INTRODUCTION
Postoperative bleeding is 1 of the most frequent complications seen in dermatologic surgery, of which hematoma formation is a known consequence.1 A hematoma is defined as a collection of blood outside of a vessel as a result of damage to the surrounding vasculature. While the incidence of hematoma formation in dermatologic surgery is less than 3%, this complication can result in unintended outcomes such as surgical site infection, wound dehiscence, tissue necrosis, and permanent damage to vital structures if located in peri-orbital or cervical regions.2-5 Consequently, sub-optimal healing outcomes may occur, such as prolonged healing time, scarring, and poor cosmesis.5 Although a seemingly rare complication, multiple studies have reported difficulties with hemostasis being the most common adverse event following cutaneous surgery in both the setting of basic standard excision and Mohs micrographic surgery (MMS).3,4,6 Recognition of risk factors associated with hematoma formation is vital in determining appropriate risk mitigation practices in order to decrease the incidence of bleeding complications and promote proper wound healing. These risks are summarized in Table 1.
Preoperative Risk Mitigation
Many factors that increase the risk of hemorrhage expectedly play a role in the formation of hematomas. These factors can be identified and addressed preoperatively by noting the patient's medication list, medical history, and social history. One prospective cohort study involving 20,821 MMS cases reported 149 adverse events, 15.1% of which were related to bleeding and hematoma formation, most of which comprised patients on anticoagulation medications.7 The use of anticoagulant medications, appreciated in approximately 25 to 46% of patients undergoing dermatologic surgery, may place the patient up to 7 times more likely to experience a moderate to severe hematoma.2,8,9 Interestingly, up to 50% of patients undergoing a dermatologic surgery may use over the counter (OTC) supplements involved in the coagulation cascade. Patients with a history of myocardial infarction, stent placement, cerebrovascular accidents (CVA), deep venous thrombosis, pulmonary embolism, and atrial fibrillation are often on anticoagulant agents.9 Anticoagulant medications are categorized by mechanism of action, and include platelet inhibitors, direct oral anticoagulants (DOACs), vitamin K antagonists, and over the counter products. Antiplatelet agents include aspirin, clopidogrel, ticagrelor, prasugrel, and nonsteroidal anti-inflammatory agents (NSAIDs). Direct oral anticoagulants include apixaban, rivaroxaban, dabigatran, edoxaban, and betrixaban. The most common vitamin K antagonist to date is warfarin. Additionally, certain herbal supplements and vitamins may increase the risk of postoperative bleeding, such as ginkgo biloba, ginseng, ginger, saw palmetto, feverfew, St. John's wort, garlic, fish oil, and vitamin E.5,10,11
While it is recommended that all vitamins be discontinued 2 to 3 weeks prior to surgery, dermatologists advise against the cessation of anticoagulation medications, as management of potential embolic or cardiac events pose more difficulties than the treatment of postoperative bleeding complications.1 Several studies have demonstrated that in patients taking aspirin or NSAIDs, there is not a significant increase in bleeding complications.2,8 Aspirin should be continued for high-risk patients, including those with a history of cerebrovascular disease, unstable angina, coronary stent placement, or cardiac
Preoperative Risk Mitigation
Many factors that increase the risk of hemorrhage expectedly play a role in the formation of hematomas. These factors can be identified and addressed preoperatively by noting the patient's medication list, medical history, and social history. One prospective cohort study involving 20,821 MMS cases reported 149 adverse events, 15.1% of which were related to bleeding and hematoma formation, most of which comprised patients on anticoagulation medications.7 The use of anticoagulant medications, appreciated in approximately 25 to 46% of patients undergoing dermatologic surgery, may place the patient up to 7 times more likely to experience a moderate to severe hematoma.2,8,9 Interestingly, up to 50% of patients undergoing a dermatologic surgery may use over the counter (OTC) supplements involved in the coagulation cascade. Patients with a history of myocardial infarction, stent placement, cerebrovascular accidents (CVA), deep venous thrombosis, pulmonary embolism, and atrial fibrillation are often on anticoagulant agents.9 Anticoagulant medications are categorized by mechanism of action, and include platelet inhibitors, direct oral anticoagulants (DOACs), vitamin K antagonists, and over the counter products. Antiplatelet agents include aspirin, clopidogrel, ticagrelor, prasugrel, and nonsteroidal anti-inflammatory agents (NSAIDs). Direct oral anticoagulants include apixaban, rivaroxaban, dabigatran, edoxaban, and betrixaban. The most common vitamin K antagonist to date is warfarin. Additionally, certain herbal supplements and vitamins may increase the risk of postoperative bleeding, such as ginkgo biloba, ginseng, ginger, saw palmetto, feverfew, St. John's wort, garlic, fish oil, and vitamin E.5,10,11
While it is recommended that all vitamins be discontinued 2 to 3 weeks prior to surgery, dermatologists advise against the cessation of anticoagulation medications, as management of potential embolic or cardiac events pose more difficulties than the treatment of postoperative bleeding complications.1 Several studies have demonstrated that in patients taking aspirin or NSAIDs, there is not a significant increase in bleeding complications.2,8 Aspirin should be continued for high-risk patients, including those with a history of cerebrovascular disease, unstable angina, coronary stent placement, or cardiac
