Pooja Chitgopeker, MD, is a board-certified dermatologist and fellowship-trained Mohs micrographic skin cancer surgeon at Medical Dermatology Associates of Chicago, IL. She has authored numerous publications in dermatologic surgery, cutaneous oncology, and cosmetic and laser surgery with one being the largest split-scar clinical study that compared fractional lasers to improve the appearance and symptoms of surgical and traumatic scars.

Dr Chitgopeker shared some of the pearls she presented during her session, “Surgical Complications and How to Avoid Them,” at the Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021.

What are the top 3 dermatologic surgical complications to watch out for?
Postoperative bleeding, postoperative wound infection, and wound dehiscence are common dermatological surgery complications. These can occur following biopsies, surgical excisions, Mohs surgery, or laser and cosmetic procedures.  

Is there a “troubleshooting algorithm” you follow when it comes to figuring out the best course of action when a patient presents with a postoperative complication?
Part of being a surgeon is being prepared and keeping at the back of your mind potential complications that can occur following a procedure as it pertains to a specific patient. For example, many patients are on blood thinners, so taking extra precaution with intraoperative hemostasis and postoperative pressure dressing can help prevent a postoperative bleed.

With each of the complications I mentioned above, I typically have an algorithm on what to do next and how to manage it. Bleeding, wound dehiscence, and infection can also be interrelated.

If a patient comes in with bleeding, I'll give them an appropriate anesthesia for the area and find the source of the bleed, which may involve taking the repair apart. Postoperative bleeding can lead to wound dehiscence, which can then provide a nidus for infection.

Regarding infection, sometimes patients may think their wound is infected while, really, the suture site is just red and inflamed. It’s important to assess for signs and symptoms of infection, such as erythema, pain, swelling, discharge, and systemic symptoms of fever and chills. If the suspicion for infection is strong, then I will treat the infection empirically until we can get definitive information via a wound culture.

What are the most common scar abnormalities typically seen postsurgery?
One of the most common scar abnormalities seen is suture track marks, which look like railroad track marks on the skin. This occurs from the epidermal sutures being too tight, which leaves an imprint on the skin. This can be prevented by ensuring the deep sutures approximate the wound well and hold the majority of wound tension.

Other scar abnormalities we commonly see are related to color. New scars may be red and vascular appearing. This tends to improve with time, but we can also intervene by using vascular lasers to treat redness. Scars can sometimes also turn brown or dyspigmented. This can be tricky to treat, so I reiterate to patients the importance of sun protection. Ablative or fractional lasers have been shown to help with dyspigmentation too.

A lot of times what the provider perceives as a normal part of wound healing—be it temporary swelling, redness, or whatnot—patients may perceive as an unsightly scar. It is important to counsel the patient on the process of normal wound healing and scar maturation, as to set appropriate expectations.

Your study¹ from June 2020 stated “scar treatment with [ablative fractional laser] or [nonablative fractional laser] is associated with high patient satisfaction. Objective evaluation of scars did not identify improvement in scar appearance.” What does this say about the technology or techniques dermatologists have to address scars?
Patient perception is everything, because scarring is going to occur no matter what. As a physician, employing great surgical technique and postoperative care is key to help create the best scar possible

When patients perceive their scar as undesirable, they appreciate interventions to help improve the appearance. I think the result of the study speaks for itself in the sense that having an intervention led to a positive outcome in the patient’s mind. In this study, there was no objective improvement in scar appearance, but this could possibly be attributed to the relatively short follow-up period.

Dermatologists have a number of options to help improve the appearance of scars and, depending on the type of scar abnormality, can decide what to use. One is the use of fractional lasers, which can improve the texture and color of scars. As mentioned before, vascular lasers can be used to improve redness. If providers don't have access to lasers, manual dermabrasion can also be used to improve the texture of a scar. Intralesional steroids can be used to improve scar hypertrophy or keloids. Other less invasive methods such as topical silicone gel or sheeting and scar massage can also be employed.

I think it is also important to counsel patients that scars mature and change over time and sometimes less is more, and sun protection and the tincture of time is all that is necessary.

Finally, regarding surgical complications and scar revision, what key takeaways do you want to share with other dermatologists?
Surgical complications will occur even with the most prepared physician. Knowing how to manage these and having an algorithm to handle them when it occurs is key.

Knowing your patient and specific factors that may put them at risk of a postoperative complication is important, eg, are they on blood thinners? Do they smoke cigarettes? Are they a triathlete who is going to go for a run the day after surgery and dehisce their wound? Understanding risk factors and patient comorbidities will help when counseling and preparing the patient for the postoperative period. 

The patient is putting trust in their provider to take care of them during surgery and be with them every step of the way. Patients are more likely to trust the process while their scar heals if they understand what is going on and if their physician is available and open. It is important for a patient to understand that their surgeon is equally invested in providing and achieving the best surgical outcome. 

Reference
1. Chitgopeker P, Goettsche L, Landherr MJ, et al. 1550-nm nonablative fractional laser versus 10,600-nm ablative fractional laser in the treatment of surgical and traumatic scars: a comparison study on efficacy and treatment regimen. Dermatol Surg. 2020;46(6):780-788.