Iyengar 2019

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Update and Review of Bleeding Considerations in

Dermatologic Surgery: Hemostatic Techniques and


Treatment Strategies for Bleeding Complications
Sanjana Iyengar, MD,* Danielle G. Yeager, MD,† Joel L. Cohen, MD,‡x and
David M. Ozog, MD†

BACKGROUND There are many intraoperative and postoperative techniques to aid hemostasis in derma-
tologic procedures. An updated understanding is critical for the surgeon.

OBJECTIVE To provide an updated review of methods for hemostasis and therapies for postprocedural
purpura and ecchymosis applicable to dermatology.

MATERIALS AND METHODS A review of Ovid MEDLINE was performed to review the English-language
medical literature of hemostatic options and their use in cutaneous surgery. All available publication years
were included from 1946 to present.

RESULTS A comprehensive and current list of hemostatic options used in the intraoperative and post-
operative period is provided along with traditional and emerging therapies for postprocedural purpura and
ecchymosis.

CONCLUSION A myriad of options exist for minimizing and treating bleeding complications. The appropriate
use and updated knowledge of hemostatic options is provided.

The authors have indicated no significant interest with commercial supporters.

E ffective hemostasis is important to optimize


surgical outcomes and prevent complications
such as hematomas, dehiscence, and infection.1
Methods

A review of the English-language medical literature


was performed using Ovid MEDLINE. Search terms
Several techniques and hemostatic agents may be used
included “dermatologic surgery procedures,” “der-
to manage bleeding complications both
matologic surgery,” “cutaneous surgery,” “hemosta-
intraoperatively and postoperatively.
sis,” “hemostasis, surgical,” “hemostatic techniques,”
In this review, we discuss current and proper tech- “electrosurgery,” “sutures,” “bone wax,” “throm-
niques to deal with bleeding complications, includ- bin,” “fibrin tissue adhesive,” “fibrin sealant,”
ing hemostatic options that can be used “fibrillar collagen,” “hydrophilic polymer,” “micro-
intraoperatively and postoperatively. Updated porous polysaccharide hemosphere,” “aluminum
therapies to manage postprocedural purpura, chloride solution,” “ferric subsulfate solution,” “zinc
ecchymosis, and expanding hematomas will also be chloride paste,” and combination thereof. The search
discussed. reviewed all relevant publications from 1946 to

*Department of Dermatology, West Virginia University, Morgantown, West Virginia; †Department of Dermatology,
Henry Ford Hospital, Detroit, Michigan; ‡AboutSkin Dermatology and DermSurgery, Greenwood Village,
Colorado; xDepartment of Dermatology, University of California Irvine, Irvine, California

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2019;00:1–13 DOI: 10.1097/DSS.0000000000002138

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
HEMOSTATIC AGENTS AND TECHNIQUES

August 3, 2018, and yielded 1,241 publications. These Electrosurgery can damage surrounding tissue and
were limited to the English language and 1,087 impede wound healing.1 In addition, there is a minimal
remained, whose abstracts were reviewed. risk of fire if the surgical area is prepped with alcohol
or aluminum chloride.3 Caution should be taken in
Results patients with implantable electronic devices due to the
risk of electromagnetic interference. Defibrillators
A summary of the results and hemostatic methods can may incorrectly identify electrosurgery as a cardiac
be seen in Table 1. arrhythmia and discharge a shock.4 The use of a
bipolar tip, however, has been reported to minimize
Discussion electromagnetic interference and avoid cardiac
complications.5
Pressure
Suture Techniques
Direct pressure over a bleeding vessel can stimulate
platelet aggregation and the resultant coagulation If bleeding from larger vessels does not respond to
cascade. Uninterrupted manual compression should electrocoagulation, suture techniques (vessel liga-
be held for 15 to 20 minutes to effectively cease tion) are often used in place to provide proper
bleeding.1 Smaller wounds may require a shorter time, hemostasis. A figure-of-eight suture can be used to
anywhere from 1 to several minutes of direct pressure.2 ligate vessels to tamponade bleeding.1 This is per-
Intraoperatively, the use of surgical instruments, such formed most commonly with an absorbable braided
as a hemostat (or even a needle-driver), can prevent suture.6 For patients with bleeding from the incision
bleeding by clamping the involved vessel and facili- site, purse-string sutures can be used to apply tension
tating electrocoagulation of the vessel or tying-off the to the wound edges and compress vessels in the
vessel with the suture. In the case of severe bleeding, dermis.7
applying pressure to the supplying artery further
upstream can help control blood loss and slow the Hemostasis can also be accomplished with horizontal
pressure in the vessel enough to allow visualization to mattress sutures or running locked sutures. Multiple
clamp. For difficult-to-reach areas, such as the nasal variations of horizontal mattress sutures include
ala, long cotton tip applicators may also be used for interrupted, buried in dermal closure, running, and
hemostasis. On digits, a tourniquet may be applied for finally modified locking horizontal mattress sutures.8
up to 20 minutes to control and help identify A potential risk of horizontal mattress sutures is tissue
bleeding.1
strangulation and wound edge necrosis if tied too
tightly.9,10 When using running locked sutures, it is
Electrosurgery
best to use monofilament sutures to minimize track
Electrosurgery is the most commonly used method for marks and foreign-body reactions.
hemostasis by dermatologic surgeons.1 Electricity
from the instrument induces thermal damage to the Additional techniques are helpful in certain loca-
tissue leading to the coagulation cascade and blockage tions. If a planned excision is close to the branches of
of the vessel. Forms of electrosurgery include electro- the superficial temporal artery, percutaneous ligature
coagulation, electrodessication, electrofulguration, of vessels with the suture near the superficial tempo-
and electrosection. Electrocoagulation is the most ral artery may be considered.11 Before the procedure,
commonly used of these modalities in dermatologic the course of the artery is palpated and traced. After
surgery and is a type of biterminal electrosurgery using excision, severed ends of the artery can be ligated or
high-amplitude, low-voltage electric currents. coagulated with subsequent removal of the percuta-
Although electricity is not lost to the surrounding tis- neous sutures.11 For the scalp, an effective technique
sue, the current in electrocoagulation is actually termed “hemostatic enclosure” has been described in
interrupted to promote vessel wall sealing. which simple stitches with 2-0 nylon are placed side

2 DERMATOLOGIC SURGERY

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

TABLE 1. Summary of Hemostatic Methods Based on Wound Type*2,30,47

Wound Hemostatic Approximate Use in


Type Method Name Cost† Dermatology Advantages Disadvantages
Deep/ Pressure — — Yes Inexpensive, May not adequately control severe,
active quick, easily persistent bleeding alone
bleeding performed
Electrosurgery — — Yes Widely Can damage surrounding tissue and
available, decrease wound healing if used in
effective excess, risk of fire if near alcohol or
aluminum chloride
Suture — — Yes Effective, inexpensive Excess pressure could cause
techniques strangulation and necrosis
Bone wax — Affordable ($4–$7/ Rare, may be Easily handled, quick application, Possible complications include foreign
2.5-gm wax) used if near effective on bony surfaces, body granulomas, local infection, and
bone nonabsorbent, malleable interference of osteogenesis
Physiologic Thrombin Expensive (range of Rare due to Useful for diffuse bleeding Postcoagulopathy
agents (Thrombostat, $46/unit–$300/ expense
Thrombin-JMI, 20,000 units; spray
Evithrom) more costly)
Fibrin sealants Expensive ($100/1 Rare due to Effective clot formation, may enhance Hypersensitivity reactions,
(Tisseel, Evicel) mL) expense wound healing neurotoxicity, and expense
Platelet gels Expensive ($100–150/ Rare due to Effective hemostatic meshwork Expense
(Vitagel, 1-mL kit) expense
Costasis)
Tranexamic acid Expensive (tablet is Limited Effective antifibrinolytic drug, May not be readily accessible, lack of
(Lysteda tablet) $50–150) (solution reversibly binds to plasminogen and high-quality trials
(Cyckloparon IV is $20–50 per 100 prevents dissolution of fibrin clots
solution) mg/mL vial)
00:00:MONTH 2019

IYENGAR ET AL
3
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

4
DERMATOLOGIC SURGERY

HEMOSTATIC AGENTS AND TECHNIQUES


TABLE 1. (Continued )

Wound Hemostatic Approximate Use in


Type Method Name Cost† Dermatology Advantages Disadvantages
Oozing Pressure — — Yes Same as above Same as above
Electrosurgery — — Yes Same as above Same as above
Noncaustic Gelatin Relatively affordable Limited Nonreactive, nonantigenic, ideal for Infection, neurovascular compression,
agents (Gelfoam, ($11–20/square). oozing, malleable, promotes healing giant-cell granuloma, can stick to
Surgifoam) Square sizes: 12, 50, by second intention, absorbed by instruments, should not be used in
100, and 200 square body in 4–6 wk closure of skin incisions as it may
cm affect healing74
Oxidized Relatively affordable Limited Easy application, conforms to wound, Inflammation, delayed wound healing
cellulose ($12/square, $25–40 left on wound to heal by second and coagulation necrosis, allergic
(Surgicel, for pad). intention, absorbed by body in 1–2 contact dermatitis
Oxycel) Variable sizes from weeks.
0.5 · 2 inches to 2 ·
14 inches
Microfibrillar Expensive ($132– Limited Ideal for large surface areas, minimal Rare granuloma or foreign body
collagen $170/1oz) swelling and risk of compression, reactions
(Avitene, hemostasis occurs in about 1–5 min
Helistat)
Hydrophilic Affordable ($2/use) Limited Inexpensive, easy to handle, 96% Only used on open wounds that heal by
polymer with success rate in treating lacerations, second intention
potassium salts skin tears, and abrasions, hemostasis
(WoundSeal) is quick and may be achieved in less
than 15 s
Microporous Expensive ($107/1 g) Limited Effective Could increase glucose levels,
polysaccharide within minutes, absorbed by body in expensive
hemospheres 24–48 hours, can be used on open or
(Arista, closed wounds, alternative to
Vitasure) electrocoagulation
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

TABLE 1. (Continued )

Wound Hemostatic Approximate Use in


Type Method Name Cost† Dermatology Advantages Disadvantages
Superficial Caustic Aluminum Inexpensive ($10–20/ Yes Less pigmentation risk, effective, Irritation, pain, delayed wound re-
Agents chloride, 20%– 37.5 mL) inexpensive epithelialization
40% soln
(Drysol, Xerac
AC)
Ferric subsulfate, Inexpensive ($0.10– Yes Inexpensive, used on Pigmentation (tattoo effect), erythema,
20% soln 0.60/mL) small wounds infection, dermal fibrosis, delayed re-
(Monsel’s epithelialization, postinflammatory
solution) hyperpigmentation
Silver nitrate Inexpensive ($0.15/ Yes Inexpensive, used on Pigmentation risk, argyria, burning
stick) small wounds
Trichloroacetic Relatively Yes Less pigmentation risk Irritation
acid, 35% inexpensive ($46/
solution 500 mL bottle)
Zinc chloride, Not widely available Rare Good for friable tissues like skin Irritation, pain
45% paste metastasis from breast
(Moh’s paste) cancer

*If the patient is on anticoagulant or antiplatelet therapy, reversal agents may be used to tamponade bleeding or oozing (e.g., vitamin k on warfarin). However, caution should be taken to
determine the benefit of reducing postprocedural bleeding versus the risk of discontinuing the anticoagulant based on the clinical scenario.
†Currency listed as United States dollars as of 2018; prices were obtained from online resources: QuickMedical, MedExSupply, eSutures, and Drugs.com.
00:00:MONTH 2019

IYENGAR ET AL
5
HEMOSTATIC AGENTS AND TECHNIQUES

by side encircling the surgical margin to provide Physical Agents


hemostasis.12 Pulley sutures also place significant
positive pressure on wound edges, eliminating Acrylates
bleeding. Bolster dressings have been used for Acrylates, such as 2-octyl cyanoacrylate (Dermabond;
second-intention healing sites.13 The bolster, formed Ethicon Inc., Somerville, NJ), are most commonly
of nonstick dressing such as petrolatum gauze, is used for small lacerations in patient populations
applied firmly over the wound with silk sutures unsuitable for suture placement, such as the pediatric
radially placed around the dressing. The constant population. Acrylates have also been used successfully
pressure has shown to successfully reduce bleeding in wounds left to heal by second intention.20 These
and prevent manipulation near the wound. If possi- agents rapidly polymerize and cause tissue adhesion,
ble, scalp wounds should not be undermined, which may help provide hemostasis for smaller
reducing the possibility of a hematoma. wounds with minimal tension.1 They are popular in
the outpatient setting due to their accessibility. With
Epinephrine
the widespread use of acrylates, dermatologists should
Epinephrine, both an alpha- and beta-adrenergic surely be aware of possible contact dermatitis.21–23
agonist, is added to local anesthetics for its vaso- Examples of acrylates include Krazy Glue (Elmer’s
constrictive activity and prolongs the anesthetic Products Inc., Columbus, OH), Dermabond (Ethi-
effect. Surgeons use varying combinations of amide con), and Band-Aid Liquid Bandage (Johnson &
anesthetics with epinephrine, including 0.5% or 1% Johnson, Somerville, NJ).2
lidocaine with epinephrine at a concentration of
1:100,000 or 1:200,000.14,15 Blanching of the skin
signifies vasoconstriction and occurs several minutes Bone Wax
after anesthesia. Tumescent anesthesia is less com- Bone wax is a paste composed of mainly beeswax and
monly used in dermatologic surgery, but if used, isopropyl palmitate.2 It is a biologically inert material
surgeons should wait 20 to 30 minutes after injection used to tamponade bleeding, especially on bony sur-
for full hemostatic effect.1 Side effects include faces. Because it is malleable, bone wax is advanta-
tachycardia, flushing, and anxiety—but are more geous in areas such as the ear, nose, or medial canthus
likely to be associated with much higher dosing of of the eye, where it may be difficult to apply pressure to
epinephrine such as that in dental dosing (1:50,000) the wound. Bone wax has been used successfully for
than the traditional dermatologic 1:100,00 or second-intention healing in patients with basal cell
1:200,000. carcinoma on the nose and medial canthus of the eye.24

Chemical Agents
Caution should be exercised when using higher dosing
of epinephrine in patients on beta blockers.16 Several Chemical hemostatic agents function by damaging the
studies have shown that patients on nonselective surrounding tissue, leading to the coagulation cascade
betablockers have an elevated blood pressure response and thrombus formation.2
after receiving epinephrine.17,18 Nonselective beta-
blockers (such as propranolol) do not have the pro- Monsel’s solution, a 20% compounded ferric sub-
tective effects of B2-adrenergic and alpha-adrenergic sulfate solution, causes occlusion of vessels by pre-
vasodilation seen in selective beta blockers. However, cipitating proteins in tissues due to its acidic pH. It is
small amounts of epinephrine combined with local effective postpunch biopsy for wounds healing
anesthetics is believed to be safe in patients on non- through second intention. Soaked cotton swabs or
selective beta blockers with the real risk limited to gauze pads are applied to the wound after the der-
those receiving systemic doses.17,19 When trying to matologic procedure.25 Side effects include infection,
achieve pain control and vasoconstriction, it is rec- erythema, dermal fibrosis, delayed re-
ommended to use the lowest effective concentration of epithelialization, and potential permanent pigmenta-
epinephrine.18 tion. Pigmentation of the skin seems to be the more

6 DERMATOLOGIC SURGERY

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IYENGAR ET AL

common issue, so many dermatologic surgeons prefer


to use this product in noncosmetically sensitive
areas—and often avoid the central face. Kuwahara
and colleagues26 suggests leaving the container of
Monsel’s solution open to the air to create a thick
paste, which is more advantageous for coagulation.

“Mohs paste,” composed of zinc chloride, was described


by Frederic E. Mohs in 1941.27 It causes tumor
destruction and is an effective hemostatic agent of friable
tissues, such as metastatic skin lesions from breast can-
cer. Disadvantages of the paste include pain and irrita-
tion during application.2 Silver nitrate, another caustic
hemostatic agent, is easy to use but may cause a tem-
porary gray to gray-black discoloration. Care should be
taken to avoid cosmetically sensitive areas. There is also a
very rare report of localized cutaneous argyria from
topical application of silver nitrate.28

A more commonly used topical hemostatic agent is alu-


minum chloride, which is formulated in a vehicle of
water, alcohol, ether, or glycerol.2 It is often used after
shave or punch biopsies with a cotton-tipped applicator.1
It has also been used successfully after nail biopsies when
combined with an absorbable gelatin sponge.29 Its
mechanism of action results from the hydrolysis of alu-
minum chloride.30 Side effects include pain at the site of
application, tissue irritation, and delayed wound healing.
Figure 1. Dermabrasion site on the nose treated with 35%
Care should be taken to avoid application near the eyes.
TCA to achieve hemostasis (A) initial bleeding site; (B)
application of 35% TCA with the use of a long Q-tip; (C)
Although TCA is most commonly used in dermato- partial hemostasis achieved during midapplication of 35%
TCA; (D) complete achievement of hemostasis
logic offices as an aesthetic chemical peel agent, it can within minutes after application. Photograph courtesy: Dr.
also serve as a topical hemostatic agent. Thirty-five David M. Ozog.
percent trichloroacetic acid can function as a hemo-
static agent by causing tissue necrosis and eschar for- phases of hemostasis and creating a physical mesh that
mation.31 Similar to aluminum chloride, but more aides in platelet aggregation and coagulation.32
effective, trichloroacetic acid has little pigmentation
residue and may be preferred to silver nitrate or ferric Wounds treated with gelatin, such as Gelfoam (Pfizer,
sulfate, which stain the skin. However, it can cause New York, NY), have successfully healed through
more irritation and should be avoided in sensitive second intention by creating a matrix that promotes
areas, such as around the eyes. Figure 1 illustrates the granulation tissue and clot formation.2 Gelatin
use of 35% TCA for hemostasis. products can also swell and double their volume,
providing mechanical hemostasis. They are absorbed
Noncaustic Agents
by the body in approximately 4 to 6 weeks. Caution
Physical noncaustic hemostatic agents promote clot should be taken when using this product near nerves
formation and can be used as an adjunct to electro- or confined spaces due to the concern for compressive
coagulation. These agents work by propagating the complications.33 Gelatin is available in several

00:00:MONTH 2019 7

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
HEMOSTATIC AGENTS AND TECHNIQUES

different vehicles, including powders, sponges/foam, StatSeal (Biolife) are trade names of WoundSeal used
and sheets/films. It has been reported to improve in the hospital. A study of Mohs patients found faster
cosmesis and hemostasis.34 However, for surgeons, hemostasis and greater reduction in wound size when
gelatin can be difficult to use because it can adhere to treated with topical hydrophilic polymer with potas-
surgical instruments. There is also a higher chance of sium compared with compressed surgical foam
infection, and hence, it should not be used for skin sponge.42 There are reports, however, of foreign body
closures. reactions after the use of these products after derma-
tologic surgery.41
Collagen, marketed as Avitene (Davol, Cranston, RI)
and Helistat (Integra LifeSciences, Plainsboro, NJ), is Purified plant starch powder, composed of micropo-
available in powder, sponge, and pad forms.2 When rous polysaccharide hemispheres, is used when closing
platelets aggregate on the collagen surface, they wounds.40 Mechanistically, it works by dehydrating
degranulate and stimulate the coagulation cascade.2 the blood and concentrating platelets and clotting
When applying collagen to the surgical wound, the factors, which helps accelerate the clotting process.
agent is kept dry and applied on the wound bed with Marketed as AristaAH (Bard, Muray Hill, NJ), the
direct pressure. Compared with gelatin products, there powder is expensive but can be used as an alternative
is minimal swelling. Absorption occurs in 8 weeks. Of to those contraindicated to receive electrocoagulation.
note, these agents can disrupt skin healing.35 Because it It is sprinkled over wounds healing by second inten-
is bovine derived, it has the potential for allergic and tion or before repair by primary closure. It has been
foreign body reactions.36 found to achieve hemostasis in less than 5 minutes
without affecting wound healing.43 Compared with
Oxidized cellulose, such as Surgicel (Ethicon) and electrosurgery, however, it is less effective and more
Oxycel (Becton Dickinson, Franklin Lakes, NJ), expensive. Thus, its use is limited to when electrosur-
tamponades vessels with absorption varying between gery is contraindicated.44 Caution is advised in dia-
1 and 6 weeks.2 It is derived from plant fiber and betic patients as the agent could theoretically increase
serves as a physical meshwork for hemostasis. glucose levels.1
Although its acidity creates a bactericidal environ-
Physiologic Agents
ment, it prolongs the inflammatory phase and delays
wound healing.37 It is used more commonly in car- Thrombin products, such as topical bovine thrombin
diothoracic and gastrointestinal surgeries.38,39 Firm and human recombinant thrombin, enhance the
pressure over the cellulose strips achieves hemostasis fibrinolytic cascade by converting fibrinogen to
and occupies space in the surgical field. Once placed fibrin. They are most useful when there is diffuse
on the wound bed, cellulose should not be removed as bleeding. The solution is either sprayed into the
bleeding can occur. Side effects include granuloma- wound bed, applied with a nonstick gauze
tous reactions and swelling. Curad Bloodstop pad/gelatin sponge, or directly applied as a powder.2
Hemostatic Gauze (Medline Industries, Mundelein, Postoperative coagulopathy is a side effect of bovine-
IL) and BloodSTOP (Life Science PLUS, Mountain- derived thrombin due to antigenic effects. Patients
view, CA) are examples of over-the-counter cellulose with decreased fibrinogen levels should not use
options for patients. thrombin products. Thrombin is marketed as
Thrombostat (Parke-Davis, Ann Arbor, MI) or
Hydrophilic polymer with potassium salt, such as Thrombin-JMI (King Pharmaceuticals, Briston, TN).
WoundSeal (Biolife, Sarasota, FL), is left on open FloSeal (Baxter Health Care, Deerfield, IL) is a com-
wounds to heal by second intention.40,41 The potas- bination product containing gelatin and thrombin. It
sium salt binds to the positively charged red blood is most effective for patients with platelet dysfunc-
cells, and an eschar forms in less than 60 seconds. The tion.45 The use of these products in dermatology and
topical hemostatic powder is inexpensive, easy to in outpatient settings is limited because of the cost
apply, and is available over-the-counter. BioSeal and and concern for potential adverse events.

8 DERMATOLOGIC SURGERY

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IYENGAR ET AL

Fibrin sealants, a mixture of thrombin and fibrinogen, causes direct vasoconstriction of cutaneous vessels. It
form an insoluble fibrin and result in clot formation.42 It should be applied to an open wound/vessel to be effective
is applied as a foam or by spraying on the wound. Fibrin and achieve high concentrations in the bloodstream. Side
sealants are marketed as Tisseel (Hemaseel; Baxter) and effects include burning, contact dermatitis, and more
Evicel (Johnson & Johnson). The use of human-derived recently, central nervous system depression. In 2017, 2
fibrin sealants, such as Evicel, decreases the risk of patients on topical brimonidine 0.33% gel for hemostasis
neurotoxicity.1 Disadvantages of fibrin sealants include developed altered mental status.51 Results from this
hypersensitivity reactions, neurotoxicity, and expense. report discourage the use of brimonidine as a hemostatic
A study of 14 dermatologic patients in Brazil found a agent until its safety is further studied. Another alpha
significant reduction in time for hemostasis in the group agonist, Rhofade, has recently been approved by the FDA
receiving fibrin glue.46 The use of fibrin glue for recur- but has yet to be examined as a hemostatic agent. It is
rent cheek hematoma after Mohs micrographic surgery likely to also result in altered mental status due to a similar
has also been recently reported.47 mechanism of action to brimonidine.

CoStasis (Ortovita, Malvern, PA) is a combination of Postoperative Care


bovine collagen and bovine platelets.48 The thrombin
Postoperative bleeding is most likely to occur within
from the bovine platelets converts the patient’s
the first 48 hours following the procedure.1,15
fibrinogen to fibrin. The collagen forms a hemostatic
Ecchymosis is defined as 1 cm or greater patch of
meshwork. Expense is a major drawback.
purple-black discoloration appearing as a result of
blood extravasation from a vessel. Purpura is the
Tranexamic acid (TXA) competitively inhibits the
name for a smaller version of the lesion between 0.3
activation of plasminogen. It is available in the United
and 1 cm. Ecchymosis is a temporary side effect,
States as either a 650 mg tablet or 100 mg/mL intra-
lasting from a few days to 2 weeks.40 Hematomas
venous solution, which can be compounded into
present as fluctuant masses often accompanied by
3.25% solution or 5% solution. The solution is used to
ecchymosis on the skin surface. Expanding hemato-
soak sponges and then applied to the surgical site.
mas occur within the first 24 to 72 hours post-
operatively and present with an expansive mass with
Overall, physiologic agents are less likely to be used
increase pressure, throbbing, ecchymosis, and fluc-
due to cost and are rarely used in an outpatient set-
tuation of tissues. If bleeding is uncontrollable and a
ting. Thrombin is used more in reconstructive plastic
hematoma is expanding, the patient should receive
surgery than in dermatology for flaps and grafts due
immediate treatment by opening the surgical wound
to its ease of application via modalities such as
and ligating or cauterizing the necessary vessel.14
sprays, pads/sponges, and powder.2,49 Fibrin seal-
During this procedure, consider using local anesthe-
ants are more commonly used in cardiothoracic
sia without epinephrine as the latter can cause tem-
procedures but have been used for skin grafts.
porary vasoconstriction and make it difficult to
Platelet gels, such as Costasis, have been used for fat
identify the bleeding vessel. If untreated, hematomas
grafts after liposuction and as an adjunct to laser
may cause infection, dehiscence, and tissue necrosis.
resurfacing. Operator experience, however, makes
Hematomas in the periorbital and cervical locations
fibrin sealants and platelet gels less desired in cuta-
are a medical emergency due to the potential for mass
neous surgery.
effect on vital structures.
Topical Brimonidine
Pressure Dressings
Topical brimonidine 0.33% gel, approved for the treat-
ment of rosacea, may have anticoagulant properties. Its A pressure dressing should be applied for at least 24
effectiveness in causing complete hemostasis of a bleeding hours after the procedure.14 Ideally, they should be left
wound in 20 minutes was first reported in 2015.50 in place for 48 hours as the risk of postoperative
Brimonidine, a selective alpha-2 adrenergic agonist, bleeding complications is highest during this time.52

00:00:MONTH 2019 9

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
HEMOSTATIC AGENTS AND TECHNIQUES

These dressings are intended to theoretically compress by Seeley and colleagues58 noted oral arnica had a
dead space and prevent hematoma formation by pre- statistically significant smaller area of ecchymosis on
venting vascular blood loss and exudate. Dressing postoperative Day 7 after rhytidectomy. However,
normally consists of a topical nonadherent petrolatum another study by Kotlus and colleagues61 reported no
jelly, a nonadherent dressing pad, and a layer of gauze significant difference with oral arnica on postoperative
that is secured by an adhesive tape. Patients should Day 7 after blepharoplasty. Owing to these conflicting
limit physical activity during the first 48 hours (to results, more studies are needed to fully evaluate oral
several days) after the procedure to allow vessels to arnica’s efficacy for patients with ecchymosis.
remain coagulated. If the patient notices increased
bleeding, pressure and ice should be applied directly to
Bromelain
the bandage without removing it for 20 minutes.
Dressing should be changed daily to allow for better Oral bromelain, arising from the pineapple plant
absorption and compression of tissues. (Ananas comosus), is hypothesized to treat ecchymosis
through its anti-inflammatory effect by reducing pros-
taglandin E2 and TXB2 along with inhibition of inter-
Topical Vitamin K
leukin 8–induced neutrophil migration and adhesion.62
Vitamin K has been used to both prevent and accelerate A few randomized controlled trials documented posi-
the clearance of bruising by an unknown mechanism. tive outcomes of bromelain in preventing or treating
Topical vitamin K in higher concentrations (5%) rather postprocedure ecchymosis, edema, and hematomas
than lower concentrations (0.5%) has been shown to after surgical and nonsurgical trauma to the face.62–64
effectively treat postprocedure ecchymosis severity.53,54 However, one study by Howat and Lewis65 reported no
Cohen and Bhatia55 showed vitamin K oxide gel has- difference in ecchymosis or edema with oral bromelain
tened the resolution of pulsed-dye laser-induced pur- postepisiotomy. Of note, oral bromelain at low doses is
pura as early as the second day post-treatment considered to be a procoagulant; however, at higher
compared with placebo in subjects being treated for doses, bromelain has antiplatelet effects and could
bilateral facial telangiectasia. A combined cream of exacerbate bleeding.53,66 Its antithrombotic properties
0.3% retinol (a low concentration) and 1% vitamin K work by increasing the mean platelet volume, inhibiting
has also been shown to be effective in reducing bruising Cox-2, and inactivating NF-kb.53 More trials evaluat-
postlaser treatment as early as Day 3.56 ing oral bromelain are warranted.

Oral Arnica Laser Therapy

Arnica, which is derived from a native plant (Aster- Various lasers have been used to treat postprocedure
aceae) in the mountains of Europe and western North purpura. Pulsed dye laser has been shown to be
America, may be used to treat ecchymosis. It is pos- effective in treating postoperative purpura after facial
tulated arnica aids in the treatment of ecchymosis by cosmetic procedures.67 Pulsed dye laser causes selec-
inhibiting thromboxane B2 (TXB2) formation and tive photothermolysis of hemoglobin and is commonly
nuclear factor kappa B (NF-kb).40 Topical and oral used for cutaneous vascular lesions.68 Studies differ
formulations exist. Studies, however, suggest topical regarding the optimal timing of laser treatment. De
arnica is ineffective for preventing or treating post- Fatta and colleagues suggest delaying PDL treatment
procedural ecchymosis. A study by Alonso and col- (fluence: 6 J/cm2, 30-ms pulse duration, 10-mm spot
leagues57 showed no statistically significant difference size) 5 to 6 days after surgery allows for extravasated
in ecchymosis between topical arnica and placebo hemoglobin to migrate superficially for the laser to
when used after pulsed dye laser (PDL) treatment for target.67–69 By contrast, a study by Karen and col-
facial telangiectasias. Although oral arnica is consid- leagues70 suggests early PDL treatment (fluence: 7.5
ered safe by the FDA, studies show mixed results J/cm2, 6-ms pulse duration, 10-mm spot size) is needed
regarding its efficacy after the procedure.58–61 A study to target the hemoglobin (absorption 595 nm) before

10 DERMATOLOGIC SURGERY

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IYENGAR ET AL

its conversion to bilirubin (absorption 460 nm). The References


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