UCSD School of Medicine: Hugh Greenway’s 28th Annual Superficial Anatomy and Cutaneous Surgery

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

SAN DIEGO – If you perform excisional surgery in your dermatology practice, don’t skimp on instrumentation, advised Dr. David E. Kent.

"Spend your money on instrumentation that’s going to get you out of trouble," Dr. Kent said at the meeting, which was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

His list of recommended instrumentation includes hemostats to clamp and tie off blood vessels, skin hooks to improve visualization, suction to remove excess blood, cotton tip applicators, and 4-by-4-inch gauze. "Be aware that the least expensive gauze may not have the best quality, so you want to evaluate different vendors," said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta.

He also recommends having electrosurgical devices on hand, liquid thrombin, Gelfoam, and oxidized cellulose to place in wounds that are going to heal by second intention. Xenografts, "which can be helpful for temporary hemostasis over a wound with exposed muscle, may serve as a very nice scaffold to seal the wound and are easy to apply," he said.

Applying pressure to the wound after surgery is key, he added. "In all of our patients who are on any aspirin products, after any closure, my nurse holds pressure for 10 minutes. We’ve found that to be very helpful."

Photo courtesy Dr. David E. Kent

He finds the Geiger Thermal Cautery Unit useful for patients who have implantable cardiac defibrillators. "We did a study of this unit years ago and found that a setting between 6 and 7.5 is fairly ideal," Dr. Kent said. "It holds its temperature reasonably well in a wet field, compared with handheld units."

For handheld cautery, he recommends the LMA Perfect Temp device for isolated small pinpoint areas of bleeding. For solid state electrosurgical generators, "there are many manufacturers including Valleylab, Bard Medical, and Aaron Medical, to name a few," he said. "When using electrosurgical devices, it is important to avoid skin edges. This can be done by approaching the bleeding site at 90 degrees to the skin edge to avoid epidermal thermal injury. Use the lowest possible setting to control bleeding."

Another worthwhile instrument to have is a hemostatic scalpel, which provides heat energy to seal vessels and tissue. "It's excellent for skeletal muscle and large defects into muscle," Dr. Kent said. "If you're doing a lot of larger cases, it can really help you avoid excessive bleeding. But they are costly," he said. Used hemostatic scalpels can cost as much as $5,000. Blades cost $10 apiece and are not reusable.

If postoperative bleeding occurs after the patient has gone home, see the patient as soon as possible. "The next day is not soon enough," Dr. Kent said. "Have someone there to help you; make sure you have a nurse on call if you need one." On return, make sure the patient's vital signs are stable. Is the bandage soiled? Is there active bleeding? "Consider removing one or two sutures to see if there is brisk bleeding," Dr. Kent said. "Try to establish if it is a single skin edge or something more. If uncertain, you may need to take the entire closure down, inspect, and control what is bleeding."

Dr. Kent said that he had no relevant financial conflicts to disclose.

SAN DIEGO – If you perform excisional surgery in your dermatology practice, don’t skimp on instrumentation, advised Dr. David E. Kent.

"Spend your money on instrumentation that’s going to get you out of trouble," Dr. Kent said at the meeting, which was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

His list of recommended instrumentation includes hemostats to clamp and tie off blood vessels, skin hooks to improve visualization, suction to remove excess blood, cotton tip applicators, and 4-by-4-inch gauze. "Be aware that the least expensive gauze may not have the best quality, so you want to evaluate different vendors," said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta.

He also recommends having electrosurgical devices on hand, liquid thrombin, Gelfoam, and oxidized cellulose to place in wounds that are going to heal by second intention. Xenografts, "which can be helpful for temporary hemostasis over a wound with exposed muscle, may serve as a very nice scaffold to seal the wound and are easy to apply," he said.

Applying pressure to the wound after surgery is key, he added. "In all of our patients who are on any aspirin products, after any closure, my nurse holds pressure for 10 minutes. We’ve found that to be very helpful."

Photo courtesy Dr. David E. Kent

He finds the Geiger Thermal Cautery Unit useful for patients who have implantable cardiac defibrillators. "We did a study of this unit years ago and found that a setting between 6 and 7.5 is fairly ideal," Dr. Kent said. "It holds its temperature reasonably well in a wet field, compared with handheld units."

For handheld cautery, he recommends the LMA Perfect Temp device for isolated small pinpoint areas of bleeding. For solid state electrosurgical generators, "there are many manufacturers including Valleylab, Bard Medical, and Aaron Medical, to name a few," he said. "When using electrosurgical devices, it is important to avoid skin edges. This can be done by approaching the bleeding site at 90 degrees to the skin edge to avoid epidermal thermal injury. Use the lowest possible setting to control bleeding."

Another worthwhile instrument to have is a hemostatic scalpel, which provides heat energy to seal vessels and tissue. "It's excellent for skeletal muscle and large defects into muscle," Dr. Kent said. "If you're doing a lot of larger cases, it can really help you avoid excessive bleeding. But they are costly," he said. Used hemostatic scalpels can cost as much as $5,000. Blades cost $10 apiece and are not reusable.

If postoperative bleeding occurs after the patient has gone home, see the patient as soon as possible. "The next day is not soon enough," Dr. Kent said. "Have someone there to help you; make sure you have a nurse on call if you need one." On return, make sure the patient's vital signs are stable. Is the bandage soiled? Is there active bleeding? "Consider removing one or two sutures to see if there is brisk bleeding," Dr. Kent said. "Try to establish if it is a single skin edge or something more. If uncertain, you may need to take the entire closure down, inspect, and control what is bleeding."

Dr. Kent said that he had no relevant financial conflicts to disclose.

SAN DIEGO – If you perform excisional surgery in your dermatology practice, don’t skimp on instrumentation, advised Dr. David E. Kent.

"Spend your money on instrumentation that’s going to get you out of trouble," Dr. Kent said at the meeting, which was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

His list of recommended instrumentation includes hemostats to clamp and tie off blood vessels, skin hooks to improve visualization, suction to remove excess blood, cotton tip applicators, and 4-by-4-inch gauze. "Be aware that the least expensive gauze may not have the best quality, so you want to evaluate different vendors," said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta.

He also recommends having electrosurgical devices on hand, liquid thrombin, Gelfoam, and oxidized cellulose to place in wounds that are going to heal by second intention. Xenografts, "which can be helpful for temporary hemostasis over a wound with exposed muscle, may serve as a very nice scaffold to seal the wound and are easy to apply," he said.

Applying pressure to the wound after surgery is key, he added. "In all of our patients who are on any aspirin products, after any closure, my nurse holds pressure for 10 minutes. We’ve found that to be very helpful."

Photo courtesy Dr. David E. Kent

He finds the Geiger Thermal Cautery Unit useful for patients who have implantable cardiac defibrillators. "We did a study of this unit years ago and found that a setting between 6 and 7.5 is fairly ideal," Dr. Kent said. "It holds its temperature reasonably well in a wet field, compared with handheld units."

For handheld cautery, he recommends the LMA Perfect Temp device for isolated small pinpoint areas of bleeding. For solid state electrosurgical generators, "there are many manufacturers including Valleylab, Bard Medical, and Aaron Medical, to name a few," he said. "When using electrosurgical devices, it is important to avoid skin edges. This can be done by approaching the bleeding site at 90 degrees to the skin edge to avoid epidermal thermal injury. Use the lowest possible setting to control bleeding."

Another worthwhile instrument to have is a hemostatic scalpel, which provides heat energy to seal vessels and tissue. "It's excellent for skeletal muscle and large defects into muscle," Dr. Kent said. "If you're doing a lot of larger cases, it can really help you avoid excessive bleeding. But they are costly," he said. Used hemostatic scalpels can cost as much as $5,000. Blades cost $10 apiece and are not reusable.

If postoperative bleeding occurs after the patient has gone home, see the patient as soon as possible. "The next day is not soon enough," Dr. Kent said. "Have someone there to help you; make sure you have a nurse on call if you need one." On return, make sure the patient's vital signs are stable. Is the bandage soiled? Is there active bleeding? "Consider removing one or two sutures to see if there is brisk bleeding," Dr. Kent said. "Try to establish if it is a single skin edge or something more. If uncertain, you may need to take the entire closure down, inspect, and control what is bleeding."

Dr. Kent said that he had no relevant financial conflicts to disclose.