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Newer hemostatic agents used in the practice of dermatologic surgery.

1. Introduction

Dermatologists are estimated to perform over 3.9 million procedures each year [1]. Although the risks and complications of dermatologic surgery are generally very low, even the most talented surgeon can experience complications related to hemostasis during both the intraoperative and postoperative periods. Minor bleeding complications are the most frequently encountered complications of cutaneous surgery, which can predispose the patient to hematoma formation, increased risk of infection, skin graft necrosis, and wound dehiscence. This chapter will highlight proper hemostasis technique to prevent complications.

2. Overview of Hemostasis

By understanding the mechanism behind the physiologic clotting system, it is easier to understand how the different hemostatic agents work in the body. The body's primary response to injury is reflex vasoconstriction of the blood vessels in the surrounding tissues, followed by formation of the platelet plug and activation of the fibrinolytic clotting cascade. There are two separate pathways of the fibrinolytic clotting system, that lead to the final common pathway and formation of the insoluble fibrin clot. Function of the body's hemostatic system can be monitored by various laboratory tests. These tests can be helpful to assess the degree of anticoagulation in patients on antiplatelet and anticoagulant medications or who have inherited coagulopathies before proceeding with dermatologic procedures (see Table 1).

3. Preoperative Evaluation

One of the most important steps that the dermatologist can take to prevent bleeding complications is to gain a thorough preoperative history of the patient before performing any kind of dermatologic procedure. This allows the physician to gain a better understanding of the patient's overall health and should include a detailed history of the patients comorbidities, prior surgeries including complications, current medications, social history, and family history, which can help reveal any potential bleeding diatheses.

Specifically, questions regarding comorbid illnesses that can lead to coagulopathies, such as chronic renal and liver disease, hematologic disorders, and malignancies, should be asked, in addition to prior diagnoses of inherited bleeding disorders such as von Willebrand's disease and hemophilia [7]. Many mild forms of bleeding disorders go undiagnosed until later in life and should be investigated by thorough questioning of bleeding complications in prior minor surgical procedures (dental/oral surgery), prolonged episodes of epistaxis, menorrhagia, bruising, history of prior blood transfusions, and any family history of bleeding disorders. On physical exam, it is important to look for any indications of hemostatic abnormalities such as increased bruising or petechiae. For more details on how to manage a patient with a bleeding disorder, please see the section titled, "Approach to the Patient with a Bleeding Disorder." It is also important to investigate the patient's cardiac history including the presence of a pacemaker or implantable cardiac defibrillator (estimated that 4% of Mohs patients are estimated to have one), because the use of certain electrosurgical agents used for hemostatic purposes may be prohibited in these patients [8]. Also, alcohol is a natural anticoagulant, and obtaining information regarding consumption could be beneficial as part of the preoperative evaluation.

4. Pharmacologic Agents and Their Effects on Anticoagulation

Many patients that are going to have dermatologic surgery are on anticoagulant and antiplatelet medications. One question many healthcare providers face prior to cutaneous surgery is whether to continue anticoagulation medications prior to surgery. The discrepancy lies between keeping the patient on their current medication regimen, potentially increasing the patient's risk for bleeding complications during the perioperative period, or discontinuing their medication, which has now been proven to increase the patient's risk of life-threatening thromboembolic events during the postoperative period. For a list of some of the most widely used anticoagulant and antiplatelet medications today, including pharmacodynamics of the different medications, and various recommendations regarding usage during the perioperative period see Table 2.

Due to several clinical studies conducted in the past ten years, the general consensus between dermatologic surgeons has been to continue patients on their anticoagulant medications preoperatively, because the benefit of these medications significantly outweighs the risk of bleeding complications during or after procedure [1, 9, 12-18]. The overall risk of hemorrhagic complications in cutaneous surgeries, such as continuous bleeding or hematoma formation in a patient who is not on anticoagulant medications, is very low (1.4%) [18].

In a 2005 nationwide survey of Mohs surgeons, 66% were found to continue Warfarin during the perioperative period [19]. Some studies have shown that there is an increase in minor bleeding complications for patients taking Warfarin chronically, which includes: minor bleeding defined as bleeding less than 24 hours postoperatively, hematoma formation, bleeding that is controlled in the office setting, and bleeding controlled with manual compression [1, 20]. For patients taking Warfarin, checking the international normalized ratio (INR) within 48 hours to one week prior to the surgery can give the surgeon a better idea of the current magnitude of anticoagulation. It is generally recommended that the INR level be within the therapeutic range of 2-3.5 preoperatively [21]. There is a suggestion that the higher the INR level (especially >3.5), the higher the risk for hemorrhagic complications [15]. Because minor bleeding can be psychologically disturbing, an elevated INR level above the therapeutic range can be an indication for postponing the procedure depending on the urgency of the surgery.

In comparison to Warfarin, the 2005 survey of Mohs surgeons found that a majority of surgeons (87%) discontinue prophylactic (not medically necessary) aspirin use 7-10 days prior to surgery, with a majority (77%) continuing medically necessary aspirin [19]. There is a consensus that the benefits of continuing medically necessary aspirin outweigh the risk of discontinuation. Patients taking another antiplatelet agent, Clopidogrel, have been found to be at increased risk of bleeding complications during cutaneous surgery. In a recent study conducted at Mayo Clinic, patients were found to be twenty eight times more likely to have a severe complication (defined as bleeding for <1 hour, bleeding not stopped with pressure, acute hematoma formation, flap or graft necrosis, or wound dehiscence >2 mm) with Clopidogrel use during surgery [13]. Patients were also found to be eight times more likely to experience a severe complication when taking Clopidogrel in combination with aspirin than aspirin monotherapy [13]. Although anatomical site has been speculated as a possible risk factor for postoperative bleeding complications, it appears that flaps and grafts are the biggest associated risk [13]. There have been reports in the literature of patients on anticoagulation medications who unfortunately developed either a thromboembolic stroke or acute myocardial infraction after stopping their anticoagulation medications to undergo cutaneous surgery [17]. Thus it is the current consensus of dermatologic surgeons in the United States, and the opinion of the authors, no matter what the increased risk of a postoperative bleeding complication might be whether influenced by anatomic site or anticoagulation, that these anticoagulation medications should not be stopped prior to cutaneous surgery regardless of the anatomic site or anticipated complicated nature of the cutaneous surgery. Although bleeding risk has been found to be significantly increased in these patients, continuation of the medication during surgery is still recommended due to the increased risk of life-threatening thromboembolic events that can accompany the discontinuation of these medications.

Many patients are not just on one type of anticoagulation or antiplatelet agent but a combination. Certain combinations of anticoagulation medications, especially with Clopidogrel, have been shown to have a more profound effect on bleeding complications. Distinctly, the combination of Warfarin and Clopidogrel is 40 times more likely to lead to increased perioperative and postoperative bleeding complications, including hematoma formation in comparison to other anticoagulant agents [1]. Patients with recent drug eluding stent placement are advised to remain on dual antiplatelet therapy with Clopidogrel and aspirin for six months to one year and are highly advised to continue both of these medications in the perioperative period due to high risk of stent restenosis [22, 23].

Although most studies support continuation of anticoagulant medications perioperatively, a 2005 survey of 271 Mohs surgeons found that 37% still discontinued medically necessary aspirin and 44% still discontinued Warfarin [19]. Discontinuation of these medications can lead to life-threatening thromboembolic events such as deep venous thromboses, pulmonary embolism, myocardial infarctions, cerebrovascular accidents, cardiac stent thrombosis, or clotted prosthetic heart valves [17, 23]. Alam and Goldberg presented two cases that led to pulmonary embolus and a clotted prosthetic heart valve within 36 hours after operative cutaneous surgery due to the patients' antiplatelet and anticoagulant medications being discontinued [17]. It appears that prophylactic aspirin use can be discontinued 7-10 days prior to the procedure without significant risk of thrombotic events.

5. Alternative Medicine and Herbal Supplements

According to the 2007 National Health Interview Survey, 4 out of 10 adults in the United States were found to have used some form of complementary alternative medicine during the past year. It has been shown that up to 70% of people do not tell their physicians that they are taking a herbal supplement [24]. Many popular alternative supplements contain a dietary ingredient, such as garlic, ginkgo biloba, feverfew, ginseng, and ginger [25]. Although it has become increasingly common for patients to be using alternative therapies such as those mentioned above, they are unlikely to volunteer this information to their physician [26]. Along with western pharmacotherapy, alternative therapies can have dose-related antiplatelet side effects especially in combination with other anticoagulant/antiplatelet pharmacologic agents (see Table 3).

6. Approach to the Patient with a Bleeding Disorder

Whether discovered upon taking a thorough preoperative history or a previously diagnosed condition, knowledge of an inherited or acquired bleeding disorder is of great importance before proceeding with dermatologic surgery. This section discusses how to approach patients with acquired disorders of coagulation due to chronic illnesses such as uremia secondary to chronic renal failure, severe liver cirrhosis, and the most commonly encountered hereditary bleeding disorders such as von Willebrand's disease and hemophilia A/B.

The rates of chronic illnesses such as chronic renal failure are on the rise in the United States, with an increase in population longevity and chronic debilitating illnesses such as hypertension and type II diabetes mellitus. Uremia secondary to chronic renal failure causes a qualitative platelet defect that can lead to a bleeding diathesis and can be monitored by checking a bleeding time or PFA-100. Knowledge of this condition can help prevent bleeding complications, and by working in conjunction with the patient's nephrologist, the platelet defects can often be improved with hemodialysis or desmopressin prior to the procedure [31]. Desmopressin improves platelet defects, providing improvement of the bleeding time for up to 24 hours [32]. Severe liver cirrhosis can also cause a coagulopathy, leading to increased risk for bleeding complications. Liver damage decreases production of the clotting factors decreasing the body's ability to form a fibrin clot, and many patients will exhibit concurrent portal hypertension causing splenic sequestration of platelets and thrombocytopenia. The patient's risk for bleeding can be monitored preoperatively by the PT, aPTT, platelet count, and bleeding time. The patient's gastroenterologist should be consulted prior to the operation, and administration of recombinant tissue factor Vila, fresh frozen plasma, or prothrombin complex concentrates may need to be given pre/postoperatively to help manage bleeding [33].

Although relatively rare in general, von Willebrand's disease is the most common inherited bleeding disorder affecting up to 1% of the population [34]. With the proper management of these conditions both pre- and postoperatively in collaboration with the patient's hematologist, the patient's risk for bleeding complications decreases substantially. The severity of the inherited defect (amount of clotting factor absent) corresponds to the amount of preoperative preparation needed. For minor surgeries, such as dermatologic surgery, it is generally recommended that coagulation factor levels approach 40-50% of normal serum levels before proceeding with the operation, with continued factor replacement 5-7 days postoperatively [34].

Although von Willebrand's disease comprises up to 1% of the population, significant bleeding has been shown to occur in only 10% of the affected patients [34]. Desmopressin is commonly given to patients with this disease preoperatively to help increase release of vWF from the endothelial cells [34]. Severely affected patients also exhibit decreased Factor VIII levels (20%) and can be given Factor VIII concentrates pre/postoperatively [34]. Hemophilia A is more common than hemophilia B, and this is due to a decrease or absence of Factor VIII (Hemophilia B has decreased Factor IX) and is most often discovered in childhood due to greater risk for developing deeper hemorrhages such as: hemarthroses, CNS bleeds, hematomas, or hematuria [31]. In conjunction with the patient's hematologist, factor VIII and IX concentrates can be given to the patient preoperatively and should be continued for up to 5-7 days postoperatively [34]. Hematoma formation is the most common complication for hemophiliacs, even with factor replacement, so patients should be monitored closely during the postoperative period (see Table 4).

The importance of the preoperative history and physical exam cannot be underestimated. If there is any suspicion by the surgeon that a bleeding diathesis is present, the patient should undergo further laboratory testing to assess coagulation status.

7. Introduction to Hemostatic Agents

There are many different hemostatic modalities that can be implemented during surgical procedures. The specific types of modalities used depend upon the surgeon's preference, the efficacy and ease of use of the products, expense, and the bleeding risks of the particular patient at hand. The next few sections explore the various hemostatic techniques used today to provide optimal outcomes for the patient.

8. Anesthetic Techniques Promoting Hemostasis

The anesthetic agent chosen for the operation can provide hemostatic benefits to the patient when applicable. Anesthetic agents can lead to vasodilation of blood vessels increasing blood loss. Thus, the addition of a vasoconstrictive agent such as epinephrine or norepinephrine can improve intraoperative hemostasis. Not only do vasoconstrictive agents decrease bleeding, but they also increase the duration of action of the anesthetics, leading to decreased anesthetics required and prolonged anesthetic effect after procedure. Premixed concentrations of epinephrine in 1:100, 000 or 1:200, 000 are generally considered safe and effective [10]. Caution should be taken in pregnant and breastfeeding patients because epinephrine is considered Category C and can be secreted in breast milk [10]. Epinephrine infused anesthetic agents should also be used cautiously in patients who have vascular compromise or who take beta blockers. In patients on beta blockers, epinephrine leads to unopposed alpha:-receptor stimulation which can lead to life-threatening increases in blood pressure [11]. Epinephrine is absolutely contraindicated in patients with severe cardiovascular disease, severe hypertension, pheochromocytoma, or severe hyperthyroidism [10]. In the past, it was generally recommended that epinephrine be avoided in procedures involving the nose, ear lobes, fingers, toes, or genitals, including the penis, but recent studies have shown that certain concentrations of anesthetic with epinephrine (0.5% lidocaine with 1 : 200, 000 epinephrine for example) show no evidence ofischemia or necrosis when injected into the digits [35]. Caution, however, should be used when operating on these special sites in patients with peripheral vascular disease and compromised circulation.

Another anesthetic technique that provides excellent hemostasis is tumescent anesthesia. This technique is often used in liposuction surgery or in areas of the body associated with increased risk for bleeding. The technique is accomplished by injecting extremely dilute concentrations of lidocaine (0.1%) and epinephrine (1 : 1, 000, 000) subcutaneously into the tissues providing anesthesia to the superficial and deeper tissues while vasoconstricting the surrounding blood vessels [10, 36]. Dr. Jeffrey Klein, the innovator of the tumescent anesthesia technique, created the original formula, adding 1, 000 mg of lidocaine and 1 amp of 1 : 1, 000 epinephrine to one liter of normal saline, creating the concentration of 0.1% lidocaine with 1 : 1, 000, 000 epinephrine [10]. The large amount of fluid injected leads to swelling and induration ofthe tissues, placing pressure on the surrounding nerves and vascular structures, providing anesthetic and hemostatic effects on the tissue [36, 38]. For full hemostatic effect, the surgeon should wait 20-30 minutes after tumescent anesthesia is started before beginning with the procedure; however most of the time, the anesthetic effect of tumescence anesthesia is almost instantaneous, especially when it involves the superficial layers of the skin [10]. This technique provides prolonged anesthesia to the patient post-procedurally for up to 48 hours [37].

9. Electrosurgery

Electrosurgery is by far the most common hemostatic technique used in cutaneous surgery due to its accessibility, multi-functionality, ease of use, low expense, and effectiveness. There are different types of electrosurgical units depending on the surgeon's desired use of the product. The electrosurgical unit can be monoterminal or biterminal depending on the number of electrodes. The biterminal electrosurgical unit works by producing a high frequency, low voltage electrical current that is transmitted from an electrosurgical generator through an active electrode to the patient's tissues, and then back to the generator through a return electrode [10, 39]. The electrical current can be transmitted through the active electrode to the skin through one tissue contact point (monopolar) or through two tissue contact points (bipolar). An example of bipolar electrocoagulation would be the use of tissue forceps. Some studies suggest that the use of bipolar electrocoagulation produces less surrounding tissue damage, due to the ability of the forceps to grasp the specific hemorrhagic vessel providing hemostasis to a localized area [40]. The waveforms that are transmitted to the tissues can be categorized as damped or undamped. Damped waveforms provide the best hemostasis by generating heat to the tissues, leading to sealing of blood vessels; however these techniques can be more destructive [8].

The most common types of electrosurgery used by dermatologic surgeons are electrodesiccation, electrosection, electrocoagulation, and electrocautery [8]. A unit such as the Bovie, capable of conducting electrosection and electrocoagulation, provides the physician the ability to cut through the tissues and simultaneously provide hemostasis in a biterminal fashion. The unit produces high amplitude, low voltage currents that can be damped or undamped depending on the desire to cut or provide coagulation. Electrocoagulation produces damped waveforms providing excellent hemostasis, while electrosection produces mainly undamped waveforms that slice through tissue layers [8]. Because these methods generate an electrical current, they can alter implantable cardioverter defibrillators and pacemakers, potentially producing premature firing of the devices, generating arrhythmias, or causing asystole. A method called electrocautery can be used in this select group of patients, because it works by generating heat from a high resistance wire instead of producing electricity [8]. Less heat can be generated in areas of increased blood flow; therefore, electrocautery is generally only used for hemostasis of small cutaneous vessels. Pooling of blood in areas of increased blood flow not only hinders the visualization of the specific bleeding vessels to be cauterized but also decreases the effectiveness of the cauterization by decreasing the conduction of electrical current to the tissues. This problem can be prevented by dabbing the site with gauze or a cotton tipped applicator followed by quick cauterization.

Electrosurgery can produce thermal damage to the surrounding healthy tissues during the procedure [41]. Excess charring of the tissues can lead to decreased wound healing and slower recovery of the tissues postoperatively. This side-effect can be prevented by using the lowest power setting for the shortest amount of time during electrocoagulation or by touching a hemostat with the tip of a monopolar unit to produce pin-point coagulation (see Figure 1). Another potentially worrisome complication of electrosurgery is the risk of fire and electrical shock. This can be prevented by ensuring that the surgical area is not prepped with ethanol based products and through the use of insulated disposable tips on the electrosurgical device [10]. 35% aluminum chloride, a popular topical hemostatic agent used for shave biopsies, should not be used in conjunction with electrosurgery as well, because of the risk of fire. Also, the active electrode transmitting the electrical current to the tissue has an insulated shaft and base preventing electrical shock to the patient and surgeon [39]. It is important to keep in mind when removing lesions caused by human papillomavirus and other viral pathogens in the skin or when operating on patients who are suffering from a concomitant viral illness such as HIV or hepatitis, that these infections have the potential to be transmitted through the smoke plume [42]. Because of this, proper protection is warranted such as protective eye wear, masks, and gloves along with a smoke evacuator, and it is generally recommended that the smoke evacuator be held within 2 cm of the area being cauterized [42].

10. Physical Hemostatic Techniques

Among the cheapest and most accessible of all the hemostatic modalities is that of manual compression. This is by far one of the most basic techniques and has been used throughout history to stop bleeding and enhance coagulation. Downward pressure should be applied firmly to the affected area for 1520 minutes depending on the extent of bleeding to tamponade the vessel(s). If the bleeding is severe, applying pressure to the supplying artery further upstream in addition to the wound area can help decrease blood flow to the affected area. This pressure applied allows time for platelets to adhere and initiation of the clotting cascade, as well as time to gather additional hemostatic agents to aid in the process. Sterile gauze pads and cotton tipped applicators can facilitate the process by soaking up the excess blood allowing better visualization of the surgical field and by providing counter pressure to aid in hemostasis. Cotton tipped applicators, (applicators with 8-inch handles and oversized cotton tips), are often used in nasal procedures, providing counterforce to the surgical field when entered in the nares for providing stabilization and hemostasis to the tissues [43]. Surgical instruments, chalazion clamp, can also provide hemostasis by manually compressing tissue during surgery [44, 45].

Tourniquets have also been used to decrease blood flow to the procedural area. An example is a digital tourniquet made out of a single finger of a surgical glove. A small hole is pierced at the end of the finger of the glove, and the glove is rolled down the patient's digit, causing exsanguination. This digital tourniquet is then rolled tightly to the base of the metacarpophalangeal joint and stabilized with a hemostat that clamps and tightens the tourniquet [46] (see Figure 2).

Another physical method providing hemostasis for smaller wounds with minimal tension is through the use of acrylates. Octyl-2-cyanoacrylate (Dermabond) is a liquid that acts by polymerization to create a barrier, reaching its full strength in 2.5 minutes [47, 48]. This adhesive is approved for skin closure and is especially beneficial in children and patients with cognitive deficits who may not tolerate suturing or the removal of nonabsorbant sutures. Studies have shown other benefits with acrylates, including lower rates of bacterial contamination [47]. An animal study conducted in 2001 also showed earlier re-epithelization as well as decreased irritation with the use of Dermabond [49]. Another study showed that compared to using an adhesive bandage, acrylates provided significant hemostasis and pain relief. Band-Aid Liquid Bandage, an acrylate available over the counter, is a less expensive, more accessible option [48] (see Figure 3).

11. Suturing Techniques

When performing punch biopsies and excisions of cutaneous lesions, preliminary sutures can be placed to decrease the hemorrhagic propensity of the procedure. One example is placing horizontal mattress sutures under the desired area prior to performing a punch biopsy. This can be very effective in areas that have an increased tendency to bleed such as the scalp [50].

Another suturing technique that can be particularly useful for larger defects and removal of non-melanoma skin cancers is the purse-string technique [51]. This suture applies tension to the wound edge and compresses vessels in the reticular and papillary dermis decreasing bleeding complications [51].

When bleeding from larger vessels (>2mm) and cannot be controlled with manual compression or electrocoagulation, the vessels can be ligated or clamped with a hemostat. A figure-of-eight is most commonly placed around the vessel to tamponade the bleeding.

12. Caustic Hemostatic Agents

This category of topical hemostatic agents is used with less frequency in dermatologic procedures today due to the corrosive effects that the agents have on the surrounding tissues. Caustic agents cause hemostasis by precipitating proteins in the tissues, causing occlusion of smaller vessels [48, 52]. One of the oldest topical hemostatic agents known as "Mohs paste" was created by Frederic Mohs in 1941 [53]. Zinc chloride is the main component of the paste, and it can be applied with a tongue depressor, cotton tipped applicator, or incorporated into gauze (product sold as Z-squares) [48]. Studies have shown that Moh's paste has been successful in providing hemostasis to friable tissues such as breast carcinomas that are metastatic to the skin [53].

Another topical agent that is still used in dermatologic and gynecologic procedures, but with decreased frequency, is Monsel's solution, which is composed of 20% ferric subsulfate [48]. Monsel's solution has an acidic pH which is thought to contribute to its hemostatic properties eliciting protein precipitation in vessels and oxidization [51]. Monsel's solution is effective after punch or shave biopsies but is used less frequently due to its tattooing effect on the skin. Upon application, iron particles deposit into the dermis, leading to hyperpigmentation of the surrounding skin and an increased inflammatory response [48, 54]. The solution is user friendly and can be applied with gauze or cotton tipped applicators to the desired area and is relatively inexpensive. Less hyperpigmentation and tattooing of the skin occur with a 10% ferrous sulfate solution when applied to the skin for 12 hours postoperatively [48]. Another caustic agent that has a better side-effect profile than others is aluminum chloride. This solution can be applied with a cotton-tipped applicator after shave biopsies and has been shown to be very effective [48].

13. Noncaustic Hemostatic Agents

This group of hemostatic agents can be a helpful addition to electrocoagulation, minimizing the amount of electrocoagulation needed during the procedure. These are beneficial alternatives to patients with a bleeding diathesis despite use of electrocoagulation and decrease thermal injury to the surrounding tissues. This section is going to focus on various subsets of noncaustic hemostatic agents. A majority of these agents enhance the patient's own clotting system, so if the patient has a hereditary or acquired deficiency in the clotting cascade, these agents are unlikely to be beneficial (see Table 5).

Physical noncaustic agents work to provide a structural meshwork that aids in platelet aggregation and coagulation [48, 52]. An example of a physical agent is the gelatin sponge. Gelatin sponges have been used for hemostasis after punch biopsies of the skin and may be more effective in areas such as cartilage or periosteum, which have a harder time forming granulation tissue [48]. One study showed that wounds treated with gelatin sponges and left to heal by secondary intention led to increased granulation tissue formation and an overall better appearance of the wound [55]. Absorbable gelatin sponges soaked in aluminum chloride have also been shown to provide quick hemostasis after nail punch biopsies when left in the wound for two weeks [56]. Another physical agent, polyethylene glycol hydrogel, is a synthetic, biodegradable hemostat that polymerizes quickly, providing hemostasis in less than 60 seconds. Caution should be taken with closed wounds because it can swell up to four times its own size, potentially leading to surrounding tissue damage [57, 58]. Another physical agent, collagen, has been shown to be a superior hemostat to other products, because not only platelets adhere more readily to the collagen matrix, but also they are stimulated to degranulate enhancing platelet aggregation [57]. This product is less effective in patients with thrombocytopenia [58]. The product is bovine derived, with the potential to cause allergic and foreign body reactions. Other hemostatic agents containing oxidized cellulose (Surgicel or Oxycel), arranged into sheets or gauze, can be durably placed into bleeding tissues, causing hemostasis by tamponading vessels and by providing a physical meshworkfor the clotting cascade to occur [48, 51]. Although relatively inexpensive and easy to use, they can potentially cause granulomatous reactions and increased swelling tissues [48, 60]. Two more physical agents, Urgent QR powder and microporous polysaccharide hemispheres, can be sprinkled topically on wounds to enhance hemostasis. Urgent QR powder is a hydrophilic polymer combined with potassium salt, used only on wounds left open to heal by secondary intention, because of the body's inability to metabolize the substance [52]. It hemostatically forms an eschar in the body in less than a minute, due to the polymers dehydrating the blood and the potassium salt binding to the positively charged red blood cells [48, 52]. It is sold over the counter and is less expensive than some of the other hemostatic agents [52]. Another physical agent, composed of purified potato starch powder, is microporous polysaccharide hemispheres. This agent can be degraded by enzymes in the body (alpha-amylase and pyrase), allowing use in closed wounds [52]. It accelerates the clotting process, by dehydrating the blood, causing concentration of the platelets and clotting factors [52, 58, 59]. This product can be sprinkled topically as a powder or incorporated into wound dressings. This agent has been shown to be less hemostatically effective and more expensive than electrocoagulation but is a good alternative in individuals that have contraindication to electrocoagulation [59]. This product should be used cautiously in diabetics, because it has the potential to increase glucose loads 58].

Physiologic agents are other hemostatic agents, which potentiate the body's own physiologic clotting mechanisms. For example, thrombin products have been created to enhance the fibrinolytic cascade and the final conversion of fibrinogen into fibrin. Topical bovine thrombin and human recombinant thrombin have been shown to be effective hemostatic agents in areas where there is diffuse bleeding (the specific vessel cannot be identified) and from direct bleeding from bone [61]. Studies have shown an increased risk for postoperative coagulopathies with bovine-derived thrombin, because antibodies formed against the thrombin are cross-reactive against human factor V [48, 57, 61]. Human recombinant thrombin has less antigenic effects, decreasing the risk for developing a postoperative coagulopathy, but carries a small risk for viral transmission to the patient [48, 57, 58, 61].

Another class of hemostatic agents gaining in popularity is the fibrin sealants. Whereas other products may rely on the patient's own platelet and clotting factors for hemostatic activation, fibrin sealants do not. This may be beneficial in situations where the patient has an inherited or acquired coagulation abnormality [62]. In order to be activated, the two compartments full of thrombin and fibrinogen must be mixed together (which can lead to clotting, if mixed prematurely) [48, 62]. When combined, thrombin (from one compartment) converts fibrinogen (from the other compartment) into insoluble fibrin in the presence of calcium [5, 48]. The amount of thrombin contained in the fibrin sealant is thought to contribute to the rapidity of clot formation, whereas the amount of fibrinogen contributes to the mechanical strength of the clot [58]. A 2009 Cochrane review showed that fibrin sealants lead to an average reduction of blood loss of 161 mL per procedure and argued that the benefits of using the product must outweigh the potential side effects of its use [5]. Potential side effects of fibrin sealants are infectious disease transmission, hypersensitivity reactions, and neurotoxicity [5, 48]. The newest fibrin sealant, Evicel, is human derived and does not contain tranexamic acid, decreasing the risk for neurotoxicity with use [58]. Newer fibrin sealant formulations are derived from autologous plasma or from pooled plasma donors, leading to decreased hypersensitivity reactions with the autologous sealants [5, 58].

The authors recommend intraoperative hemostasis that is done with precision via electrosurgery as the mainstay of hemostasis in routine cutaneous surgeries. For smaller biopsies, where electrosurgery is not necessary, aluminum chloride is cheap and easily accessible and should also be considered as a mainstay. For postoperative bleeding complications, the other measures discussed in this section can be considered if physical hemostatic techniques (manual pressure) are inadequate.

14. Postoperative Recommendations and Complications

Patients that have increased intraoperative bleeding are at greater risk for postoperative bleeding complications, with complications most likely to occur within the first 48 hours following the procedure [10, 63]. A pressure dressing should be applied to the operative area for at least 24 hours postoperatively to ensure adequate compression of the tissues. The typical wound dressing normally consists of a topical antibiotic ointment, a Telfa pad cut to conform to the operative area, and a layer of gauze secured and compressed to the skin by adhesive tape [64]. It is generally recommended that patients avoid minor activity during the first 24 hours, allowing the vessels to remain coagulated, and to keep the wound site elevated for edema prevention. For procedures of the face, scalp, or neck, placing pillows underneath the head and neck areas while lying down can help to alleviate pressure and edema. Strenuous activity and heavy lifting should remain limited during the first month following the operation because the wound has only 40-50% of its tensile strength [64]. It is important to discuss with the patient that mild bleeding is anticipated, and if the patient starts to exhibit signs of increased bleeding, pressure and ice should be applied to the wound dressing for up to 20 minutes [63, 64]. Also, if the patient's wound dressing appears saturated with blood, it should be removed and a clean dressing should be applied to allow for better absorption and compression of the tissues. If the patient continues to have increased bleeding, the patient should return to the office for reevaluation. Alcohol ingestion is generally not recommended during the first week postoperatively due to ethanol's vasodilatory effects on the blood vessels leading to increased risk for bleeding (see Table 6).

Hematomas are most likely to occur within the first 24-72 hours postoperatively and can present with increased pressure sensation, throbbing pain, ecchymosis, and fluctuation of the tissues [10, 63]. Hematomas can form slowly due to continuous bleeding of smaller blood vessels into the newly closed wound or can expand rapidly when involving larger vessels.

Early recognition of a rapidly expanding hematoma is important. Usually a hematoma is easily evaluated and diagnosed clinically as an expansile fluctuant mass under a recent surgical site that is accompanied by the characteristic expansile ecchymosis on the skin surface. If a hematoma is suspected clinically, the wound should be reopened and the affected vessels should be localized and treated with suture ligation or electrocoagulation. If bleeding continues despite prior attempts at coagulation, a drain can be placed in addition to other topical hemostatic agents [7, 10]. The drain should not be left for more than 24 hours, because of an increased risk for infection if left longer [65]. When hemostasis is achieved, all of the layers of the wound should be resutured closed and a clean pressure dressing should be reapplied.

Hematomas become increasingly gelatinous and firm over time with the formation of clots. Patients who delay seeking treatment during the first week or who develop a hematoma very gradually can undergo observation or have their wound evacuated and left open to heal by secondary intention [63]. Weeks to months later, hematomas undergo liquefactive necrosis and resorption. During this stage, the hematoma can be aspirated and drained with a 16-18 gauge needle [63, 65]. Because hematomas are a nidus for bacteria, prophylactic antibiotics should be given early for infection prevention [7, 10]. If rapidly expanding hematomas are not controlled, they can lead to further complications such as wound dehiscence and skin graft necrosis (see Table 7 and Figure 4).

15. Summary

Hemostasis is an important concept to consider when performing dermatologic surgery. With careful attention paid to the preoperative evaluation, the patient's comorbidities and risk factors for bleeding, proper intraoperative hemostasis technique, and postprocedure monitoring, wound care, and education, many bleeding complications can be avoided or attended to promptly and effectively. During the procedure, many different hemostatic modalities are available, with electrocoagulation being among the most effective and commonly used. Many other methods of hemostasis can be used in conjunction with electrocoagulation with the optimal goal of minimizing blood loss. Postoperative complications due to increased bleeding include hematoma formation, skin or flap necrosis, and graft necrosis. Early evaluation of hematoma formation can help prevent the development of further complications such as infection, wound dehiscence, and skin graft necrosis.

Conflict of Interests

The authors have no conflict of interests.


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Jill Henley (1) and Jerry D. Brewer (2)

(1) College of Osteopathic Medicine Glendale, Midwestern University, 13989 N59th Avenue, Glendale, AZ 85308, USA

(2) Division of Dermatologic Surgery, Department of Dermatology Mayo Clinic, Mayo Clinic College of Medicine Rochester, 200 First Street SW, Rochester, MN 55905, USA

Correspondence should be addressed to Jerry D. Brewer;

Received 7 June 2013; Accepted 7 July 2013

Academic Editor: Giuseppe Argenziano

TABLE 1: Overview of hemostasis.

Stages of hemostasis     Physiology                        Monitoring

Primary hemostasis

  Formation of the       Platelets first adhere to the     BT, PFA-100
  platelet plug          exposed collagen and von           analysis
                         Willebrand's factor on the
                         subendothelium. Then,
                         circulating stimuli activate
                         the platelets, causing shape
                         changes in the platelets [2].
                         Upon activation, platelet
                         receptors get transferred to
                         the surface, allowing for
                         platelet aggregation. Platelets
                         then release granules that
                         stimulate further platelet
                         aggregation and
                         vasoconstriction [2, 3].

Secondary hemostasis

  Intrinsic pathway      Plasma proteins get activated        aPTT
                         in contact with negatively
                         charged surfaces, leading to
                         activation of factor XII and
                         other clotting factors,
                         ultimately leading to the final
                         common pathway and formation of
                         the fibrin clot [4].

  Extrinsic pathway      Damaged endothelium exposes           PT
                         tissue factor, activating the
                         extrinsic pathway, leading to
                         thrombin production, and
                         activation of other clotting
                         factors, ultimately leading to
                         the final common pathway and
                         formation of the fibrin clot

  Final common pathway   Both pathways lead to
                         activation of factor X, which
                         converts prothrombin into
                         thrombin. Thrombin leads to
                         formation of the insoluble
                         fibrin clot, by converting
                         fibrinogen into fibrin [5]. The
                         clot is then stabilized by
                         factor XIII [6].

Abbreviations: ADP: adenosine diphosphate, aPTT: activated partial
thromboplastin time, BT: bleeding time, PFA-100 analysis: platelet
function analysis, PT: prothrombin time, and [MATHEMATICAL EXPRESSION
NOT REPRODUCIBLE IN ASCII] : thromboxane [A.sub.2].

TABLE 2: Anticoagulant and antiplatelet medications [9-11].

Drug             Pharmacodynamics           Indications and

Warfarin         Coumarin inhibits the      Indications: acute/
                 enzyme epoxide             chronic venous
                 reductase, inhibiting      thromboembolism,
                 the [gamma]-               pulmonary embolism,
                 carboxylation of Vitamin   atrial fibrillation,
                 K-dependent clotting       prosthetic heart valves.
                 factors: II, VII, IX, X,
                 Protein C, and S [11],     Monitoring: PT and INR.
                                            When combined with
                                            aspirin, heparin, herbal
                                            supplements, or other
                                            acquired coagulopathies,
                                            can lead to potentiated
                                            increase in PT-INR in
                                            the patient. Generally
                                            recommend a PT-INR level
                                            1 week prior to surgery
                                            (2-3.5 range

Unfractionated   Binds to antithrombin      Indications: DVT,
Heparin          III which leads to         pulmonary embolism,
                 inactivation of thrombin   acute arterial
                 and Factor Xa.             occlusion, as a bridge
                                            in conjunction with
                                            Warfarin until Warfarin
                                            levels become

                                            Monitoring: aPTT. Check
                                            aPTT level 1 week prior
                                            to surgery as well as a
                                            CBC to check for
                                            platelet levels.

Dabigatran       Direct thrombin            Indications: Atrial
                 inhibitor.                 fibrillation.
                                            Monitoring: Not

Aspirin          Irreversibly inhibits      Indications: MI, TIA/
                 the cyclooxygenase         stroke prevention, CAD,
                 enzymes, which decreases   fever, pain,
                 the levels of TXAo,        inflammatory diseases
                 decreasing platelet        (RA), cardiac stent
                 aggregation.               placement.

                                            Monitoring: Not
                                            recommended, but
                                            platelet inhibition can
                                            be monitored by bleeding
                                            time or PFA-100.

Ticlopidine      Thienopyridines that       Indications: Drug
and              irreversibly inhibit       eluding stent, TIA/
Clopidogrel      adenosine-diphosphate      stroke, MI, PVD.
                 receptors, decreasing
                 platelet aggregation       Monitoring: Not
                 [12].                      recommended. Can be
                                            monitored by bleeding
                                            time or PFA-100.

Cilostazol       Vasodilator that           Indications: Commonly
                 inhibits cellular          used in treatment of
                 phosphodiesterase,         peripheral arterial
                 decreasing platelet        disease for intermittent
                 aggregation.               claudication.

                                            Monitoring: Not

Dipyridamole     Vasodilator that           Indications: Mostly used
                 inhibits cGMP              in combination with
                 phosphodiesterase and      other drugs such as
                 cellular uptake of         aspirin (Aggrenox) or
                 adenosine.                 warfarin after cardiac
                                            valve replacement.

                                            Monitoring: Not

NSAIDs           Reversibly inhibit         Indications: Pain,
(Ibuprofen,      cyclooxygenase,            inflammatory conditions
diclofenac)      inhibiting TXAo,           (RA), fever,
                 decreasing platelet        dysmenorrhea, HA.
                                            Monitoring: Not

Drug             Discontinuation            Reversal

Warfarin         Discontinuation not        Reversal generally not
                 recommended for            needed. If an emergent
                 dermatologic surgery. If   situation arises, fresh
                 patient is at high risk    frozen plasma,
                 for bleeding during the    prothrombin complex
                 procedure, consider        concentrates, or
                 delaying the surgery       recombinant Factor Vila
                 until better hemostatic    can be used. Parenteral
                 control is obtained.       Vitamin K administration
                                            can also be used, but
                                            takes longer for effects
                                            to be seen.

Unfractionated   Discontinuation not        Reversal generally not
Heparin          recommended for            needed. If an emergent
                 dermatologic surgery.      situation, 1 mg of
                                            protamine sulfate for
                                            every 100 units
                                            ofheparin in vivo can be

Dabigatran       Discontinuation not        No reversal agent.
                 recommended for            Control bleeding site,
                 dermatologic surgery.      give supportive care.

Aspirin          Prophylactic aspirin       Reversal generally not
                 with no prior history of   needed.
                 myocardial infarction or
                 cerebral vascular events
                 should be discontinued
                 10-14 days prior to
                 procedure due to
                 irreversible effect on
                 platelets and started 1
                 week postoperatively.

                 ASA used for therapeutic
                 purposes or
                 prophylactically in high
                 risk individuals should
                 be continued.

Ticlopidine      Discontinuation not        Reversal generally not
and              recommended, although      needed.
Clopidogrel      Clopidogrel has been
                 shown to lead to greater
                 bleeding complications
                 than other antiplatelet
                 agents [12].

Cilostazol       No recommendations have    Reversal generally not
                 been made regarding        needed.

Dipyridamole     No recommendations have    Reversal generally not
                 been made regarding        needed.

NSAIDs           Recommended to be          Reversal generally not
(Ibuprofen,      discontinued 3-5 days      needed.
diclofenac)      preoperatively, with
                 resumption 1 week post-

Abbreviations: aPTT: activated partial thromboplastin time, ASA:
aspirin, CAD: coronary artery disease, DVT: deep venous thrombosis,
INR: international normalized ratio, MI: myocardial infarction, PVD:
peripheral vascular disease, PFA-100: platelet function analyzer, PT:
prothrombin time, RA: rheumatoid arthritis, TIA: transient ischemic
Thromboxane [A.sub.2].

TABLE 3: Dietary supplements and anticoagulant properties.

Type of supplement   Mechanism of action       Comments

Garlic               Allicin, adenosine, and   Should be used in
                     paraffinic sulfide in     caution in conjunction
                     garlic inhibit platelet   with other
                     aggregation, increasing   anticoagulants such as
                     bleeding time [26, 27].   Coumadin and heparin

Ginkgo-biloba        Inhibits platelet         Discontinue 36 hours
                     activating factor [26].   before surgery [27].
                     Platelet aggregation      One energy drink
                     thought to be inhibited   contains more than
                     by terpene ginkgolide B   recommended dosage
                     [24, 28].                 [28]. Caution should be
                                               used when combining
                                               with Cilostazil [28].
                                               Some studies have shown
                                               no increase in bleeding
                                               when compared to a
                                               placebo [29].

Ginseng              Inhibits platelet         Large ingredient in
                     aggregation by altering   energy drinks.
                     inhibiting thromboxane
                     function [24, 27].

Ginger               Gingerol in ginger        Has not shown to
                     inhibits platelet         interact with NSAIDs or
                     function by inhibiting    warfarin. More studies
                     platelet activation       need to be performed on
                     also decreases            the extent of ginger's
                     synthesis of              anticoagulant
                     thromboxane [24, 27].     properties.

Vitamin E            Decreased platelet        Anticoagulant
                     adhesion and              properties are
                     aggregation [24].         dosedependent. Because
                                               it is a fat soluble
                                               vitamin, large doses
                                               can be stored in the
                                               body causing toxicity
                                               as well as increased
                                               propensity to bleed

Omega-3-fish oil     Decreased platelet        Has not been shown to
                     adhesion and              increase bleeding
                     aggregation [24].         complications in spinal
                                               surgery [30]. In
                                               conjunction with other
                                               medications, may lead
                                               to increased effect

TABLE 4: Acquired and inherited coagulopathies and management.

                           Mechanism                  Monitoring
Acquired coagulopathies

  Uremia (chronic          Qualitative defect       BT or PFA-100
  renal failure)           in platelets with a
                           normal platelet

  Liver cirrhosis          Decreased production   PT, aPTT, BT, and
                           of the clotting          platelet count
                           factors; coincident
                           splenomegaly can
                           lead to
                           sequestration of
                           platelets and

Inherited coagulopathies

  Von-Willebrand's         Decreased production        BT, aPTT
  disease                  of von-Willebrand's
                           factor and factor

  Hemophilia A             Decreased Factor              aPTT

  Hemophilia B             Decreased factor IX.          aPTT

Acquired coagulopathies

  Uremia (chronic          DDAVP; per patients
  renal failure)           nephrologist,
                           hemodialysis, or
                           peritoneal dialysis

  Liver cirrhosis          Vitamin K, FFP,
                           recombinant Factor
                           Prothrombin complex
                           concentrates, and
                           Desmopressin [33].

Inherited coagulopathies

  Von-Willebrand's         DDAVP, factor VIII
  disease                  concentrates,

  Hemophilia A             Factor VIII
                           concentrates, DDAVP

  Hemophilia B             Factor IX
                           concentrates [34].

Abbreviations: aPTT: activated partial thromboplastin time, BT:
bleeding time, DDAVP: desmopressin, FFP: fresh frozen plasma,
PFA-100: platelet function analyzer, and PT: prothrombin time.

TABLE 5: Hemostatic agents.

Hemostatic agent   Product information        Mechanism of action

Caustic agents

Zinc chloride      Paste that can be          Precipitates proteins
(Mohs paste)       applied topically. Used    causing coagulation of
                   infrequently, but is       small vessels [48]. Eeft
                   effective in providing     on for up to 48 hours.
                   hemostasis to metastatic
                   cutaneous wounds [53].

Ferric             Solution can be applied    Precipitates proteins
subsulfate         with a cotton tipped       intravascularly and
(Monsel's          applicator or gauze pad    oxidizes tissues. Eess
solution)          [48, 54].                  expensive, more
                                              accessible, and easy to
                                              apply [48, 54].

Aluminum           Solution can be applied    Precipitates proteins
chloride           with a cotton tipped       causing coagulation of
                   applicator after shave     vessels [48]. Easily
                   biopsy [48].               accessible and easy to


Gelatin            Comes in a sterile         The gelatin is able to
(Gelfoam,          powder or sponge.          absorb more than 45x its
Surgifoam)         Porcine derived [48].      weight, providing a
Gelfoam Plus                                  matrix for the clotting
(Gelatin                                      cascade in addition to
combined with                                 providing a physical
human thrombin)                               barrier. Absorbed by the
                                              body in 4-6 weeks [48,
                                              55, 56].

Polyethylene       Liquid composed of two     Increases platelet
glycol Hydrogel    PEG polymers that          adherence, providing
(CoSeal)           polymerize and cross-      quick hemostasis [57].
                   link in the tissue [57,

Microporous        Comes in a white powder    Dehydrates the blood,
polysaccharide     that is 100% plant         concentrating RBC's,
spheres (Arista)   based. Formed by cross-    platelets, proteins,
                   linking of purified        promoting adherence to
                   plant starch [52, 58,      the gel matrix. Also
                   59].                       causes a physical
                                              barrier in the tissue

Microfibrillar     Bovine collagen formed     Collagen framework
collagen           into flour, sheets, or     promotes platelet
(Avitene,          sponges [48].              aggregation and
Helistat)                                     coagulation cascade

Cellulose          Oxidized cellulose         Physically acts to
(Surgicel,         arranged into sheets,      tamponade the vessels
Oxycel)            gauze, or smaller          and provide a meshwork
                   strips. Can durably be     for the fibrinolytic
                   placed in the tissue       cascade to occur.
                   [48, 60],                  Becomes gelatinous in
                                              24-48 hrs and is
                                              absorbed by the body by
                                              1-6 weeks. Relatively
                                              inexpensive [48].

Pro QR powder      Combination of a           Forms an eschar in body
                   hydrophilic polymer and    in <60 seconds, due to
                   potassium salt packaged    the polymers dehydrating
                   into a powder [48, 51].    the blood and the
                   Available over the         potassium salt binding
                   counter, relatively        to the positively
                   inexpensive and easy to    charged red blood cells
                   apply.                     [48, 52].

Thrombin           Can be bovine derived or   Promotes body's
(Thrombin-JMI,     human recombinant          physiologic clotting
Recothromb,        thrombin. Comes in a       cascade by actively
Evithrom,          powder or solution.        converting fibrinogen
Floseal)           Floseal is composed of a   into fibrin. Should not
                   gelatin matrix and         be used in patients that
                   thrombin and comes in      have decreased
                   two separate               fibrinogen levels [48,
                   compartments that are      57, 60].
                   not mixed until time of
                   use [48, 60].

Fibrin sealant     Human and bovine derived   Comes in a two
(Tisseal,          forms. Can be formed       compartment syringe with
Crosseal,          from autologous plasma     one compartment
Evicel)            or pooled from donors.     containing fibrinogen,
                   Also comes in an           factor XIII,
                   aerosolized form [5].      fibronectin, and
                   Entails different          fibrinolysis inhibitors
                   methods of preparation     (aprotinin), and in the
                   depending on the           other is thrombin and
                   product. Can be frozen     calcium chloride [5, 48,
                   in premixed form for up    60]. When combined,
                   to two years, can be       thrombin becomes
                   heated, and stirred for    activated and activates
                   20 minutes prior to use    the clotting cascade and
                   [48, 60]. Can also be      enhances conversion of
                   sprayed directly to the    fibrinogen to fibrin.
                   area in the aerosolized    Absorbed from the body
                   form [5].                  within 5-10 days [48].
                                              Very effective in
                                              patients with

Octyl-2-           Comes as a topical         Polymerization creates a
cyanoacrylate      liquid adhesive best       physical barrier,
(Dermabond)        used for smaller           tamponading the vessels
                   lacerations. May have      [47-49].
                   some antibacterial
                   properties. Good in
                   pediatric population and
                   people with cognitive
                   deficits who cannot
                   stitch removal.
                   Moderately expensive

Hemostatic agent   Potential side effects

Caustic agents

Zinc chloride      Can be very painful and
(Mohs paste)       irritating to the
                   patient [53].

Ferric             Being used less due to
subsulfate         infra dermal ferruginous
(Monsel's          deposits causing
solution)          tattooing of the skin
                   after use [48,54].

Aluminum           Can be painful and
chloride           irritating to the
                   patient [48].


Gelatin            Can interfere with
(Gelfoam,          healing of wound edges,
Surgifoam)         generally not
Gelfoam Plus       recommended for use in
(Gelatin           skin incisions. Can
combined with      facilitate bacterial
human thrombin)    growth leading to
                   infection or leading to
                   foreign body reactions
                   when left in the tissue.
                   Can increase in size
                   leading to compression
                   of surrounding
                   structures, including
                   nerve damage. When
                   combined with thrombin
                   can lead to allergic/
                   anaphylactic reactions
                   [48, 55].

Polyethylene       Swells up to 4x its size
glycol Hydrogel    potentially causing
(CoSeal)           damage to the
                   surrounding tissues

Microporous        Causes immediate
polysaccharide     swelling, has the
spheres (Arista)   potential to cause
                   damage to surrounding
                   structures. Use
                   cautiously in diabetics
                   due to potential to
                   increase glucose load

Microfibrillar     Side effects are rare.
collagen           Allergic and foreign
(Avitene,          body reactions have
Helistat)          occurred [48].

Cellulose          Can cause granulomatous
(Surgicel,         reactions and should be
Oxycel)            used carefully in closed
                   spaces due to increased
                   risk of swelling in the
                   tissues, can cause
                   compression of
                   surrounding structures

Pro QR powder      Few side effects

Thrombin           Bovine thrombin has been
(Thrombin-JMI,     shown to cause
Recothromb,        coagulopathy weeks after
Evithrom,          use, due to antibodies
Floseal)           forming against factor
                   V. Human thrombin
                   although cleansed
                   thoroughly, has the
                   potential to transmit
                   viruses [48, 57, 60].

Fibrin sealant     Pooled donor plasma and
(Tisseal,          older sealants
Crosseal,          containing bovine
Evicel)            derived aprotinin
                   increased the potential
                   to cause
                   reactions and to
                   transmit infectious
                   diseases such as prion-
                   related diseases [5,

Octyl-2-           Small risk for
cyanoacrylate      inflammatory reactions
(Dermabond)        and fibrosis [48].

Abbreviations: PEG: polyethylene glycol.

TABLE 6: Postoperative recommendations.

Postoperative recommendations

(i) A pressure wound dressing       (i) If bleeding is apparent, ice
should be applied for at least 24   and cool compresses can be
hours, providing adequate           applied to the surgical area to
compression to the tissues [10,     vasoconstrict the blood vessels
63].                                and decrease bleeding [64].

(ii) Activity should be limited     (ii) Manual compression can be
during the first 48 hours due to    applied externally to the wound
the increased risk for bleeding     area for up to 20 minutes to
complications. Small blood          control minor bleeding.
vessels are vulnerable to rupture
with minor activity. Strenuous      (iii) If the gauze and current
activity should be limited until    wound dressing appear to be
the wound regains tensile           saturated in blood, a clean
strength (up to 2 weeks for         dressing should be applied to the
facial/neck wounds and up to 6      area to allow for better
weeks for lower extremity wounds)   absorption and compression of the
[10].                               tissues.

(iii) Elevation of the operative    (iv) If the patient begins to
area within the first 24 hours of   experience throbbing pain,
the operation is important to       increased pressure sensation, or
decrease the amount of gravity      heavy bleeding that is
and pressure on the tissues. For    uncontrollable, they should
procedures of the face, scalp, or   return to the office immediately
neck, placing pillows underneath    for further intervention and
the head and neck areas while       treatment [63].
lying down can help to alleviate
pressure [64].

TABLE 7: Hematoma management.

Early hematoma formation

(i) Reopen the wound and localize   (i) If small, may only require
the bleeding site.                  observation. area with a 16-18
                                    gauge needle; [63, 65].
(ii) Achieve hemostasis by
electrocoagulation/ligation of      (ii) If large and within the
the affected vessels or by          first week, evacuate the area and
application of topical hemostatic   leave open to heal by secondary
agents.                             intention [63].

(iii) If bleeding cannot be         (iii) If not discovered until
adequately controlled, place a      late (weeks to months later),
drain into the wound for up to 24   aspirate the

(iv) Resuture the site and apply
the appropriate pressure
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Author:Henley, Jill; Brewer, Jerry D.
Publication:Dermatology Research and Practice
Date:Jan 1, 2013
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