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A surgeon should never perform a procedure for which he or she is incapable of dealing with potential adverse consequences. Even in the most capable hands, approximately 1% of flap reconstructions will result in a complication requiring a postoperative intervention.1 For all of the meticulous attention given during a reconstruction, the greatest test of a surgeon’s mettle occurs when a serious complication occurs and must be resolved. Patients often find even a routine and uneventful flap reconstruction to be emotionally challenging. Adding a complication greatly increases anxiety and requires the surgeon to act quickly and effectively and provide appropriate reassurance.


Periocular surgery often causes substantial edema, especially when muscle tissues have been removed and/or manipulated. Some patients will develop profound edema and will be quite alarmed (Fig. 16.1). In cases where an extensive reconstruction has been performed, this may last for weeks to months. Patients concerned with edema should be seen and evaluated. Luckily, even when swelling is extreme, ocular complication is exceptionally unlikely. Simple measures such as head elevation when sleeping along with reassurance are sufficient in most cases.

Figure 16.1

Edema 1 day following removal of a skin cancer. This will resolve spontaneously but can be frightening to the patient


Hematoma formation occurs in less than 1% of facial flap reconstructions. While linear repairs are relatively unaffected by anticoagulation, the incidence of hematoma following adjacent tissue transfer is somewhat higher in patients on anticoagulants.2 With the pervasive utilization of multiple antiplatelet agents, often in combination with warfarin or thrombin inhibitions, patients are at risk of postoperative hemorrhage.3 The management of anticoagulant therapy in patients undergoing cutaneous surgery is an area of evolution. Given the real risk of cerebral and myocardial infarction with anticoagulant change and/or cessation, many surgeons opt to continue anticoagulation therapy during skin surgery, unless a particularly aggressive repair will be required. The authors of this book have not discontinued any form of anticoagulation in 10 years, and multiple of the cases shown in this book were performed in patients on warfarin, clopidogrel, aspirin, and/or a combination of these and similar medications. In the case of warfarin, it is easy to check an international normalized ratio (INR), and if this is markedly elevated, it is reasonable to adjust the dosage.

Minor Hematomas

Small hematomas will often form without a patient being entirely aware that something has gone wrong. Patients who expect swelling may wake up in the morning with a hematoma that has already undergone tamponade and that is not expansile. They may call the physician or may not present until suture removal. Modest, static hematomas, which do not cause tissue compromise, can be managed expectantly and will usually resolve spontaneously and without ...

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