Preoperative assessment includes a thorough medical and social history, and physical examination.
The choice and route of anesthesia are determined by the nature and duration of the procedure, and by patient-dependent factors.
Suture material and technique are selected based on the surgical procedure, anatomical location, and patient-related qualities of the wound.
Proper perioperative care is essential to decrease risk of complications.
Dermatologists likely perform more cutaneous surgical procedures than any other medical or surgical specialty.1 In addition to mastery of the technical aspects of a surgical procedure, the provider must also navigate a variety of perioperative considerations to maximize treatment efficacy and minimize complications. This chapter outlines the preoperative, operative, and postoperative considerations in dermatologic surgery.
Preoperative assessment is a critical component of ensuring a safe and successful surgical procedure. A detailed review of a patient’s history, including past medical and surgical history, medications, allergies, and social history, should be conducted. This serves to identify and enable appropriate planning around factors that may contribute to increased potential for intraoperative and postoperative complications.
HISTORY AND PHYSICAL EXAMINATION
PAST MEDICAL AND SURGICAL HISTORY
Common conditions such as hypertension and diabetes may impact surgical outcome. Hypertension may increase the risk of bleeding both during and after surgery, while uncontrolled diabetes may result in delayed wound healing and increased risk of infection. Patients with inherited bleeding disorders may require administration of clotting factors.
Cardiac history, including valve replacement and history of joint replacement, may impact the decision to prescribe prophylactic antibiotics. The presence and proximity of implantable electronic devices, such as a pacemaker or defibrillator, may require a modification of the intraoperative approach to hemostasis to reduce risk of adversely affecting the function of such a device.
Antibiotics have an important role in the setting of dermatologic surgery. A wound infection following surgery may increase symptoms including pain, and can result in complications, including poor wound healing. The presence of skin microflora at baseline results in some level of bacterial contamination of a surgical wound following compromise of the epidermal barrier during surgery. Therefore, careful attention to maintaining as close to a sterile procedural field as possible during surgery is imperative to minimize the risk of postsurgical wound infection. Additional factors that may increase risk of infection include microbial pathogenicity, length of surgery, the presence of foreign material including suture or dead space, poor suturing or reconstructive technique, poor vascular supply, and host immunity.
As routine use of antibiotics may promote antibiotic resistance, the judicious use of antibiotics surrounding surgery is essential. Table 202-1 provides examples of clinical scenarios in which prophylactic antibiotics should be considered to prevent surgical site infection. The most common organism resulting in infection following cutaneous surgery is Staphylococcus aureus, and ...