 million procedures yearly in the United States alone.

  • The rate of complications remains under 1%, and the rate of serious complications is vanishingly rare.

  • The risk of bleeding is the greatest in the first 24 hours postoperatively and is most frequent in the first 6 hours.

  • Prophylactic antibiotics are only indicated in specific circumstances (surgery on the mucosa or infected skin) to prevent joint infection, endocarditis, and surgical site infection.

image Beginner Tips

  • Be able to recognize signs and symptoms of vasovagal reaction, epinephrine reaction, anesthetic overdose, and anaphylaxis.

  • To avoid a delayed suture reaction, or spitting suture, place absorbable sutures deep in the dermis, cut sutures at the knot, and close wounds with minimal tension.

image Expert Tips

  • Digital blocks with lidocaine with epinephrine are considered safe, though the surgeon should avoid using more than 2 to 4 mL of anesthesia per digit, as the mass effect of the anesthetic volume added can lead to nerve and artery compression.

image Don’t Forget!

  • The nerves at the greatest risk for injury during cutaneous surgery are the temporal and marginal mandibular branches of the facial nerve and the spinal accessory nerve. Know the anatomical danger zones of these nerves, but also appreciate that nerve location cannot be precisely identified by anatomic location due to extensive individual variability.

image Pitfalls and Cautions

  • Poor closure design can lead to tension on an anatomic free margin and subsequent cosmetic and functional impairment. The surgeon should design closures that place tension perpendicular to the free margins.

image Patient Education Points

  • While complications in dermatologic surgery are uncommon, even a 1% complication rate translates into a risk of possibly weekly complications given the volume of procedures performed by many dermatologic surgeons.

  • Taking time to actively consent patients and inform them of possible complications may lead to a significant improvement in patient satisfaction.

image Billing Pearls

  • Dermatologic surgeons should be familiar with global periods; most complications treated within the global period of a given procedure cannot, by definition, be billed for separately.

  • Weigh the value of charging patients for revision procedures against the goodwill fostered by performing these procedures as a courtesy.

INTRODUCTION

Dermatologists perform approximately 10.5 million procedures each year.1 Of these, about 68% are cosmetic procedures and the remainder are procedures such as Mohs micrographic surgery (MMS) and surgical excisions.1 The vast bulk of dermatologic surgery is performed in an outpatient, office-based setting.

The safety and efficacy of dermatologic surgical procedures has been supported by multiple clinical studies. A prospective study following 2370 surgical procedures, including 934 MMS cases, over a 1-year period found a total of 56 surgical complications in 51 patients. Bacterial wound infections occurred in 13 cases (0.5%) and bleeding complications occurred in 5 cases (0.2%)....

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