Iyengar 2019
Iyengar 2019
Iyengar 2019
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.
*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
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IYENGAR ET AL
3
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4
DERMATOLOGIC SURGERY
TABLE 1. (Continued )
*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.
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IYENGAR ET AL
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HEMOSTATIC AGENTS AND TECHNIQUES
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
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IYENGAR ET AL
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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.
00:00:MONTH 2019 9
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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.
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
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IYENGAR ET AL
reported accelerated bruise reduction as soon as 6 2. Palm MD, Altman JS. Topical hemostatic agents: a review. Dermatol
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© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.