Surgical Complications of bleeding, infection dehiscence and necrosis are interelated

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

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

Typical examples include lower-leg complications, where lack of skin laxity and excess wound tension can lead to tissue ischemia and necrosis, as well as infection and dehiscence.
Bleeding risks

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

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

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

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