Complications of tissue ischemia in dermatologic surgery

Abstract

Ischemic complications in cutaneous surgery can be devastating. Tissue ischemia can result from improper technique or closure design (i.e., increased tension), inadequate hemostasis, or infection, all of which result in decreased blood supply to the surgical site. Knowledge of patient characteristics that affect blood supply to the surgical site, including comorbid conditions, medications and behaviors (i.e., tobacco and alcohol use), is essential. Also, a thorough understanding of cutaneous anatomy, principles of surgical design, coupled with meticulous technique will minimize the likelihood of ischemic complications. Prompt recognition of hematoma, infection and impending ischemia/necrosis, and proper treatment of such complications, can minimize poor outcomes.

Newer Hemostatic Agents Used in the Practice of Dermatologic Surgery

“…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.…”

“…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.…”

“…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.…”

“…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.…”

A dissolved oxygen dressing: A pilot study in an ischemic skin flap model

“…1 Prevalent ischemia can impair incision healing and contribute to the development of surgical site infection. 2 Surgical incisions disrupt normal perfusion, which may lead to ischemia in the surrounding tissues. However, ischemic tissues often remain viable long enough to benefit from angiogenesis, which may re-establish perfusion to overcome the ischemic condition.…”