Dermatologic surgery
Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications

Presented at the 2008 Annual American College of Mohs Surgery, Vancouver, Canada, May 1, 2008.
https://doi.org/10.1016/j.jaad.2011.02.012Get rights and content

Background

Few prospective studies have evaluated the safety of dermatologic surgery.

Objective

We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use.

Methods

Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded.

Results

Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae.

Limitations

The study was limited to one academic dermatology practice.

Conclusion

The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events.

Section snippets

Patients enrolled

Institutional review board approval was obtained March 12, 2006, from the Committee for the Protection of Human Subjects in Research at the University of Massachusetts Medical School. All patients presenting to the University of Massachusetts Medical School Dermatology Clinic (academic group practice) from March 15, 2006, to June 15, 2007, were eligible for the study. Patients undergoing MMS or scalpel-based excisional surgery requiring sutures were included. MMS patients were excluded from the

Descriptive statistics

During the 15-month period, 1911 patients meeting inclusion criteria were included in the study. Of the 1911, 1369 (72%) had undergone MMS, and 542 (28%) underwent surgical excision. The majority (68%) of surgical closures were intermediate-layered, whereas 20% were flaps, grafts, or both (Fig 1). The most common anatomic sites of surgery were the nose (21%), cheek (16%), forehead (15%), and back (8%) (Fig 2). In all, 731 (38%) of patients were on one anticoagulant or antiplatelet medication,

Discussion

The findings of our study are the most generalizable of their kind to date. The surgeons performing the MMS and excisions were two fellowship-trained Mohs surgeons, two MMS fellows, and 4 general dermatologists who perform excisions. Other studies examining complications have included data from surgeries by only one or two physicians, often Mohs surgeons.13, 14 Also, we did not discontinue anticoagulant medications before surgery. Many patients are now continued on these medications because of

Conclusion

Dermatologic surgery in the outpatient setting has very low rates of complications. Hemorrhagic complications are rare, even when anticoagulant and antiplatelet medications are continued. Complex, flap, graft, and partial closure types; warfarin use; and clopidogrel use increase the risk of hemorrhage. Patients taking both warfarin and clopidogrel have an even higher risk of bleeding, and care should be taken when operating on these patients. However, given the risk of thrombotic events, we

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    Funding sources: None.

    Conflicts of interest: None declared.

    Reprints not available from the authors.

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