๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
Introduction
CHAPTER 36 Managing Surgical
Complications
Eileen Axibal Ramin Fathi Mariah Ruth Brown
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.
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.
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.
Donโt 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.
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.
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.
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.
CHAPTER 36 Managing Surgical
Complications
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%).2 A prospective multicenter study examined the intraoperative and postoperative adverse events at 23 centers performing MMS. Among 20,821 MMS 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 Even for staged interpolation flaps, among the most invasive of dermatologic surgery procedures, the complication rate remains quite low. A review of 653 staged interpolation flaps at a single center revealed no major complications. Minor complications consisted of active bleeding requiring physician intervention (8.4%), hematoma (0.4%), postoperative infection after initial surgery (1.7%), and after division of pedicle (3.4%), dehiscence (0.5%), and partial- (2.3%) or full-thickness (0.6%) flap necrosis.4 Noninvasive to minimally invasive cosmetic dermatologic procedures are also associated with a low rate of adverse events. A multicenter, prospective cohort study of procedures performed using laser and energy devices, injectable neurotoxins, and soft-tissue augmentation materials (20,399 total procedures) reported only 48 adverse events (0.24%) and no serious adverse events.5
Overall, the risk of minor adverse events in dermatologic surgery is low, and severe
complications such as hospitalization and death almost never occur. Nonetheless, complications still arise in dermatologic surgery and surgeons must be able to successfully prevent, diagnose, and manage these complications. This chapter will address preoperative techniques to minimize adverse events in dermatologic surgery, as well as the identification and management of complications in the intraoperative and postoperative time periods.