Perioperative Considerations in Dermatologic Surgery

Preoperative Assessment and Anticoagulant Management

Managing Anticoagulants and Antiplatelet Drugs

Contrary to traditional thinking, essential anticoagulant or antiplatelet medications are not stopped before routine dermatologic surgery. The risk of a clotting event (stroke, heart attack, embolism) from stopping these drugs is far greater than the risk of local bleeding or hematoma, which can be controlled with good surgical technique.

• Aspirin and clopidogrel (Plavix): Continue as usual. Stopping clopidogrel raises the risk of acute coronary stent thrombosis.
• Warfarin (Coumadin): Continue if the INR is within a safe therapeutic range (INR below 3.0, ideally 2.0–3.0). An INR test within 24–48 hours before surgery is mandatory.
• Direct oral anticoagulants (DOACs: rivaroxaban, apixaban, dabigatran): Continue for most minor skin surgery. For complex flaps or large grafts, skipping one dose on the morning of surgery and resuming the next day may be considered.
• Supplements and herbal products (vitamin E, ginkgo biloba, garlic, ginseng, omega-3/fish oil): Must be stopped 10–14 days before surgery because they disrupt platelet function unpredictably.

Prophylactic Antibiotics

Oral prophylactic antibiotics are not given routinely for all dermatologic surgery, to avoid antibiotic resistance and allergic reactions. They are reserved for high-risk situations:

• Infective endocarditis (IE) prophylaxis: Only when operating on actively infected skin in patients with a prosthetic heart valve, a history of endocarditis, or unrepaired cyanotic congenital heart disease.
• Prosthetic joint infection prophylaxis: Only when operating on infected skin in patients within the first 2 years after joint replacement.
• Surgical site infection (SSI) prophylaxis: For surgery on sites with a heavy bacterial load (nose, ears, lips, external ear canal, genital area), or for long, complex flaps or grafts.
• Standard regimen: Amoxicillin 2 g (or cephalexin 2 g) by mouth 30–60 minutes before surgery. For penicillin allergy, use clindamycin 600 mg or azithromycin 500 mg instead.

Managing Pacemakers and Defibrillators (CIEDs) During Surgery

When electrosurgery is used to stop bleeding or cut tissue, the high-frequency current can cause electromagnetic interference (EMI) that makes a pacemaker or implantable cardioverter-defibrillator (ICD) malfunction.

• Prefer bipolar electrocautery: The current flows only between the two tips of the forceps and does not pass through the patient's body, making it very safe for people with pacemakers.
• Rules for monopolar electrosurgery:
  • Place the grounding pad so that the current path does not cross the chest or the pacemaker.
  • Use short bursts (under 5 seconds) at the lowest effective power.
  • Keep a dedicated magnet on hand to switch the ICD into safe mode if a problem occurs.

Complication Control and Postoperative Care

• Managing acute hematoma: A hematoma within the first 24 hours causes severe pain, a tense, swollen wound, and a risk of tissue necrosis. Management: open part of the suture line, remove the clot, find and seal the bleeding point with bipolar cautery, irrigate with saline, and re-close with a pressure dressing.
• Flap or graft necrosis: Usually caused by too much tension on the closure, an underlying hematoma, or a flap designed too thin. Management: antibiotic ointment to keep the wound moist, yellow/infrared LED light to support circulation, and delayed debridement of dead tissue.
• Protecting the wound after surgery:
  • Leave the pressure dressing in place for the first 24–48 hours.
  • Patients are told to apply cold packs for 15–20 minutes every hour during the first 24 hours to reduce swelling.
  • Keep the wound dry for 24 hours, then clean it gently with saline and apply petroleum jelly or antibiotic ointment.

Preparation and Surgical Workflow at Haute-Derma

Preoperative Screening and Safety Documentation

• Review allergy history (amide/ester local anesthetics, latex tape, chymotrypsin).
• Review current medications, check blood pressure, and do a rapid blood glucose test and INR (if on warfarin).
• Obtain signed informed consent after clearly explaining the risks of scarring, bleeding, and infection.

Preparing the Patient in the Operating Room

• Position the patient comfortably (lying on the back or side) and disinfect a wide area around the site with povidone-iodine 10% or chlorhexidine 2% in alcohol.
• Mark the lesion margins and plan the incision along relaxed skin tension lines (RSTL).
• Give local anesthesia with lidocaine 1–2% plus epinephrine 1:100,000 (or 1:200,000), injected slowly through a fine 30G needle to reduce pain.

Aftercare Instructions and Follow-Up

• Provide detailed written wound care instructions.
• Schedule suture removal: 5–7 days for the face; 10–14 days for the trunk and limbs.