MIAMI BEACH Minimizing bleeding during and after Mohs surgery can be a challenge, according to Dr. Susan H. Weinkle.
"In Bradenton [Fla.] where I practice, almost everyone is taking an anticoagulant," Dr. Weinkle said. As a Mohs surgeon "we realize that the risk of a thrombotic event is much worse for the patient than the risk of bleeding." She recommended that patients with a history of a transient ischemic attack or thrombotic event, in particular, be allowed to continue their anticoagulant therapy.
Ask patients to provide a comprehensive list of all the medications and supplements they take, Dr. Weinkle said at the South Beach Symposium. "Sometimes patients do not tell you the whole story, so you need a complete history." Patients may be taking ginkgo biloba or consuming a lot of cinnamon, which can thin the blood.
Meticulous hemostasis is important; do your best to maintain a dry field intraoperatively during Mohs surgery, said Dr. Weinkle, a private practice dermatologist in Bradenton. Epidermal sutures often can halt superficial bleeding along the edge of a wound. If excessive bleeding occurs intraoperatively, you may need to tie off a larger vessel. Also, avoid placing a patient in the Trendelenburg position.
How you bandage is also important to minimize the risk of postoperative bleeding. Provide pressure with a large bandage because "as the anesthetic goes away, you can get rebound vasodilatation," Dr. Weinkle said. Consider using flesh-colored bandages, and provide written instructions to leave bandages in place for 48 hours and to restrict activities.
Other strategies to prevent or manage postoperative bleeding include the application of ice, direct pressure for 15 minutes, and the use of Surgicel Absorbable Hemostat (Ethicon Inc.).
Surgicel looks like a little piece of gauze, Dr. Weinkle said. "One of my patients [who lives] 2 hours away went to the ED. They laid this on top of his sutured wound and it stopped" bleeding.
"One thing I want you to take home todaySurgicel is absolutely magical stuff," Dr. Weinkle said. (She stated that she had no relevant disclosures.) It is particularly helpful for controlling bleeding on more challenging wound sites.
Consider using flesh-colored bandages, and provide written instructions to leave them on for 48 hours. DR. WEINKLE