Postsurgical closure complications limited with patient cooperation

June 1, 2010

Keeping good closures from going bad requires not only thorough patient education and surgical planning by the physician, but also patient adherence to pre- and post-surgical instructions, according to an expert who spoke at the 68th annual meeting of the American Academy of Dermatology.

Key Points

Miami - Keeping good closures from going bad requires not only thorough patient education and surgical planning by the physician, but also patient adherence to pre- and post-surgical instructions, according to an expert who spoke at the 68th annual meeting of the American Academy of Dermatology.

Common surgical complications include bleeding, infection, dehiscence and necrosis, all of which are usually interrelated, says Emily J. Fisher, M.D., chief of cosmetic and laser dermatology, Lahey Clinic, Burlington, Mass. "It's very unlikely to have one of these without a second, third or fourth complication occurring," she says.

Bleeding and infections represent the most common types of postsurgical complications, Dr. Fisher says. "Minor hemorrhagic complications include increased intraoperative bleeding, which can be a challenge. But if you get it under control, it doesn't usually cause long-term problems," she says.

However, intraoperative bleeding also can increase the length of procedures and drive surgeons to choose less-than-optimal closures. "If the patient is having significant bleeding, performing a complicated flap or graft can be challenging and poses an increased risk of bleeding due to the amount of undermining necessary," Dr. Fisher says. "As a result, a surgeon may opt to perform a simpler closure to decrease this risk, but that may not be the best from a cosmetic standpoint.

"More worrisome complications include postoperative bleeding," she says. "That may require flap takedown and additional hemostasis." Often, Dr. Fisher's patients who experience postoperative bleeding will seek treatment at emergency rooms - even though she warns them not to - where ER physicians may make unwise or unnecessary alterations to the flap or graft. Fortunately, she says, although studies show postoperative bleeding is the most common dermatosurgical complication, it only impacts about 2 percent of patients (Cook JL, Perone JB. Arch Dermatol. 2003 Feb;139(2):143-152).

Minimizing hemorrhagic complications begins with thorough preoperative assessments that seek out histories of medical issues such as liver and renal disease, malignancies and hypertension, Dr. Fisher says. "Any history of significant bleeding during other minor procedures may indicate diseases such as von Willebrand disease or another bleeding disorder."

Somewhat similarly, she says patients with histories of heavy drinking may face increased bleeding risk, while vitamin and supplement use also has created worries. Specifically, "Garlic irreversibly inhibits platelet aggregation, which suggests this could have a negative effect on bleeding," Dr. Fisher says. However, in vivo studies in this regard have shown no effect on platelet function.

Similarly, "Ginkgo inhibits platelet activating factor. But research has shown it exerts no impact on platelet aggregation. And the only evidence of ginseng increasing bleeding is limited to a few case reports," she says.

Vitamin E inhibits the vitamin K-dependent coagulation cascade. "In vitro studies show that it inhibits platelet aggregation, but a 2006 in vivo study showed no effect on PT, PTT, INR, bleeding time or platelet aggregation (Dereska NH, McLemore EC, Tessier DJ, et al. J Surg Res. 2006 May;132(1):121-129. Epub 2005 Dec 9)," Dr. Fisher says.

Overall, "Many studies show we probably don't need to worry as much as we do about patients' vitamin and supplement use, but the studies are all relatively small. Considering that these products aren't doing anything significant for patients on a day-to-day basis, it's probably better to avoid them all before surgery," she says.