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  • 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 clinician 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 clinician should design closures that place tension perpendicular to the free margins.

image Patient Education Points

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

image Billing Pearls

  • Clinicians 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.


The safety and efficacy of dermatologic surgical procedures have been supported by multiple clinical studies.1 A prospective study following 2370 surgical procedures 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%).2 A prospective multicenter study examined the intraoperative and postoperative adverse events at 23 centers. Among 20,821 Mohs surgery procedures, there were 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Of the adverse events, 61.1% were infections, 20.1% were wound dehiscence or partial- or full-depth necrosis, and 15.4% were related to bleeding or hematomas.3

Noninvasive to minimally invasive cosmetic dermatologic procedures are also associated with a low rate of adverse events.4 A multicenter, prospective cohort study of procedures ...

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