Derm Topics

Intraoperative Complications in Dermatologic Surgery: What To Do STAT

During the 2022 ODAC Dermatology, Aesthetic and Surgical Conference, Dr. James Spencer (ODAC conference chair emeritus, former director of Mohs surgery at the University of Miami Miller School of Medicine, and past member of the Board of Directors of the American Academy of Dermatology) gave us a critical talk on effectively managing intraoperative surgical complications. This was seriously a talk you DIDN’T want to miss, so in case you did, here are the key concepts to take away!

Problem #1. It Won’t Stop Bleeding

Rule #2:
Unfortunately wall-hyfrecators don’t really stop a major bleed —“they put a char on the surface.” Dr. Spencer likes to have an electrosurgery unit on hand. His personal favorite Ellman Surgitron (~$2000-$4000, with radiofrequency, bipolar and monopolar settings).

Rule #3: Hold pressure proximal to where you know the artery is.

Rule #4: Both ends of the bleeding artery are under high pressure and need to be dealt with (ideally tied off).

    • First apply a hemostat to the pulsating artery/arteriole (sometimes we have to do this blindly until we properly clamp the artery). Use multiple hemostats if needed.
    • Tie off the vessel with a 4-0 vicryl (figure of 8 stitch) around the hemostat, then release the hemostat.
    • You can try Monsel’s solution in the wound. It forms a crust where the vessel is and helps you identify the source of the bleed.1
Problem #2:  It Hurts Too Much!


Rule #1: If a patient seems resistant to lidocaine, try bupivacaine 0.25% (longest duration of action of local anesthetics – up to 8hrs with epi. Remember risk of cardiotoxicity, pregnancy category C).

Rule #2: Redheads experience less efficacy of subcutaneous lidocaine2 (hence potential need for trial of bupivacaine as above).

Rule #3: If a patient is hysteric, we let things get too far. Try prescribing the patient Xanax 2mg and have them return with this prescription to perform the surgery next day. You can also try nitrous oxide. Worse case: some patients need to be scheduled for surgical procedures in the OR.

Problem # 3: The Patient Passes Out


Rule #1: If a patient passes out, make sure they have a pulse. (Remember BLS protocol, call 911 if needed).

Rule #2: If the patient has a pulse and is arousable, there’s a strong chance that a vasovagal episode occurred. It is more common in men than women and is harmless. Warning signs are nausea and sweating.

    • Lower the table to the ground
    • Place the patient in Trendelenburg
    • The patient will wake up in a few minutes, and you can likely finish the surgery at that point

Rule #3: If the patient has a seizure, this can occur from any insult to the brain, including a vasovagal episode. Follow the same BLS protocol as above, lower the table to the ground, and place a neurology referral for a witnessed seizure.

Problem #4: No Room for Dog Ears


Rule #1: “A short flat scar is better than a long flat scar.”

Dr. Spencer reminded us that we have an option for dog ears: leave it!!

A lot of dog ears settle out on their own – especially the hand. A 2017 study suggested dog ears <4mm on the hand and trunk may be observed without additional surgical correction. This same study showed that approximately 77% of head and neck cases completely resolved (with dog ears < or = 4mm)3.

An earlier 2008 Dermatologic Surgery article suggested that dog ears less than or equal to 8mm in height be observed only after observing 43 cases of dog-ears.4 The mean time to 50% flattening was 21 days and the median time to complete regression was 132 days.

Problem #5. Do You Need to Rethink a Closure? What Could You Do to Get More Movement?


Rule #1: “No one ever came for a flap or graft; they came to be cured.” Simplest may be best, secondary intent is an option.

Rule #2: Remember some basic modifications:

    • An advancement flap can become a double-sided advancement flap
    • We can enlarge a rotation flap
    • We can close as much as possible and leave the rest to close by granulation (secondary intent)
Problem #6. “Uh oh. This is Going to Cause Ectropion or Eclabium”


Rule #1: Ectropion and eclabium will NOT settle out, unlike dog-ears.

Rule #2: To avoid ectropion or eclabium, we need to completely change the vector of tension (should be perpendicular to the eyelid/lip margin). For example, a horizontal closure may need to become a vertical closure.

Rule #3: In secondary intent wounds, 40% contracts and 60% doesn’t move. This may be a good option for small wounds near the eyelid. If the scar doesn’t look good, we can always cut it out and/or use alternative methods to improve appearance of the scar.

Dr. Spencer concluded his talk with some important pearls to keep in mind as dermatologic surgeons:

“Remember when a problem arises, relax and rethink. There is almost always a solution, just take your time.”

“Flaps and grafts are fun and interesting, and we enjoy doing them. No one ever came to you for a flap or graft, they come to get cured.  A large flap introduces risk of cutting a nerve, an artery, or some other misadventure. So, remember, next time you consider that enormous, complicated flap: who are you treating, the patient or yourself?”

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    1. Poletto, Gustavo Z. MD*,†; Dyson, Mary E. BS†; Goldberg, Leonard H. MD†,‡,§; Kimyai-Asadi, Arash MD†,‡,§ The Use of Monsel’s Solution to Reduce Postoperative Bleeding From Paramedian Forehead Flap Pedicles, Dermatologic Surgery: January 2021 – Volume 47 – Issue 1 – p 144-145 doi: 10.1097/DSS.0000000000002157
    2. Liem EB, Joiner TV, Tsueda K, Sessler DI. Increased sensitivity to thermal pain and reduced subcutaneous lidocaine efficacy in redheads. Anesthesiology. 2005 Mar;102(3):509-14. doi: 10.1097/00000542-200503000-00006. PMID: 15731586; PMCID: PMC1692342.
    3. Jennings, T. , Keane, J. , Varma, R. , Walsh, S. & Huang, C. (2017). Observation of Dog-Ear Regression by Anatomical Location. Dermatologic Surgery, 43 (11), 1367-1370. doi: 10.1097/DSS.0000000000001186.
    4. Lee KS, Kim NG, Jang PY, Suh EH, Kim JS, Lee SI, Kang D, Han K, Son D, Kim JH, Choi TH. Statistical analysis of surgical dog-ear regression. Dermatol Surg. 2008 Aug;34(8):1070-6. doi: 10.1111/j.1524-4725.2008.34208.x. Epub 2008 May 6. PMID: 18462422.

This information was presented by Dr. James Spencer at the 2022 ODAC Dermatology, Aesthetic and Surgical Conference held January 14-17, 2022. The above highlights from her lecture were written and compiled by Dr. Jacqueline McKesey.

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