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Operative considerations
Operative considerations
All surgical approaches have risks including but not limited to bleeding, infection, risk of hypertrophic scar development, dyspigmentation, poor cosmetic outcome, and risk of incomplete treatment. These risks must be discussed with the NMSC patient in order to ensure that the patient as part of the informed consent process prior to deciding whether to undergo surgical management.
A detailed medical history should be obtained by the surgeon to ensure a thorough understanding of the patientโs comorbidities and overall immune status.45 In addition, the skin should be cleaned preoperatively in enlarging concentric circles beginning at the excision site and extending outward beyond the area covered by the sterile drape.46 Bacteremia rates during cutaneous surgery have been documented ranging from 0.7% to 7%, which is similar to spontaneous bacteremia rates in healthy adults.47,48 The American Academy of Dermatology has recently reviewed and published a statement on the use of prophylactic antibiotics in dermatologic surgery, stating that it is unnecessary for cutaneous surgery unless mucosal skin is involved, the operative site is inflamed or infected, or the patient is high risk.49 In these situations, a single dose of antibiotics should be administered 1 hour prior to surgery. Despite proper precautionary measures, wound infections will occur in approximately 2% of cases.50 If this occurs, sutures should be removed and the patient should be started empirically on antibiotics such as a first-generation cephalosporin until culture and sensitivity results from the wound are obtained.46
The risk of postoperative bleeding is generally low for dermatologic surgery. In
order to minimize bleeding complications, all medications and supplements should be disclosed to the surgeon preoperatively.51 Patients taking aspirin are more susceptible to bleeding complications. There have been several published studies regarding the cessation of anticoagulants prior to dermatologic surgery, and in general the risk of postoperative bleeding after dermatologic surgery is much less than the risk of thromboembolic events. Therefore, medically necessary anticoagulants should not be routinely discontinued prior to surgery.52