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Dermatologic surgery is an increasingly common practice, but there are limited data on the risk of postoperative hemorrhage in patients treated with anticoagulants. We examined the rate of postoperative hemorrhage or hematoma in patients undergoing outpatient dermatologic surgical procedures at two dermatologic surgery sites in the United States.

Subjects and Methods

  1. Top of page
  2. Subjects and Methods
  3. Results
  4. Discussion
  5. References

In this prospective study, postoperative hemorrhage was defined as hemorrhage requiring intervention (surgical hemostasis, electrocoagulation, or topical aluminum chloride) in an office or emergency department or postoperative hematoma necessitating incision and drainage. Mohs surgery was categorized according to the preoperative measurement of clinically identifiable margins of tumor and excision or biopsy according to the maximum diameter of skin incision.

Results

  1. Top of page
  2. Subjects and Methods
  3. Results
  4. Discussion
  5. References

Of 2,418 subjects (60% male, 40% female; mean age 68) undergoing dermatologic surgery procedures from February 1, 2010, through December 14, 2010, 1,234 (51.0%) patients were receiving one or more anticoagulant medications at the time of surgery. The most common procedure performed was Mohs surgery of a tumor smaller than 2 cm in diameter (54%), followed by shave biopsy (18%), and excision of a tumor smaller than 2 cm in diameter (12%) (Table 1).

Table 1. Incidence of Postoperative Hemorrhage by Procedure Type and Location in Patients Undergoing Dermatologic Surgery
 n (%)Incidence of Hemorrhage, %
  1. No statistically significant association was found between the incidence of postoperative hemorrhage and procedure type or location.

Procedure type
Biopsy or excision824 (34)0.1
<2 cm749 (31)0.1
≥2 cm75 (3)0.0
Mohs surgery1,541 (64)0.6
<2 cm1,307 (54)0.5
≥2 cm234 (10)1.3
Not reported53 (2)0.0
Procedure site
Head and neck1,789 (74)0.5
Face1,249 (52)0.4
Trunk217 (9)0.5
Extremities388 (16)0.3
Not reported24 (1)0.0

Eleven postoperative hemorrhages were recorded; eight occurred in subjects treated with one or more anticoagulants (8/1,234; 0.65%) and three in subjects not receiving any anticoagulants (3/1,184; 0.25%). The difference was not statistically significant (p = .1; Fisher exact test). Patients receiving only warfarin, but not patients receiving only aspirin, had a statistically significantly higher incidence of hemorrhage than patients not receiving any anticoagulant (p = .005 and p = .5, respectively; Fisher exact test, Figure 1). There was no hospital admission, significant persistent disability, threat to life, or death associated with postoperative hemorrhages.

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Figure 1. Incidence of postoperative hemorrhage by anticoagulant drug therapy. Aspirin was the most frequently used anticoagulant, but the incidence of postoperative hemorrhage was greatest in patients undergoing warfarin therapy. OA, other anticoagulant, including aspirin in 50 patients, aspirin and clopidogrel in two, and clopidogrel in six.

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Discussion

  1. Top of page
  2. Subjects and Methods
  3. Results
  4. Discussion
  5. References

Highest rate of hemorrhage in this study was 0.6%, in patients undergoing Mohs surgery. This rate was lower than reported rates in previous multicenter studies.[1] Although we found a higher rate of postoperative hemorrhage in subjects treated with warfarin, the rate of postoperative hemorrhage in warfarin-treated patients was less than 3%. Other anticoagulants did not appear to increase the risk of hemorrhages, even when they were added to warfarin. Similar to our study, in previous studies, risk of postoperative hemorrhage has been highest in patients receiving warfarin.[2-4] Clopidogrel also has been associated with risk of postoperative hemorrhage.[2] Although risk of postoperative hemorrhage may be a little higher in patients receiving aspirin, a statistically significant association has never been demonstrated.[2, 3]

Of frequent debate among dermatologic surgeons is what should be done with regard to anticoagulant therapy before dermatologic surgery. Bleeding after surgery is potentially inconvenient to manage and may expose patients to additional procedures or affect final cosmetic outcome, but postoperative bleeding from a dermatologic procedure is easier to manage than a stroke or embolus that may happen during discontinuation of drugs. In 2012, the American College of Chest Physicians recommended continuing warfarin or aspirin perioperatively and optimizing local hemostasis during minor dermatologic procedures.[5] There may be instances in which reduction or cessation of anticoagulation is warranted. In such instances, the decision is best made on an individual basis with the explicit involvement of the prescribing provider. Cessation of anticoagulation before dermatologic surgery does not appear warranted under usual circumstances.

References

  1. Top of page
  2. Subjects and Methods
  3. Results
  4. Discussion
  5. References
  • 1
    Merritt BG, Lee NY, Brodland DG, Zitelli JA, et al. The safety of Mohs surgery: A prospective multicenter cohort study. J Am Acad Dermatol 2012;67(6):13029.
  • 2
    Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011;65(3):57683.
  • 3
    Lewis KG, Dufresne RG Jr. A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery. Dermatol Surg 2008;34(2):1604.
  • 4
    Otley CC, Fewkes JL, Frank W, Olbricht SM. Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol 1996;132(2):1616.
  • 5
    Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, et al. Perioperative management of antithrombotic therapy: antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl 2):e326S50S.