Dermatologic Preoperative Evaluation and Management

The preoperative consultation and evaluation is an important interaction between the patient and the physician. This process allows the surgeon to carefully assess the medical condition, evaluate the patient's overall health status, determine risk factors against the procedure, educate the patient, and discuss the procedure in detail. In return, the patient should gain a realistic understanding of the proposed surgery, consider alternative treatment options, and realize the possible complications during the perioperative period. The additional time invested in a preoperative evaluation yields an improved patient-physician relationship and reduces surgical complications.

The preoperative management of a patient with a surgical problem involves a diagnostic workup, a preoperative evaluation, and the preoperative preparation. The diagnostic workup determines the cause and the extent of the patient's condition. The preoperative evaluation is an overall assessment of the patient's health to identify operative risks that may influence the recovery period. This evaluation includes an anesthetic plan that take into consideration the patient's medical condition, the requirements of the surgical procedure, and the patient's preferences. A thorough assessment ensures that the patient's chronic diseases are under appropriate medical therapy prior to an elective procedure and establishes a rapport and confidence with the patient to allay fears and answer any questions. Finally, the preoperative preparation involves procedures that are implemented based on the nature of the expected operation and the findings of the diagnostic workup and preoperative evaluation.

Many dermatologic surgical procedures are uncomplicated, and extensive patient evaluation is unnecessary. Some of these simple procedures include limited cryosurgery, curettage, electrosurgery, punch and saucerization biopsies, and simple excisions. However, the need for patient evaluation is greater with more complex procedures, such as dermabrasion, hair transplantation, flaps, and grafts. Certain underlying physiologic and pathophysiologic problems demand attention and caution. Medications and dietary supplements are often numerous and need to be scrutinized for their impact on anesthetic agents, hemostasis, and wound healing. With the appropriate preoperative evaluation and precautions, many dermatologic procedures may be safely performed.

For most nonmelanoma skin cancer, a pathologic diagnosis should be established by punch or shave biopsy. For small, low-risk nonmelanoma skin cancer of the head and neck, routine imaging is not usually performed. For larger ones, CT scanning may be the preferred imaging modality, as it allows reasonable evaluation of the extent of ostial involvement (eg, temporal bone, zygoma, maxilla, mandible, orbit), as well as nodal basins. MRI may be used as an adjunct to CT scanning if clinical suspicion for perineural invasion is elevated. Positron-emission tomography scanning generally is not used preoperatively, but rather used to assess the progression of metastatic disease and response to systemic therapy. However, in selected cases, it may be used to assess the extent of regional disease prior to treatment. ^[1]

Preoperative ultrasound-guided incisional biopsy may enhance the pathologic accuracy of cutaneous melanoma diagnosis. ^[2] Sentinel lymph node mapping by single photon emission computed tomography (PET-CT)/CT in early-stage malignant head and neck skin tumors may be desirable. ^[3]

The goals of this article are to present guidelines for performing a complete preoperative evaluation and to highlight specific issues and management problems that arise in patients undergoing dermatologic surgery.

Initial diagnostic workup

The initial diagnostic workup of the surgical patient determines the cause of the presenting complaints. Such an evaluation seeks to identify abnormalities that may influence the operative risk and may have a bearing on the patient's future well-being. A complete history and a comprehensive physical examination are essential.

The history should include a past medical history, a surgical history, a family history, a social history (use of tobacco, alcohol, and illegal drugs), a history of allergies, and the use of medications (prescribed, over-the-counter, vitamins, and herbal preparations). Questions about previous anesthetic problems experienced by the patient and/or blood relatives are also important.

Existing and past medical conditions

Diabetes mellitus

Patients with poorly controlled diabetes may have adverse wound healing and an increased propensity toward infections because of defects in chemotaxis, opsonization, and phagocytosis. This becomes critical when areas of microvascularization, such as the digits, are the proposed sites of surgery. Additionally, the high prevalence of microangiopathy in the skin and peripheral neuropathy make wound healing in acral sites more difficult in this population. The physician may administer postoperative antibiotics to avoid potential wound infections and may use epinephrine with caution. Given the high potential risk of perioperative wound infections, several authors recommend the use of prophylactic antibiotics in patients with diabetes. Ideally, the patient's blood glucose level should be fairly controlled, and the insulin doses should be adjusted as needed. Management of hypoglycemic agents and different types of insulin can be pivotal. ^[4]

Hypertension

A history of hypertension should alert the physician to check the patient's blood pressure. Patients with elevated pressures may bleed profusely. This is especially true when working on larger areas of the body or in highly vascular regions, such as the scalp.

Hypertension is an important cause of perioperative bleeding and hematoma formation. It can become a significant cause of poor outcome after flap or graft surgery. Preoperative anxiolytics or sedation and adequate postoperative pain control are important in alleviating unwanted stress and anxiety, which can consequently elevate blood pressure in this population.

Cardiovascular disease

Inquiry into the details of a patient's cardiovascular disease is essential. Patients with histories of ischemic coronary artery disease or angina may need sublingual nitroglycerin, which should be readily available. The use of epinephrine in local anesthetics may be detrimental because of the vasoconstrictive and cardiostimulatory effects.

Patients with valvular heart disease or prosthetic valves have a greater risk of developing endocarditis. However, the occurrence of bacteremia with routine skin surgery is very low and may not necessitate prophylactic antibiotics. Nevertheless, the anticipated manipulation of abscesses or infected regions warrants prophylactic antibiotic coverage. Eroded skin lesions are most frequently colonized by Staphylococcus aureus and require prophylaxis. First-generation oral cephalosporins or oral dicloxacillin are considered useful.

Furthermore, patients with cardiac pacemakers or defibrillators should be identified during the history. Potential pacemaker interference is a consideration if using electrocautery, particularly with demand-type pacemakers. Heat coagulation devices or carbon dioxide lasers provide safe alternatives for coagulation. Simple electrodesiccation of small lesions located distant to the pacemaker poses negligible risk. However, a patient's cardiologist should be notified in advance if the defibrillator requires inactivation with magnetic fields. Bipolar cautery obviates the concern of disabling the pacemaker or initiating arrhythmia.

Bleeding diathesis

The presence of a bleeding diathesis is important to detect and reverse prior to surgery. Many underlying diseases, inherited disorders, and medications can interfere with the normal coagulation process. In general, bleeding disorders are due to abnormalities of the platelets, the intrinsic coagulation system, the extrinsic coagulation system, or a combination of these factors.

To properly screen for such abnormalities, one should inquire about a family history of bleeding problems; a personal history of problematic bleeding with prior trauma, surgeries, or dental procedures; a history of epistaxis or bleeding from the gums; a history of requiring blood transfusions; and a complete medication history. If a bleeding diathesis is suspected, the following tests should be obtained: a complete blood cell count, a platelet count, a prothrombin time (PT), and an activated partial thromboplastin time (aPTT). Further testing and management advice are best obtained by consulting with a hematologist.

Hepatitis/HIV disease

Severe liver disease is associated with decreased protein synthesis, which can manifest in disorders of coagulation and impaired wound healing. End-stage liver disease caused by hepatitis B or hepatitis C may create bleeding dyscrasias. The patient may require preoperative fresh-frozen plasma or clotting factors. Additionally, antibiotics and anesthetics that are metabolized in the liver should be avoided. Drugs to avoid or to use with extreme caution include sedatives, lidocaine, and amide-linked local anesthetics.

Surprisingly, patients with HIV disease are not predisposed to postoperative infections and decreased wound healing.

Organ transplantations/artificial joints

Patients with organ transplants or artificial joints may require prophylactic antibiotics, especially if the transplant has occurred within a year. This can vary according to the discretion of the primary care physician.

Pregnancy

Nonemergent procedures should be postponed until the postpartum period to avoid any potential adverse effects during organogenesis. Although antibiotics such as penicillin and erythromycin are considered safe during pregnancy (Class B), others, such as tetracycline, can cause bone growth retardation and staining of dental enamel in the fetus. Lidocaine also appears to be safe in low doses, although excessive amounts can cause fetal CNS and cardiac depression. Acetaminophen (Class B) is routinely used during pregnancy despite its ability to cross the placenta. ^[5] Drugs should also be selected carefully during lactation. ^[6]

Snoring/sleep apnea

Eighty percent of patients with breathing problems related to sleep disorders are male. Conscious sedation may exacerbate such conditions and is best avoided. An ancillary oxygen source may be needed for those patients and is provided using a nasal prong. Electrocautery should be used cautiously in the surgical field in order to avoid an inadvertent fire from a spark while obtaining hemostasis.

Seizure disorders/stroke

A history of seizures should warn the surgeon to avoid large doses of anesthetic because precipitating convulsions is possible.

Cerebrovascular accidents are a major cause of morbidity and mortality in elderly persons. Monitoring the blood pressure is essential, and, if accelerated hypertension occurs, it must be immediately treated or the procedure must be terminated. Eliciting a history of a previous stroke is important for several reasons. A cerebrovascular accident may be a clue to underlying coronary heart disease, and it is also an indication that the patient is most likely on an antiplatelet agent (eg, aspirin, ticlopidine) or warfarin (Coumadin).

Nutrition

Deficiencies of vitamins A, C, and K impair normal wound healing. Zinc deficiency affects protein synthesis and cell migration. Zinc deficiency can be treated with oral zinc at 222 mg. Vegetarian patients have also been reported to experience delays in wound healing.

Malnutrition leads to a significant increase in the operative death rate. Weight loss of more than 20% caused by illness (eg, cancer, intestinal disease) results in a higher death rate and a greater than 3-fold increase in the postoperative infection rate. Obtaining a dietary history is of major importance in the preoperative evaluation, as is a working knowledge of the basic nutritional deficiencies associated with certain disease states, particularly vitamin deficiencies. Standard biochemical parameters that indicate impairment in the visceral protein mass include a serum albumin level of less than 3 g/dL or a serum transferrin level of less than 150 mg/dL.

When malnutrition is diagnosed, no consensus has been reached regarding the indications of short-term (7-10 d) preoperative hyperalimentation. The appropriate nutritional state can improve wound healing and immune function. Current indications for supportive measures before elective surgery include a history of weight loss in excess of 10% of body weight or an anticipated prolonged postoperative recovery period during which the patient will not be fed orally. Patients who have had a gastric bypass or lap band procedure have surgically induced malabsorption syndromes. Vitamin supplements and protein shakes preoperatively improve healing.

Herpes simplex virus

A history of herpes simplex virus infection is important when surgery in the genital or perioral areas is considered. Trauma or stress, which includes surgery itself, can precipitate an active infection and antiviral prophylaxis is required. Doses differ depending on whether or not a history of herpes simplex virus infection is known. In general, persons with frequent outbreaks need higher doses. For most perioral procedures, acyclovir is sufficient (400 mg tid beginning 2 d preoperatively and continued until reepithelialization occurs, approximately 10-14 d). Lysine at 1500 mg/d is a naturopathic supplement effective for stabilizing the lip mucosa preoperatively to avoid herpes breakouts.

Coronavirus disease 2019

There are many new preoperative challenges due to the coronavirus disease 2019 (COVID-19) pandemic. Special screening protocols for COVID-19 may facilitate safe elective surgery. ^[7] They may include a telephone interview, blood test, pharyngeal swab, and chest CT. Preparing previously COVID-19–positive patients for elective surgery is another consideration. ^[8]

Other conditions

Endocrine problems, such as thyrotoxicosis, may increase cardiac sensitivity to epinephrine. Pertinent skin problems, such as discoid lupus erythematosus, psoriasis, lichen planus, or extensive verrucae, may be exacerbated following surgery. Patients should be made aware of this phenomenon. Patients with connective-tissue diseases or Ehlers-Danlos syndrome may have delayed wound healing or widening of their scars. Permanent sutures placed in the dermis decrease scar widening postoperatively. The patient must be informed of the possibility of suture reaction, including secondary removal due to granuloma formation.

Surgical site infections

Wound infections may occur after surgical procedures. Reduction of skin microflora leads to a lower incidence of surgical site infection. No clear evidence of benefit was shown for preoperative showering or bathing with chlorhexidine compared with other wash products for reducing surgical site infection. ^[9] Each dermatologic surgeon should adapt the best antiseptic regimen for his or her specific needs. ^[10]

Cardiovascular system

The patient's capacity to increase cardiac output in response to intraoperative and postoperative challenges may be the most fundamental determinant in the final outcome after complex operations. The presence of congestive heart failure, unstable angina, or recent myocardial infarction should prompt a thorough cardiac workup before an extensive elective operation involving regional or general anesthesia. Most patients require either stress thallium echocardiography or dobutamine echocardiography to determine whether coronary ischemia is reversible. This test maybe followed by angiography to precisely define anatomical lesions of the coronary arteries that would be potentially amenable to revascularization with either intraluminal stents or open cardiac bypass surgery.

Several risk factors are useful predictors of fatal or life-threatening complications of cardiac origin after noncardiac operations. Diabetes mellitus, smoking, hypertension, hyperlipidemia, stable angina pectoris, remote myocardial infarctions, ST-segment or T-wave changes on electrocardiogram, bundle-branch blocks, mitral valvular disease, and cardiomegaly are conditions that must not be ignored. However, these conditions are apparently less pertinent determinants of cardiac risk than had been previously thought. The Goldman criteria (see Table 1 below) take precedence over the aforementioned risk factors.

Table 1. Weighting of Cardiac Risk Factors (Open Table in a new window)

Of the 53 total possible points in the scheme of weighting cardiac risk factors, 28 points are attributable to conditions that are potentially treatable. Surgical procedures should be deferred until the patient's overall cardiac status improves, including potential revascularization. For patients with myocardial ischemia, elective surgery should be postponed and urgent surgery should be preceded by coronary artery bypass. The risk of reinfarction during an elective procedure performed within 3 months after a myocardial infarction exceeds 30%, while the infarction rate decreases to 4.5% after 6 months.

Thromboembolism is an extremely infrequent but potentially lethal event. Patients with a clear history of prior thrombosis or embolism, those likely to have a prolonged operation (with special emphasis on procedures that temporarily interfere with lower extremity blood flow), and those undergoing certain reconstructive operations of the hip are at increased risk. Clinicians can reduce the risk of thromboembolism by having the patient use pneumatic compression stockings, by advising the patient to exercise, and by having the patient ambulate early. Generally, heparin or levoxin are not required for simple ambulatory procedures. Orthopedists commonly begin warfarin (Coumadin) therapy in their patients 1 day after total hip and knee replacements without a loading dose. This therapy is continued until the patient is fully ambulatory.

Virtually all studies of systemic anticoagulation in patients undergoing general surgical operations have shown an increase in wound complications from bleeding. Systemic anticoagulation with low-dose heparin should be reserved for patients with morbid obesity or a history of prior pulmonary embolism or deep venous thrombosis. Low molecular weight heparin compounds have shown advantages over conventional low-dose heparin in the prevention of thromboembolic events in patients who are at high risk and have sustained trauma and in those undergoing knee and hip replacement procedures.

Respiratory system

Respiratory complications occur in 2 major patient groups: (1) patients with normal lungs who develop respiratory abnormalities secondary to anesthetic agents and (2) patients with overt chronic lung disease in whom the problems of anesthesia and the operation are superimposed on intrinsically diseased pulmonary tissue.

The preoperative risk factors for pulmonary complications include the following:

• Thoracic and upper abdominal surgery

• Preoperative history of chronic obstructive pulmonary disease

• Preoperative purulent productive cough

• Anesthesia time greater than 3 hours

• History of cigarette smoking

• Age older than 60 years

• Obesity

• Poor preoperative state of nutrition

• Symptoms of respiratory disease

• Abnormal findings upon physical examination

• Abnormal findings on chest radiographs

The distinction between obstructive pulmonary emphysema and nonobstructive pulmonary emphysema can be made with the standard pulmonary function tests. Although several specific tests delineate minimal acceptable function, careful evaluations by both the surgeon and the pulmonologist are often indicated. A simple, useful test is having the patient take a brisk walk up a flight of stairs and observing his or her tolerance. A split pulmonary ventilation-perfusion scan can be helpful in determining which portions of the lungs are most likely to be involved in functional gas exchange to predict postoperative pulmonary function. Arterial blood gas levels should be obtained as a baseline in patients who are symptomatic and who undergo major surgery, especially thoracic procedures.

Preoperative preparatory maneuvers aimed at preventing postoperative respiratory complications include cessation of smoking, use of bronchodilators, chest physical therapy, education, and, occasionally, antibiotics (if sputum is purulent). All the maneuvers cited are important for patients with chronic obstructive pulmonary disease. Vigorous pulmonary physical therapy in the form of nasotracheal suction and even bronchoscopy can be used to maintain alveolar patency postoperatively and to minimize atelectasis and its associated risk of pneumonia.

Renal system

With the screening procedures of blood urea nitrogen level, creatinine level, and urinalysis, an operation and fluid therapy may proceed with the confidence that the patient can tolerate judiciously managed fluid loads. Patients undergoing massive liposuction procedures requiring fluid replacement of more than 5000 mL should be staged if greater amounts of fat are to be removed.

Patients requiring dialysis are chronically anemic and have acquired platelet dysfunction. However, dialysis patients tolerate most procedures that require general anesthesia well with proper monitoring. The timing of dialysis and appropriate transfusions are important preparations, as is the decision to use heparin. Additionally, catheter drainage of an obstructed urinary tract (as in benign prostatic hypertrophy in elderly men) and elimination of infection should be completed before an elective procedure is performed to allow the return of adequate function.

Hepatic system

In patients with cirrhosis, the preoperative period should focus on nutrition and avoidance of hepatotoxins. The risk of operation is directly correlated with the Child classification of the patient. Hepatic function can be improved by nutritional support and the reduction of ascites and encephalopathy. Factors that preclude all but life-saving operations include Child class C, bacterial contamination, bilirubinemia levels greater than 3 mg/dL, albumin levels less than 3 mg/dL, and malnutrition. Alcoholic hepatitis should be allowed to clear before elective procedures are undertaken. The process of hepatic stabilization may take several weeks past the risk period of delirium tremens following alcohol withdrawal. Hepatic function is best assessed by the clinical status, the return of transaminase levels to baseline, and/or a repeat biopsy of the liver.

A natural decline in hepatic function occurs with age, which is important with respect to drug metabolism. The amide class of anesthetics (eg, lidocaine, prilocaine, mepivacaine, bupivacaine, etidocaine) is primarily metabolized by the liver. The ester-linked local anesthetics (eg, procaine, tetracaine) are mainly metabolized by a plasma cholinesterase and can be used safely in an elderly patient with impaired liver function. Most sedative agents are also metabolized by the liver. A good rule of thumb is to use a reduced dosage of these agents in patients with reduced hepatic function.

Neurologic system

A careful history remains the best determinant of whether cerebrovascular disease poses a real or imagined risk to a patient who requires another operation. Patients who are at high risk, such as those with carotid bruits or cardiovascular disease, should undergo duplex ultrasonography of the carotid arteries before the operation to determine whether a significant stenosis (>70%) exists. If such lesions are found in patients who are symptomatic, endarterectomy should generally be considered before the other procedure. If the patient is asymptomatic with regard to the stenosis, then individual clinical judgment must be used to prioritize the sequence of operations.

Allergies of particular concern to the cosmetic surgeon should be stressed.

Local anesthetics

True allergic reactions to local anesthetics are rare. In many cases, substituting a different class of anesthetic, such as an amide (eg, Xylocaine) for an ester (eg, Novocain), may be all that is needed because they display different antigenic determinants. More likely, sensitivity to the paraben preservatives in these agents, such as methylparaben or propylparaben, is the true culprit. Epinephrine used in some local anesthetics for hemostasis may result in a temporary tachycardia, which the patient may report erroneously as an allergy.

Topical anesthetics

EMLA cream (eutectic mixture of 5% lidocaine and 5% prilocaine) is now widely used alone or in combination with other anesthetics. Topical sensitization can result from prolonged or repeated contact. The use of an occlusive waterproof dressing (plastic wrap) reportedly enhances EMLA absorption. Application of EMLA to large body surface areas has resulted in arrhythmia and death.

Antibiotics

Surgeons frequently use both systemic antibiotics and topical antibiotics, necessitating inquiry into possible adverse reactions. Topical antibiotics can cause sensitization, especially when used for a prolonged period. White petrolatum is a safe and less costly alternative to bacitracin for healing uncontaminated cutaneous wounds with less risk of allergy and secondary colonization. Evaluation of new tinted 2% chlorhexidine gluconate/70% isopropyl alcohol film-forming sterile preoperative skin preparation showed it does not interfere with antimicrobial efficacy and it does not demonstrate a potential for the development of resistance or cross-resistance with antibiotics. ^[11]

Adhesives/skin preparations

Many of these products induce acute contact dermatitis. The surgeon should have more than one option available for such patients. ^[12]

Latex

Latex allergy is a rising problem, with symptoms varying from localized urticaria to anaphylaxis. Items other than the surgeon's gloves may be an issue in the operating room. Extra pairs of vinyl examination gloves should be readily available for patients with such sensitivities. ^[13]

Analgesics

Allergies or toxicities to administered analgesics should be noted and avoided.

Medications

In addition to a thorough medical history, the surgeon must inquire about all prescribed, over-the-counter, and herbal medications that a patient is taking. Many common medications can profoundly affect the perioperative and postoperative outcomes. Three major areas in which certain medications may interfere with surgical outcomes include hemostasis, wound healing, and drug interactions.

Hemostasis

Intraoperative or postoperative bleeding is one of the most undesirable surgical complications. Several commonly prescribed medications can interfere with the normal coagulation process. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit platelet function, thereby serving as a major source of perioperative bleeding in surgery. Aspirin irreversibly inhibits cyclooxygenase, the enzyme responsible for ultimately catalyzing the formation of prostaglandins. Aspirin irreversibly inhibits cyclooxygenase, and its effect lasts the entire duration of the platelets' lifespan (7-11 d). Aspirin can be restarted 1 day after surgery if medically necessary. Otherwise, restarting the drug 5-7 days after surgery is probably best.

During surgery, compression stockings are recommended, and altering the amount of calf compression is ideal.

Most dermatologic procedures are superficial, and although the patients may have increased bleeding with the use of aspirin, warfarin (Coumadin), and enoxaparin (Lovenox), it is advised that these medications be continued if the patient has had atrial fibrillation, previous stroke, or other cardiac conditions that mandate these medications. ^[14] Understandably, wound healing difficulties will occur with anticoagulation; nonetheless, this does not preclude the need for maintenance of the above medications.

NSAIDs reversibly inhibit cyclooxygenase, causing a similar effect that only lasts as long as the NSAID is in the system. It takes approximately 4.5 half-lives for any drug to reach negligible levels from its effective dose. Similar to aspirin, NSAIDs can be restarted 1 day after surgery if absolutely necessary, but using nonaspirin, non-NSAID pain relievers postoperatively is most prudent. Discontinuation of aspirin 2 weeks prior to surgery and of NSAIDs at least 5 half-lives of that particular NSAID dose prior to surgery is recommended.

Heparin is a glycosaminoglycan with potent anticoagulant activity. Its anticoagulant activity is due to a portion of the molecule's high affinity binding to antithrombin III and subsequent acceleration of its already potent anticoagulant action. Heparin also inhibits platelet function and increases the permeability of vessel walls. Low-dose heparin (5000 U subcutaneously bid) has a negligible effect on measurable coagulation and does not require discontinuation or adjustment prior to surgery. Full-dose intravenous or subcutaneous heparin does have a significant effect and needs to be stopped prior to surgery. The half-life of standard heparin ranges from approximately 45-60 minutes. Therefore, it should be discontinued 5 half-lives, or at least 5 hours, prior to the surgery.

Low molecular weight heparin (eg, enoxaparin) is a relatively new heparin that is increasingly being used. It has a lower molecular weight and negligible effects on platelet function and vascular permeability. It inhibits activated factor Xa. The average half-life of low molecular weight heparin is approximately 3 hours. Therefore, discontinuation at least 15 hours prior to surgery is recommended.

Warfarin (Coumadin) is another commonly used anticoagulant that acts by inhibiting a hepatic microsomal reductase that converts vitamin K to its active form. With vitamin K in an inactive form, the vitamin K–dependent clotting factors cannot be formed. Anticoagulant effects are delayed in onset and persist for several days after discontinuation. Stopping warfarin at least 3 days prior to surgery is recommended. In situations in which anticoagulation is absolutely necessary, heparin can be started while warfarin is stopped. The heparin can then be stopped hours prior to surgery. Warfarin can be restarted at the presurgery dosage 1 day after surgery.

Always carefully consider the underlying reason (eg, stroke, thrombosis) for anticoagulation before it is discontinued. For many patients, the risks of discontinuing their anticoagulant agents exceed the risk of perioperative bleeding, which may be as low as 1.6%. Thoughtful consideration of the risk-to-benefit ratio is needed. Consultation with the patient's primary care physician is warranted if any doubt exists with regard to managing the perioperative dose of warfarin or heparin.

Wound healing

Several medications have been shown to retard wound healing and should be discontinued before surgery if possible.

Absolute discontinuation is for the following medications:

• Glucocorticoids

• Antiplatelet agents

• Anticoagulants

• Nicotine

Relative discontinuation is for the following medications:

• Antineoplastic agents

• Immunosuppressive agents

• Colchicine

• Penicillamine

• Isotretinoin

• Phenytoin

Antiplatelet agents and anticoagulants can have an adverse effect on wound healing. Resultant hematoma formation has been shown to cause mechanical disruption, increase the risk of infection, and disturb the fibrin matrix needed for proper wound healing.

Glucocorticoids profoundly inhibit normal wound healing in several ways. Fibroblast proliferation is decreased, and the amount of granulation tissue is reduced. Inflammation is diminished. Protein and collagen production is decreased. Epidermal proliferation is reduced, and the host defense mechanisms are altered. Of all the systemic corticosteroids, cortisone acetate is the least harmful in this regard. A single dose of a corticosteroid and doses less than the equivalent of 10 mg/d of prednisolone are thought to have little effect on wound healing. In patients on large doses of corticosteroids, switching the corticosteroid to cortisone acetate and administering supplemental vitamin A are recommended. Vitamin A, in doses of 25,000 IU/d, has been shown to reverse many of the adverse effects of corticosteroids, except for restoration of wound contraction.

Nicotine is a potent vasoconstrictor that has been shown to have a detrimental effect on wound healing. Nicotine can be an important cause of flap necrosis, especially where extensive surgical undermining is needed. A history of cigarette smoking is important to elicit in elderly persons, in whom slow wound healing is already a risk. Patients should be urged to discontinue smoking before and after surgery. In general, persons who smoke should be strongly encouraged to stop smoking for at least 1 week preoperatively and 2 days postoperatively to minimize adverse reactions.

Many antineoplastic and immunosuppressive agents have been thought to retard wound healing. Alkylating agents, antimetabolites, and antibiotics have all been considered inhibitors of wound healing. Actinomycin, bleomycin, or carmustine (BCNU) causes greater impairment than does vincristine, methotrexate, 5-fluorouracil, or cyclophosphamide. Most of these drugs have little effect on minor dermatologic surgical procedures. However, the use of immunosuppressive or antineoplastic agents may predispose the patient to an even greater risk of infection, and physicians may consider the use of prophylactic antibiotics.

Several other systemic medications have been cited as wound inhibitors, primarily in animal studies. These medications include colchicine, penicillamine, isotretinoin, and phenytoin. Penicillamine decreases wound tensile strength at clinical dosages. Colchicine may have antifibroblastic properties. These agents are best considered to be minimal inhibitors of wound healing in surgery. Patients who are considering ablative skin resurfacing should have isotretinoin discontinued for 6 months before treatment.

Drug interactions

The geriatric population consumes more systemic medications than any other group. Numerous drug interactions and complications arise in this population, and special attention should be paid to them.

Diuretics are commonly prescribed medications for hypertension, congestive heart failure, and other fluid-retaining states. Common complications of diuretic therapy are hypokalemia and hypomagnesemia. Both abnormal electrolyte states, especially in combination with epinephrine use and a diseased heart, can predispose the patient to unwanted cardiac arrhythmias. In such patients, a baseline potassium and magnesium level prior to surgery may be indicated because these abnormalities are easily corrected with oral potassium and magnesium supplementation.

Monoamine oxidase inhibitors, phenothiazines, and tricyclic antidepressants may also potentiate the cardiostimulatory effects of epinephrine. In the elderly population, discontinuation of these agents 1-2 weeks prior to any elective surgery in which epinephrine will be used is recommended. Monoamine oxidase inhibitors can be restarted the day after surgery.

Propranolol has been reported to cause malignant hypertension and reflex bradycardia when used together with epinephrine. This adverse reaction is thought to result from blockade of peripheral beta-receptors (propranolol) in the face of unopposed alpha-receptor, vasoconstrictive stimulation (epinephrine). In the face of a crisis, intravenous hydralazine or chlorpromazine may be effective. In one series of patients taking propranolol prior to Mohs surgery in which epinephrine was used, no instance of hypertension was noted. Overall, this adverse reaction is thought to be uncommon. One must therefore consider the amount of epinephrine used and the magnitude of the surgery against the risk of stopping a beta-blocker in a patient with ischemic heart disease or unstable hypertension. Discontinuation of propranolol should be completed in consultation with the patient's primary care physician because an abrupt discontinuation of the antihypertensive drug can result in rebound hypertension or angina.

Medical devices

In the preoperative screening, physicians should inquire about artificial assistive devices, such as pacemakers, artificial cardiac valves, and artificial joints. The presence of any one of these foreign objects can affect the surgical course and the outcome. An electrosurgical grounding pad should be placed remotely from a metallic indwelling prosthesis.

Pacemakers

The patient with a modern cardiac pacemaker is most likely at low risk for adverse outcomes from the use of electrosurgery. However, Leshin and McCalmont suggest the following precautions ^[15] :

• Avoid electrosurgery in patients who are unstable and who are strongly dependent on the pacemaker.

• Perioperatively, monitor the patient's pulse and level of consciousness.

• Ground the patient with an indifferent electrode at a site that is away from the heart and the pacemaker.

• Avoid the use of the cutting current except in settings in which cardiac monitoring and resuscitation equipment are available.

• Use short bursts of electric current (< 5 seconds' duration).

• Avoid surgery near the heart or the pacemaker.

Artificial heart valves and other valvular heart diseases

In addition to inquiring about the presence of a pacemaker, physicians should ask about artificial heart valves and other valvular heart diseases, such as aortic stenosis, mitral valve prolapse, mitral stenosis, rheumatic heart disease, and a history of infective endocarditis. Many patients are not familiar with these medical terms and diseases. A good general question to ask is if the patient has ever had to take antibiotics before a surgical procedure or a dental visit.

Consensus exists on the use of antibiotic prophylaxis against endocarditis before certain procedures in patients with certain cardiac conditions. In a review of the literature on endocarditis precipitated by skin procedures, Spelman et al found only 4 cases of endocarditis following skin procedures in which no prophylaxis was given. ^[16] The skin procedures included cryoremoval of a nevus, a punch biopsy, acupuncture, and excision of 3 melanomas from the head and the neck. Three of these patients were known to have abnormal cardiac valves at the time of the procedure, and 2 of these 3 had prosthetic valves. This study recommended that patients with valvular heart disease or prosthetic valves should receive antibiotic prophylaxis before punch and incisional skin biopsies or excisions.

Table 2. Endocarditis Antibiotic Prophylaxis Regimens for Cutaneous Procedures (Open Table in a new window)

Prosthetic joints

The issue of chemoprophylaxis for prosthetic joint infections is controversial. According to a review by Choi, most routine prophylaxis for patients with prosthetic joints is not necessary. ^[17] Two other authors, based on their cost-to-benefit analysis, disagree with withholding antibiotic prophylaxis. They suggest that antibiotic prophylaxis should be administered to patients likely to have a poor outcome and to those patients at higher risk for infection, such as those with rheumatoid arthritis or chronic debilitating diseases and those on immunomodulatory medications.

Choi's summary of the available studies concludes that advocating routine antibiotic prophylaxis for most invasive procedures in patients with prosthetic joints is difficult, but targeting prophylaxis to patients at greater risk of poor outcomes is probably prudent. Antibiotic prophylaxis should cover the major pathogens (S aureus and Staphylococcus epidermidis). A first-generation cephalosporin, clindamycin, dicloxacillin, and vancomycin are all appropriate choices.

An enormous public enthusiasm exists for herbal medications. Herbal medications are widely used among the presurgical population. Morbidity and mortality associated with herbal medications may be more likely in the perioperative period because of the polypharmacy and the physiological alterations that occur. Such complications include myocardial infarction, stroke, bleeding, inadequate oral anticoagulation, prolonged or inadequate anesthesia, organ transplant rejection, and interference with medications indispensable for patient care.

In 1997, approximately 12% of the US population used herbal medications; this rate represents a 380% increase from 1990. Patients undergoing surgery appear to use herbal medications more frequently than the general population. ^[18] For instance, Tsen et al reported that 22% of patients who underwent evaluation in their preoperative clinic took herbal medications. ^[19] Kaye et al found that 32% of patients in an ambulatory surgical setting admitted to using herbal medications. ^[20] More than 22.8 million Americans use herbs instead of prescription medications, and 30 million Americans use herbal medication instead of over-the-counter medications. A study sampling 601 parents found that 16.6% of children have used or currently use herbal medications. A positive correlation exists between parental use and children use of herbal medication. ^[21]

In the study by Kaye et al, more than 70% of patients failed to disclose their herbal medicine use during routine preoperative assessment. ^[20] Explanations for this lack of disclosure include patient-held beliefs that physicians are not knowledgeable about herbal medications or that they are prejudiced against herbal use. In addition, some patients fear to admit their use of unconventional therapies to their physician. Others may neglect to mention that they are taking herbal medications because they are using them for reasons perceived as unrelated to their medical care. Some patients do not consider herbal substances to be medications, and they consequently neglect to report them during routine preoperative questioning. For these reasons, physicians need to specifically seek out a history of herbal medicine use in patients before surgery.

Despite many uncertainties in commercial preparations, herbal medications adhere to modern pharmacologic principles. A single herbal medication may adversely affect the patient during the perioperative period through a number of different mechanisms. These effects are direct interactions (intrinsic pharmacologic effects), pharmacodynamic interactions (alteration of the action of conventional drugs at effector sites), and pharmacokinetic interactions (alteration of the absorption, distribution, metabolism, and elimination of conventional drugs). ^[22]

Eight commonly used herbal medications are echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John's wort, and valerian. These herbs account for more than 50% of all single-herb preparations among the 1500-1800 herbal medications sold in the United States.

Echinacea

In the past 2 years, echinacea was the most common herb used by the American public. It was reported that of all herbs used as a medicine, the rate of echinacea use was 48%. Three species of echinacea are used to treat viral, bacterial, and fungal infections of the upper respiratory tract. Preclinical studies of echinacea have revealed a number of immunostimulatory effects. Although no study specifically addresses the interactions between echinacea and immunosuppressive drugs, experts generally warn against the concomitant use of this herb and immunosuppressive drugs because of the probability of diminished effectiveness.

Patients who may require perioperative immunosuppression, such as those awaiting organ transplantation, should be counseled to avoid taking echinacea. In contrast to the immunostimulatory effects with short-term use, the long-term use of echinacea (>8 wk) is accompanied by the potential for immunosuppression and a theoretically increased risk of certain postsurgical complications, such as poor wound healing and opportunistic infections.

Echinacea has been associated with allergic reactions, including 1 reported case of anaphylaxis. Echinacea should be used with caution in patients with asthma or allergic rhinitis. Concerns of potential hepatotoxicity have been raised, although documented cases are lacking. Patients with preexisting liver dysfunction should be cautious when taking echinacea. Echinacea has been suggested to have the potential to stimulate tumor necrosis factor-alpha, interleukin 1, and interleukin 6. In light of this, some believe that it should not be used in AIDS patients due to the possibility of accelerating the course of the disease.

Furthermore, the pharmacokinetics of echinacea have not been fully studied. Patients should discontinue echinacea as far in advance of surgery as possible when compromises in hepatic function or blood flow are anticipated. These situations often occur secondary to concomitant anesthetic drug administration or as an effect of surgical manipulation.

Ephedra

Ephedra is used to promote weight loss; to increase energy; and to treat respiratory tract conditions, such as asthma and bronchitis. It contains alkaloids, including ephedrine, pseudoephedrine, norephedrine, methylephedrine, and norpseudoephedrine. Ephedra causes dose-dependent increases in blood pressure and heart rate. Ephedrine, the predominant active compound, is a noncatecholamine sympathomimetic agent that exhibits alpha₁, beta₁, and beta₂ activity by acting directly on adrenergic receptors and by indirectly releasing endogenous norepinephrine. These sympathomimetic effects have been associated with more than 1070 reported adverse events, including fatal cardiac and CNS complications.

Ephedrine is widely used as a first-line therapy for intraoperative hypotension and bradycardia; the unsupervised preoperative use of ephedra raises certain concerns. Vasoconstriction and vasospasm of coronary and cerebral arteries may cause myocardial infarction and thrombotic stroke. Patients who have consumed ephedra and are anesthetized with halothane may be at risk of intraoperative ventricular arrhythmias because halothane sensitizes the myocardium to ventricular arrhythmias caused by exogenous catecholamines. Ephedra may affect cardiovascular function by causing hypersensitivity myocarditis characterized by cardiomyopathy with myocardial lymphocyte and eosinophil infiltration.

The long-term use of ephedra causes tachyphylaxis from the depletion of endogenous catecholamine stores and may contribute to perioperative hemodynamic instability. In these situations, direct-acting sympathomimetic agents may be preferred as first-line therapy for intraoperative hypotension and bradycardia. The concomitant use of ephedra and monoamine oxidase inhibitors can result in life-threatening hyperpyrexia, hypertension, and coma. In addition, the heavy use of ephedra has been documented to cause radiolucent kidney stones. Ephedra used as an appetite suppressant has resulted in numerous deaths and FDA regulation is forthcoming.

The pharmacokinetics of ephedrine have been studied in humans. Ephedrine has an elimination half-life of 5.2 hours, with 70-80% of the compound excreted unchanged in the urine. Based on the pharmacokinetic data and the known cardiovascular risks of ephedra, patients taking this herb should discontinue use at least 24 hours prior to surgery.

Garlic

Of the 38% of Americans using herbal medications in the past 2 years, 27% of them were garlic users. Garlic has the potential to modify the risk of atherosclerosis by reducing blood pressure and thrombus formation and by lowering serum lipid and cholesterol levels. These effects are primarily attributed to the sulfur-containing compounds, particularly allicin and its transformation products.

Garlic inhibits platelet aggregation in a dose-dependent fashion. The effect of one of its constituents, ajoene, appears to be irreversible and may potentiate the effect of other platelet inhibitors, such as prostacyclin, forskolin, indomethacin, and dipyridamole. The platelet-altering effects of garlic have not been consistently demonstrated in volunteers taking high doses. However, one case report documented in the literature is that of an octogenarian who developed a spontaneous epidural hematoma attributed to the heavy use of garlic. In addition to concerns about bleeding, garlic has the potential to lower blood pressure. In laboratory animals, allicin decreased systemic and pulmonary vascular resistance and lowered blood pressure. In humans, the antihypertensive effect of garlic is marginal. Garlic results in the potential adverse effects of dizziness, headache, irritability, nausea, vomiting, anorexia, and irritation of oral mucosa.

Although the pharmacokinetic data of the constituents of garlic are insufficient, the potential for irreversible inhibition of platelet function may warrant patients to discontinue the use of garlic at least 7 days prior to surgery, especially if postoperative bleeding is a particular concern or if other platelet inhibitors have been given.

Ginkgo

Of the 38% of Americans using herbal medications in the past 2 years, 22% of them were ginkgo users. Ginkgo has been used for cognitive disorders, peripheral vascular disease, age-related macular degeneration, vertigo, tinnitus, erectile dysfunction, and altitude sickness. Studies suggest that ginkgo may stabilize or improve cognitive performance in patients with Alzheimer disease and multi-infarct dementia.

Ginkgo appears to alter vasoregulation, to act as an antioxidant, to modulate neurotransmitter and receptor activity, and to inhibit platelet-activating factor. Of these effects, the inhibition of platelet-activating factor raises the greatest concern for the perioperative period because platelet function may be altered. Clinical trials with small numbers of patients have not demonstrated complications from bleeding; however, 4 cases of spontaneous intracranial bleeding, 1 case of spontaneous hyphema, and 1 case of postoperative bleeding after laparoscopic cholecystectomy have been attributed to ginkgo use.

Studies have shown that the component of ginkgo, ginkgolgic acid, may lead to dermatological problems similar to those resulting from poison ivy and poison oak. This is due to the fact of the acid being structurally similar to the Toxicodendron species, the species including poison ivy and poison oak. Other cases show a correlation with ginkgo usage and seizures in patients with previously controlled epilepsy.

Terpenoids are the compounds believed to be responsible for the pharmacologic effects of ginkgo. They are highly bioavailable when orally administered. The elimination half-lives of the terpenoids after oral administration are 3-10 hours. Based on the pharmacokinetic data and the risk of bleeding, particularly in the surgical population, patients should discontinue taking ginkgo at least 36 hours prior to surgery.

Ginseng

Of the 38% of Americans using herbal medications in the past 2 years, 28% of them were ginseng users. Ginseng has been labeled as an adaptogen because it reputedly protects the body against stress and restores homeostasis. Most pharmacologic actions are attributed to the ginsenosides that belong to a group of compounds known as steroidal saponins.

Ginseng has a broad but incompletely understood pharmacologic profile because of the many heterogeneous and sometimes opposing effects of different ginsenosides. The underlying mechanism appears to be similar to that classically described for steroid hormones. A potential therapeutic use for this herb has to do with its ability to lower postprandial blood glucose levels both in patients with type 2 diabetes mellitus and in those without diabetes. This insulinlike effect may create unintended hypoglycemia, particularly in patients who have fasted before surgery.

A concern exists about the effect of ginseng on coagulation pathways. Ginsenosides inhibit platelet aggregation in vitro and in laboratory rats. They prolong the coagulation times of thrombin and activated partial thromboplastin. One study suggests that the antiplatelet activity of panaxynol, a constituent of ginseng, may be irreversible in humans. These findings await further confirmation. Although ginseng may inhibit the coagulation cascade, its use has been associated with a significant decrease in warfarin anticoagulation in 1 reported case. The pharmacokinetics of ginsenosides show an elimination half-life of 0.8-7.4 hours. These data suggest that patients should discontinue ginseng at least 24 hours prior to surgery. However, because the platelet inhibition caused by ginseng may be irreversible, patients probably should discontinue ginseng use at least 7 days prior to surgery.

Kava

Kava has gained widespread popularity as an anxiolytic and a sedative. ^[23] The results from clinical trials suggest that kava has a therapeutic potential in the symptomatic treatment of anxiety. The kavalactones appear to be the source of the pharmacologic activity of kava.

Due to its psychomotor effects, kava was one of the first herbal medications expected to interact with anesthetics. The kavalactones have dose-dependent effects on the CNS, including antiepileptic, neuroprotective, and local anesthetic properties. Kava may act as a sedative-hypnotic by potentiating gamma-aminobutyric acid (GABA) inhibitory neurotransmission. This effect may explain the mechanism underlying the report of a case of coma attributed to an alprazolam-kava interaction. With heavy use, kava produces a condition called kava dermopathy, which is characterized by reversible, scaly, cutaneous eruptions.

Research findings show that kava is potentially associated with cardiovascular complications. Kava may inhibit sodium and calcium channels, thereby decreasing systemic vascular resistance and secondarily decreasing blood pressure. Kava also inhibits cyclooxygenase, which may interfere with platelet aggregation and renal blood flow.

Peak kava plasma levels occur 1.8 hours after an oral dose, and the elimination half-life of kavalactones is 9 hours. Unchanged kavalactones and their metabolites are eliminated through urine and feces. The pharmacokinetic data and the possibility for the potentiation of the sedative effects of anesthetics suggest that patients taking kava should discontinue its use at least 24 hours prior to surgery.

St. John's wort

A number of clinical trials have reported efficacy in the short-term treatment of mild-to-moderate depression. The most recent multicenter clinical trial concluded that St. John's wort is not effective in treating major depression. Nonetheless, St. John’s wort is widely used by many patients. The compounds believed to be responsible for pharmacologic activity are hypericin and hyperforin. Commercial preparations are often standardized to a fixed hypericin content of 0.3%.

St. John's wort exerts its effects by inhibiting serotonin, norepinephrine, and dopamine reuptake by neurons. Concomitant use of this herb with or without serotonin reuptake inhibitors may create a syndrome of central serotonin excess. Contradictory studies report that St. John's wort is comparable in effectiveness to most antidepressant agents. In 13 studies comparing the herbal remedy with placebo, 55.1% of St. John's wort–treated depressed patients showed significant improvement, versus 22.3% with placebo. The use of St. John's wort can significantly increase the metabolism of many concomitantly administered drugs, some of which are vital to the perioperative care of certain patients.

Single-dose and steady-state pharmacokinetics of hypericin, pseudohypericin, and hyperforin have been determined. After oral administration, peak plasma levels of hypericin and hyperforin were obtained at 6 hours and at 3.5 hours, and their median elimination half-lives were 43.1 hours and 9 hours, respectively. The long half-life and alterations in the metabolism of many drugs make concomitant use of St. John's wort particularly risky in the perioperative setting. The pharmacokinetic data suggest that patients taking this herbal medication should discontinue wort use at least 5 days prior to surgery. This discontinuation is especially important for patients waiting for organ transplantation or for those who may require oral anticoagulation postoperatively. St. John's wort also affects digoxin pharmacokinetics, possibly by inducing the P-glycoprotein transporter. Patients should be counseled to avoid taking St. John's wort postoperatively.

Valerian

Valerian is an herb used as a sedative, particularly in the treatment of insomnia. Virtually all herbal sleep aids contain valerian. Valerian contains many compounds that act synergistically. Sesquiterpenes are the primary source of the pharmacologic effects of valerian.

Valerian produces dose-dependent sedation and hypnosis. These effects appear to be mediated through the modulation of GABA neurotransmission and receptor function. Based on these findings, valerian should be expected to potentiate the sedative effects of anesthetics and adjuvants (eg, midazolam) that act at the GABA receptor. The pharmacokinetics of the constituents of valerian have not been studied, although their effects are thought to be short-lived. Valerian has also been used to reduce headaches, chest tightness, mydriasis, abdominal pain, and tremor of the hands and feet.

Caution should be taken with abrupt discontinuation of use in patients who may be physically dependent on valerian because of the risk of benzodiazepinelike withdrawal. In these individuals, with close medical supervision, the dose of valerian should be tapered during the several weeks before surgery. If tapering is not feasible, physicians can advise patients to continue taking valerian up until the day of surgery. Based on the mechanism of action and a reported case of effectiveness, benzodiazepines can be used to treat withdrawal symptoms if they develop during the postoperative period.

A thorough examination of the lesion or lesions in question and any associated areas for treatment is essential. An assessment of the patient's overall health status should be performed. Findings may mandate further evaluation by laboratory tests and diagnostic studies, thus avoiding surgical complications.

The lesion should be evaluated for size, location, proximity to old scars, and relationship to potentially dangerous areas or natural skin lines. Any unusual features or preexisting abnormalities, such as eyelid ptosis or nasal alae asymmetry, should be carefully recorded. This documentation is especially important if the lesion occurs in close proximity to the proposed surgery site. Nasal valve insufficiency may be anticipated in planning for tumor removal and/or reconstruction for defects larger than 1 cm on the ala, sidewall, or alar crease. ^[24]

Several methods can be used to describe the location of the lesion. One method is to measure from 2 distinct landmarks. Physicians may also use the New York University numbering system, which uses standardized numbers assigned to anatomical regions for consistent identification. Photographing the lesion provides the most accurate description (digital imaging). Digital imaging and archiving simplify follow-up. ^[25] See Digital Photography for detailed information.

Awareness of anatomical structures residing close to the intended surgical field is essential. A thorough understanding of vascular networks, neural innervation, and structural anatomy is needed. For example, the head and the neck are frequent domains for the cosmetic surgeon. Here is where many cutaneous malignancies occur and cosmetic enhancements are performed. A surgeon should appreciate that the external carotid artery supplies most of the face. From this artery, the superficial temporal artery is amenable to injury as its course becomes superficial en route from the preauricular region to the scalp. This branch can often be easily palpated and its location noted prior to embarking on surgery. Likewise, the inferior and superior labial branches of the facial artery are frequently encountered during lip surgery. If anticipated, these vessels can be suture ligated to avoid excessive bleeding when performing wedge excisions.

The facial nerve (5 branches: temporal, zygomatic, buccal, marginal mandibular, and cervical) is responsible for motor innervation to the face. Of these branches, the temporal and mandibular branches become superficial during their course and are subject to damage during surgery. Injury to the temporal branch results in ipsilateral eyebrow ptosis and paralysis of the frontalis muscle (inability to wrinkle the forehead on the affected side). The marginal mandibular nerve, if injured, results in drooping of the lower lip. These potential occurrences should be discussed with patients in advance of their procedure. Surgeons must always be alert to these and other "danger zones."

As the surgeon evaluates the lesion, several questions should come to mind:

• Is the lesion near a critical structure?

• Is the lesion at risk for recurrence?

• If malignant, can adequate margins be taken? Is there evidence of metastasis?

• How is the lesion positioned in relation to the resting skin tension lines?

• What treatment and closure options are available?

• Is there a preexisting abnormality?

• How do previous surgical scars appear?

• How is the patient's skin (eg, texture, laxity)?

These questions aid the surgeon in determining the optimal treatment and in directing the discussion with the patient

Many surgical procedures require specialized information in addition to the routine history and physical examination discussed previously. The following procedures are discussed to outline potential areas of concern.

Hair transplant

The main concern during hair transplantation is bleeding. Many bleeding diatheses (platelet dysfunction and von Willebrand disease) manifest when the scalp, a highly vascularized field, is stressed during a transplant in which the donor sites are not frequently sutured. Many physicians recommend evaluating the patient's PT, aPTT, international normalized ratio (INR), and bleeding time prior to the procedure.

In general, the donor site and the recipient site need to be inspected for hair density, quality, and texture. After an estimation of the yield of grafts is made, the physician should discuss where and how the hair grafts will be implanted. Some hair grafts become dislodged overnight and can easily be reseated the next day. No exercise or heavy lifting should be performed for several days. The scalp dressing should remain intact overnight, and the hair grafts should not be washed for about 3-4 days. Ideally, all dressings should be removed by trained personnel only. Compliance with these recommendations ensures success of the transplants.

General laser treatments

Depending on which laser is being used, a careful history should be obtained. For pediatric patients with vascular lesions, a history of seizures and a careful review of systems should be completed. A detailed history helps detect syndromes associated with vascular lesions, such as Sturge-Weber syndrome and Klippel-Trenaunay syndrome. More than one treatment session is necessary in most cases of vascular lesion ablation, and this should be explained to the patient.

Tattoos generally require several treatment sessions. Colors respond differently to the various wavelengths due to selective photothermolysis of each particular wavelength. Pigment changes may occur with tattoo removal. Generally, patients with Fitzgerald skin type I or II experience hypopigmentation of the treated tattoo, and patients should be informed of this potential. Similarly, type III or IV skin may become hyperpigmented.

Toenail surgery

The most specific evaluation related to toenail surgery is the adequacy of the peripheral vascular system. Assessment of peripheral vascular disease can be obtained by history. Intermittent claudication or evidence of arteriosclerotic disease in other sites, such as the heart or the brain, are indicative of vascular disease. Peripheral pulses should be palpated before toenail surgery. Cutaneous signs of vascular insufficiency include thin, shiny skin; thickened, ridged nails; absence of dorsal digital hair; and dependent rubor followed by a pallor with elevation. Appropriate consultation and vascular flow studies may be indicated.

Liposuction  ^[26]

The preoperative consultation is essential for the patient seeking liposuction. The dermatologic surgeon must fully interview the patient. Inquiries about diet, exercise, weight stability, and familial body shape should be made. Patients should be asked about specific areas that they find cosmetically bothersome and about aspects of their body shape that seem refractory to caloric restriction or exercise expenditure.

At the time of the preoperative consultation, an assessment of weight stability is performed. Is the patient of normal weight for height or is he or she a little overweight? Liposuction is not a therapy for patients who are morbidly obese. Is the patient actively gaining weight and seeking liposuction to slow down his or her weight gain? Liposuction is best performed on the patient with a stable weight and a regular exercise routine. If a patient continues to gain weight after liposuction, he or she may feel that the procedure was ineffective. If a patient's weight varies by 10-20 lb, performing the procedure at the higher end of the weight fluctuations is better.

A psychological assessment is necessary for every patient undergoing a cosmetic procedure. Physicians should be aware that some patient's expectations for liposuction may be excessive. For example, patients may expect that liposuction of the thighs may correct their marital difficulties. Ensure that the patient is seeking liposuction for the right reasons.

A thorough physical examination of the body sites to be treated, overall physique, and body shape is required. Assessment for skin tone and elasticity must be carried out by the dermatologic surgeon. In general, good skin tone and elasticity are advisable because skin retraction and remodeling occurs around the debulked fatty tissue. Patients with poor skin elasticity must be warned that they may have some postoperative draping of the skin, which could require surgical correction following liposuction. Patients having rare syndromes with poor skin elasticity, such as Danlos syndrome or cutis laxa, should be identified.

The benefits of tumescent anesthesia should be detailed. Although many patients wish to be treated under general anesthesia, a careful discussion of the risks associated with heavy sedation or general anesthesia emphasizes the benefits of the tumescent anesthetic technique. Oral sedatives the night before and 1 hour prior to the procedure may be helpful for some patients.

Informed consent is important. Liposuction procedures may have serious complications, including death, resulting from perforation of a viscus. Fluid shifts, disseminated intravascular coagulation, emboli, hematomas, and seromas all have been reported. Uneven skin contour changes may occur but can be ameliorated by massage and compression dressings. Preoperative laboratory evaluation may include a complete blood cell count, a chemistry profile, and aPTT/PT determinations. Female patients should stop birth control pills 1 month prior to liposuction, owing to the high risk of thromboembolism postoperatively.

Mohs micrographic surgery

Patients with skin cancer require detailed information about the possibility of an extensive defect. The defect after Mohs treatment cannot always be determined during the time of the preoperative evaluation. Vital structures, such as nerves, may be sacrificed during extensive surgeries. Repercussions of the cancer treatment should be outlined. Options for wound closure should be discussed and include healing by secondary intention, primary closure, flap, or graft. At times, a multidisciplinary approach may be needed. Reassure the patient that a revision in the future is possible. Recurrences are possible, and patients with skin cancer should be carefully monitored posttreatment. In vivo reflectance confocal microscopy of basal cell carcinomas may aid in preoperative mapping of cancer margins. ^{[27, 28]}

Shared medical appointments have been advocated for patients prior to Mohs micrographic surgery, providing multiple patients with appropriate information on skin cancer and its treatment. This concept was used in a study of 149 patient for the Mohs preoperative consultation and earned a high patient satisfaction rate. ^[29]

Sclerotherapy

Contraindications to sclerotherapy are a history of deep vein thrombosis, pulmonary embolism, or phlebitis. A history of easy bruising may indicate a clotting problem, and an appropriate laboratory workup should be performed. Ideally, anticoagulation treatment should be discontinued to avoid further bruising. Guidelines for further evaluation, such as Doppler ultrasonography or ultrasonography, are available. Ultrasonographic-guided injections secure more optimal results for large varicose veins and perforators over palpation techniques. The use of support stockings and moderate exercise postoperatively aid in the success of the sclerotherapy procedure. Inform patients that multiple sessions may be required.

Skin resurfacing

Skin resurfacing can be accomplished via dermabrasion, chemical peeling, or ablative lasers. ^[30] Commonly used for scar revisions and treatment of aging skin, these procedures have several adverse effects, such as milia, erythema, pigment changes, and increased sun sensitivity. A test spot may be recommended to assess response and healing in advance of the procedure.

An increased risk of scarring exists, especially with bacterial or viral infection. If a patient has a history of frequent herpes eruptions, the patient should be treated prophylactically. Herpes simplex virus may disseminate on the denuded skin of a dermabraded site during the healing phase. Acyclovir has been used as a treatment, as well as to prevent this occurrence in patients with a history of recurrent herpes simplex. Acyclovir is given 1-2 days prior to dermabrasion or laser skin ablation, and the prophylactic treatment should be continued during the time of healing.

Skin refrigerants are used in dermabrasion for anesthesia and hemostasis and to establish a firm surface. Cryopathies and diseases associated with cryopathy should be investigated in the medical history. Some physicians may test for cryoglobulin and cryofibrinogen levels prior to dermabrasion. Additionally, some of the refrigerants have been associated with increased scarring.

Isotretinoin has been associated with unusual postoperative scarring after dermabrasion, despite intervals as long as 6-14 months between discontinuation of the drug and the dermabrasion.

The geriatric patient

Elderly patients who present for surgery often have a multitude of health problems, including severe cardiovascular-vascular disease, renal insufficiency, and diabetes. ^{[31, 32]} Many geriatric patients are on medications that can endanger them if discontinued for surgery. Alternative, nonsurgical treatments for very frail patients include radiation for basal cell carcinoma, squamous cell carcinoma, or Merkel cell tumors. With some neoplasms, particularly of the submandibular glands, ultrasound-guided fine-needle aspiration cytology may be useful in preoperative examination. ^[33]

The pediatric patient

A parent or a legal guardian must accompany the child and should be present during the consultation and informed consent. If the child is of a relatively mature age, the child should be included in the conversation. The child's concerns and wishes should always be addressed. Creating a child-friendly environment with toys and offering stickers or other rewards are helpful. Allow the child to bring a favorite toy or personal stereo to the procedure. EMLA cream applied prior to a procedure decreases the pain of any needed injections.

The psychiatric patient

Psychological problems are often the cause of "doctor shopping." Warning signs to the physician include the following:

• Unrealistic expectations regarding the outcome of a procedure

• Obsession about cosmetic appearance (ie, the problem is exaggerated beyond reality)

• Wrong perception of the surgery (eg, the patient expects cosmetic surgery to help other aspects of his or her life)

• Reluctance to accept the physician's explanation or excessive criticism of prior physicians treatment

If a mutual satisfactory understanding has not been established prior to the procedure, the patient may not be a surgical candidate.