Leflunomide-Associated Wound Complication After Cochlear Implantation: A Case Report.

INTRODUCTION: Cochlear implantation has become an increasingly common strategy for aural rehabilitation in patients with severe to profound hearing loss who no longer benefit from conventional amplification. In conjunction, immunosuppressive therapies (e.g. disease-modifying anti rheumatic drugs (DMARDs) have become the keystone of management in numerous autoimmune conditions. Given the increasing prevalence of both, a greater proportion of patients will undergo cochlear implantation while on immune-modulating medications. While these medications are usually well tolerated, immunosuppression may put patients a higher risk for device infections. At present, this is not extensively studied within the cochlear implant literature. METHODS: We conducted a retrospective chart review and review of the literature.Results:We present the case of an 81-year-old male who experienced wound dehiscence and infection secondary to leflunomide use for treatment of rheumatoid arthritis. Resolution of these issues was noted with a therapeutic drug holiday, and the patient has subsequently undergone re-implantation without issue.Conclusions:The case highlights a potential CI-associated wound complication in the setting of DMARD therapy. Given the increasing prevalence of both CIs and immunosuppressive therapy, future study on the potential for interaction is warranted to identify the best management strategy in the perioperative setting.

Risk of postoperative infectious complications from medical therapies in inflammatory bowel disease.

BACKGROUND: Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk. OBJECTIVES: To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery. SEARCH METHODS: We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles. SELECTION CRITERIA: Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls. AUTHORS' CONCLUSIONS: The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.

Prediction of Complications, Readmission, and Revision Surgery Based on Duration of Preoperative Opioid Use: Analysis of Major Joint Replacement and Lumbar Fusion.

BACKGROUND: Preoperative opioid use results in adverse outcomes and higher costs after elective surgery. However, duration thresholds for higher risk are not entirely known. Therefore, the purpose of our study was to determine the number and duration of preoperative opioid prescriptions in order to estimate the risk of postoperative adverse events after major joint replacement and lumbar fusion. METHODS: National insurance claims data (2007 to September 30, 2015) were used to identify primary total knee arthroplasties (TKAs), total hip arthroplasties (THAs), and 1 or 2-level posterior lumbar fusions (PLFs) performed for degenerative disease. The effect of preoperative opioid burden (naive, ≤3 months, >3 to 6 months, >6 months but stopped 3 months before surgery, and >6 months of continuous use) on the risks of various adverse outcomes was studied using Cox proportional hazards analysis with adjustment for demographic and clinical covariates. RESULTS: A total of 58,082 patients stratified into 3 cohorts of 32,667 with TKA, 14,734 with THA, and 10,681 with 1 or 2-level PLF were included for this analysis. A duration of preoperative opioids of >3 months was associated with a higher risk of 90-day emergency department (ED) visits for all causes and readmission after TKA. Preoperative opioid prescription for >6 months was associated with a higher risk of all-cause and pain-related ED visits, wound dehiscence/infection, and hospital readmission within 90 days as well as revision surgery within 1 year after TKA, THA, and PLF. Stopping the opioid prescription 3 months preoperatively for chronic users resulted in a significant reduction in the risk of adverse outcomes, with the greatest impact seen after THA and PLF. CONCLUSIONS: Patients with a preoperative opioid prescription for up to 3 months before a major arthroplasty or a 1 or 2-level lumbar fusion had a similar risk of adverse outcomes as opioid-naive patients. While >6 months of opioid use was associated with a higher risk of adverse outcomes, a 3-month prescription-free period before the surgery appeared to mitigate this risk for chronic users. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Safety of mTOR inhibitor continuation in pediatric heart transplant recipients undergoing surgical procedures.

mTOR inhibitors have been associated with SWC when used in the perioperative period. Limited literature is available to guide providers in managing chronic mTOR inhibitor use in the perioperative period, especially in the pediatric setting. The primary aim of this study was to describe the prevalence of SWC with mTOR inhibitor continuation during the perioperative period for major surgeries. Heart transplant recipients ≤25 years old at the time of primary heart transplant receiving sirolimus maintenance therapy during a surgical procedure and within the study period were included. Surgeries identified within the study period included otolaryngology procedures (46.2%), such as tonsillectomies with or without adenoidectomies, cardiac surgeries (30.8%) including a sternal revision, pulmonary vein repair, and pacemaker placement in two patients, orthopedic surgeries (15.4%) including a posterior spinal fusion and an Achilles tendon lengthening with ankle and subtalar joint release, and a neurosurgery (7.7%), which was a ventriculoperitoneal shunt revision. Thirteen surgical encounters were examined. One SWC was observed, an infected pacemaker requiring systemic antibiotics and removal of the device. The results of this study suggest that sirolimus may be continued in the perioperative period based on the low rate of SWC observed.

Autoconjunctival Graft Compromise After Pterygium Surgery in a Patient Receiving Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

PURPOSE: To report on a case of autoconjunctival graft compromise after pterygium surgery in a patient on long-term anti-vascular endothelial growth factor (anti-VEGF) therapy, due to the deleterious effects of anti-VEGF agents on ocular wound healing. METHODS: A white female in her early eighties presented with large right nasal pterygium, first noted 5 years previously. She also had macular degeneration and had been receiving monthly injections of ranibizumab, which was later switched to aflibercept. She proceeded to have a right nasal pterygium excision with a conjunctival autograft, 9 days after her last dose of intravitreal aflibercept. RESULTS: Surgery was uneventful; however, at the week 2 postoperative review, there was conjunctival graft dehiscence with melting of the graft and underlying sclera. The patient was administered hyperbaric oxygen treatments, topical antibiotics, steroids, and lubricating eye drops, and aflibercept injections ceased. The scleral melt slowly resolved and her aflibercept was restarted 3 months later. CONCLUSIONS: This case highlights the potential hazards of performing elective surgery in patients on VEGF inhibitors and the need for an appropriate interval between cessation/subsequent restart of anti-VEGF agents and surgery to be established.

Uterine Scar Dehiscence Associated with Misoprostol Cervical Priming for Surgical Abortion: A Case Report.

BACKGROUND: Cervical priming prior to pregnancy termination is a common treatment. Both osmotic agents such as laminaria and Dilapan or pharmacologic agents such as misoprostol and mifepristone have been used for this purpose. CASE: A 30-year-old patient with a previous cesarean delivery was undergoing surgical termination of pregnancy at 13 weeks' gestation for a lethal fetal malformation. During preoperative cervical priming with misoprostol the uterine scar dehisced. Interval laparoscopic repair was performed. CONCLUSION: Uterine scar dehiscence can occur with misoprostol preoperative cervical priming for second trimester surgical termination of pregnancy.

Bemiparin versus enoxaparin as thromboprophylaxis following vaginal and abdominal deliveries: a prospective clinical trial.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of maternal mortality and morbidity, with the highest incidence occurring during the postpartum period. This study compared the ability of two types of low-molecular-weight heparin, enoxaparin and bemiparin, to decrease the incidence of VTE following elective caesarean section, emergency caesarean section, and vaginal delivery in women who had risk factors for thromboembolism. METHODS: In this prospective clinical trial using a sequential group allocation method, 7020 haemodynamically stable women delivered vaginally or abdominally at the Maternity Teaching Hospital, Kurdistan region, Erbil, Iraq, between May 1, 2012, and November 1, 2013. These women had risk factors for VTE and were allocated to the following groups: treatment with 3500 IU/day of bemiparin, 4000 IU/day of enoxaparin, or no intervention (control). The first dose was administered 6 hours after vaginal or abdominal delivery, or 8 hours after delivery in women receiving spinal anaesthesia. Subsequent doses were administered daily for up to 6 days. The incidence of VTE was assessed for up to 40 days postpartum. Data were analyzed using the Statistical Package for Social Sciences version 19. Proportions were compared using the chi square test of association or Fisher's exact test. Binary logistic regression analysis was used with VTE as the dependent variable. RESULTS: VTE occurred in 1 (0.042%) woman in the bemiparin group, two (0.085%) women in the enoxaparin group, and nine (0.384%) women in the control group (P = 0.017). Regression analysis showed that women on bemiparin (OR = 0.106; 95% CI = 0.013-0.838) and enoxaparin (OR = 0.226; 95% CI = 0.049-1.049) were at lower risk of developing VTE than control women. Adverse events in the enoxaparin group included wound dehiscence, haematoma, and separation. None of these occurred in the bemiparin group. CONCLUSIONS: Postpartum bemiparin is significantly effective as a prophylaxis for VTE. Wound complications develop after use of enoxaparin, but not after bemiparin. TRIAL REGISTRATION: ClinicalTrials.gov; Identifier: NCT01588171 ; date: April 26, 2012.

Impaired wound healing and expansion of a large ulcer after bevacizumab with paclitaxel for skin metastases from breast cancer: report of a case.

A 48-year-old Japanese woman was found to have local recurrence of breast cancer in the chest wall following neoadjuvant chemotherapy, total mastectomy with axillary lymphadenectomy, postoperative radiation therapy to the chest wall, and adjuvant systemic therapy using trastuzumab. As a third line of treatment after recurrence, bevacizumab with paclitaxel was initiated for several metastatic lesions on the skin of the chest wall, left internal costal lymph nodes, and right axillary lymph nodes. The wound on the chest wall continued to expand in diameter and depth after the third course of bevacizumab with paclitaxel until the rib was exposed. After stopping the bevacizumab, granulation tissue expanded and by 3 months, had covered the bottom of the ulcer. The patient died soon thereafter, despite systemic chemotherapy with eribulin; however, there was no further bleeding from the ulcer on the chest wall or the exposed ribs.

Perioperative pain relief by a COX-2 inhibitor affects ileal repair and provides a model for anastomotic leakage in the intestine.

The authors examined the potential of the cyclooxygenase 2 (COX-2) inhibitor carprofen to reproducibly induce anastomotic leakage. In experiment 1, an anastomosis was constructed in both ileum and colon of 20 rats, and they were given carprofen (5 mg/kg subcutaneously every 24 hours) or buprenorphine (0.02 mg/kg subcutaneously every 12 hours). In another 20 rats an anastomosis was constructed in either ileum or colon, and all received carprofen (experiment 2). Animals were sacrificed after 3 days. In experiment 1, the ileal dehiscence rate was 60% in the carprofen group and 0% in the buprenorphine group (P = .0108). Colonic anastomoses in both groups remained patent. In experiment 2, the anastomotic leakage rate was 80% in ileum and 0% in colon. Thus, COX-2 inhibitors can severely interfere with intestinal healing, particularly in the ileum. Perioperative administration of carprofen yields a unique model for anastomotic leakage, which allows translational research on the effectiveness of perisuture line reinforcement.

Bevacizumab and wound-healing complications: mechanisms of action, clinical evidence, and management recommendations for the plastic surgeon.

Reflecting the growing understanding of vascular endothelial growth factor (VEGF) in cancer survival and growth, the anti-VEGF antibody bevacizumab (Avastin) is increasingly used to treat advanced malignancy. However, because VEGF also mediates proper wound healing, bevacizumab may lead to potentially severe wound-healing complications (WHCs). Because bevacizumab expands in use, the plastic surgeon will increasingly be entrusted to manage such WHCs successfully. Therefore, this review summarizes the pathophysiological evidence, systematically reviews the available clinical evidence, and provides management guidelines for bevacizumab-related WHCs. Bevacizumab produces WHCs by disrupting vasodilation, increased vascular permeability, and angiogenesis. Current clinical evidence suggests that bevacizumab may increase WHC risk. This risk seems higher with neoadjuvant than adjuvant bevacizumab use and may be decreased by extending the bevacizumab-surgery interval. Further research is required to quantify the exact bevacizumab-related WHC incidence and optimize the bevacizumab-surgery interval. We propose management guidelines for bevacizumab-related WHCs by indication that should be integrated with clinical judgment, input from the oncology team, and patient wishes when making therapeutic decisions.

A positive-margin resection model recreates the postsurgical tumor microenvironment and is a reliable model for adjuvant therapy evaluation.

Up to 30% of cancer patients undergoing curative surgery develop local recurrences due to positive margins. Patients typically receive adjuvant chemotherapy, immunotherapy and/or radiation to prevent such relapses. Interestingly, evidence supporting these therapies is traditionally derived in animal models of primary tumors, thus failing to consider surgically induced tumor microenvironment changes that may influence adjuvant therapy efficacy. To address this consideration, we characterized a murine model of local cancer recurrence. This model was reproducible and generated a postoperative inflammatory tumor microenvironment that resembles those observed following human cancer surgery. To further validate this model, antagonists of two pro-inflammatory mediators, TGFß and COX-2, were tested and found to be effective in decreasing the growth of recurrent tumors. We appreciated that preoperative TGFß inhibition led to wound dehiscence, while postoperative initiation of COX-2 inhibition resulted in a loss of efficacy. In summary, although not an exact replica of all human cancer surgeries, our proposed local recurrence approach provides a biologically relevant and reliable model useful for preclinical evaluation of novel adjuvant therapies. The use of this model yields results that may be overlooked using traditional preclinical cancer models that fail to incorporate a surgical component.

Biologic treatment or immunomodulation is not associated with postoperative anastomotic complications in abdominal surgery for Crohn's disease.

OBJECTIVES: There are concerns that biologic treatments or immunomodulation may negatively influence anastomotic healing. This study investigates the relationship between these treatments and anastomotic complications after surgery for Crohn's disease. PATIENTS AND METHODS: Retrospective study on 417 operations for Crohn's disease performed at four Danish hospitals in 2000-2007. Thirty-two patients were preoperatively treated with biologics and 166 were on immunomodulation. In total, 154 were treated with corticosteroids of which 66 had prednisolone 20 mg or more. RESULTS: Anastomotic complications occurred at 13% of the operations. There were no difference in patients on biologic treatment (9% vs. 12% (p = 0.581)) or in patients on immunomodulation (10% vs. 14% (p = 0.263)). Patients on 20 mg prednisolone or more had more anastomotic complications (20% vs. 11% (p = 0.04)). Anastomotic complications were more frequent after a colo-colic anastomosis than after an entero-enteric or entero-colic (33% vs. 12% (p = 0.013)). Patients with anastomotic complications were older (40 years vs. 35 years (p = 0.014)), had longer disease duration (7.5 years vs. 4 years (p = 0.04)), longer operation time (155 min vs. 115 min (p = 0.018)) and more operative bleeding (200 ml vs. 130 ml (p = 0.029)). Multivariate analysis revealed preoperative treatment with prednisolone 20 mg or more, operation time and a colo-colic anastomosis as negative predictors of anastomotic complications. CONCLUSIONS: Preoperative biologic treatment or immunomodulation had no influence on anastomotic complications. The study confirms previous findings of corticosteroids and a colo-colic anastomosis as negative predictors and also that surgical complexity, as expressed by bleeding and operation time, may contribute to anastomotic complications.

Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion.

The Food and Drug Administration (FDA) indicates that bone morphogenetic protein (BMP) products are contraindicated in pediatric patients. However, it acknowledges the off-label use of BMP in difficult cases. Although the relative safety of BMP in children has been reported for lower extremity and spine procedures, little information exists for the safety of BMP used in the pediatric upper extremity. We present a case of a massive inflammatory reaction after use of recombinant human BMP-2 for repair of a symptomatic ulnar nonunion in a child. The case illustrates the potential difficulties of using the dose-dependent properties of BMP in the treatment of pediatric upper extremity nonunions when the dose calculations of BMP for children have not yet been defined.

Late anastomotic colonic dehiscence due to antiangiogenic treatment, a specific drug-class complication requiring specific treatment: an example of pazopanib complication.

Bevacizumab, a recombinant humanized monoclonal antibody against vascular endothelial growth factor (VEGF), was the first angiogenesis inhibitor approved for the first-line treatment of metastatic colorectal cancer in combination with intravenous fluorouracil-based chemotherapy. Two major cohort studies--BRiTE and BEAT--reported a 2% incidence of bowel perforation, which remains a rare, but serious, complication of bevacizumab treatment. Late anastomotic complications, arising > 3 months after surgery, are emerging occurrences that may be associated with bowel perforation. We report here on such a case caused by pazopanib, a new antiangiogenic agent, and also include a review of the published cases in the literature (n = 23) and an analysis of their management. Proctectomy was the initial surgery in 17 patients (74%) with rectal cancer, and 13 of these patients had undergone adjuvant radiation prior to surgery. The majority (84%) of the complications occurred with antiangiogenic treatment after a mean number of four cycles. Patients' management was invariably associated with withdrawal of the antiangiogenic agent, together with conservative treatment in 14 patients (66%).

Rate of wound complications with enoxaparin use among women at high risk for postpartum thrombosis.

OBJECTIVE: To estimate the rate of wound complications associated with protocol-driven postcesarean enoxaparin thromboprophylaxis. METHODS: After implementing an Institutional Clinical Practice Guideline for postoperative cesarean delivery thromboprophylaxis among at-risk gravid women (older than 35 years of age, body mass index greater than 30 kg/m2, or both), data on all cesarean deliveries over the first 23 months of guideline implementation were extracted and analyzed. Primary (wound hematoma, separation, or dehiscence) and secondary (venous thromboembolism) outcomes were compared in stratified and multivariable models controlling for potential confounders. RESULTS: Over 23 months, 2,509 cesarean deliveries were performed. A total of 1,677 (68%) gravid women met criteria for thromboprophylaxis; 653 received enoxaparin per protocol ("cases"), and, at the discretion of the ordering physician, 1,024 did not (at-risk, protocol-noncompliant "controls"). Cases differed significantly by virtue of maternal age, body mass index, and diabetic status. Univariable analysis subsequently revealed a higher rate of wound separation (6.8% compared with 3.6%, P=.003), rehospitalization (2.1% compared with 0.8%, P=.017) and composite score (8.9% compared with 4.8%, P=.002) among protocol-compliant cases, but no increased risk of wound hematoma (P>.06). In multivariable analysis, adjusted odds ratios continued to reveal an association between enoxaparin use and wound separation (OR 1.66, P=.04) as well as higher composite score (OR 1.69, P=.01). However, among the protocol-noncompliant controls, a nonsignificant increase in the rate of venous thromboembolism occurred. CONCLUSION: In our series, prophylactic enoxaparin use among at-risk gravid women undergoing cesarean delivery was accompanied by an increased risk of wound separation. LEVEL OF EVIDENCE: II.

Wound complications after bevacizumab treatment in patients operated on for ovarian cancer.

UNLABELLED: The aim of this study was to report and analyze the rate of wound complications in patients treated for ovarian cancer with or without adjuvant bevacizumab. PATIENTS AND METHODS: Were included in a prospective cohort study, all the patients with advanced ovarian cancer who received adjuvant chemotherapy with or without bevacizumab in our center from April 2007 to January 2009. The patients were separated into a bevacizumab adjuvant therapy group (n=13) and a control group without bevacizumab (n=12). All the patients underwent upfront surgery and received standard chemotherapy (carboplatin with paclitaxel). The patients were examined every two months by a gynecological surgeon and underwent abdomino pelvic CT-scan regularly. RESULTS: Among the 25 patients included in the study, six experienced wound dehiscence (24%). Five out of these six patients had received bevacizumab in addition to standard chemotherapy (p=0.078). CONCLUSION: We report a high rate of wound complications in ovarian cancer patients receiving bevacizumab after surgery.

Lack of complications in skin surgery of patients receiving clopidogrel as compared with patients taking aspirin, warfarin, and controls.

Clopidogrel, a new antiplatelet agent that irreversibly inhibits platelet aggregation, is widely used today. This prospective work was conducted to evaluate the safety of performing skin surgery on patients taking clopidogrel. Patients undergoing surgery for excision of skin or subcutaneous lesions under local anesthesia taking clopidogrel were the study group. The control group comprised 2073 historical patients who had undergone a similar procedure. Data collected included: age, sex, past medical history, medications, and late complications. Follow-up was done at 1 to 2 weeks and 3 to 6 months. There were 32 patients on clopidogrel, having 38 lesions removed. Of these, seven patients were on aspirin and clopidogrel combined. The groups taking clopidogrel, aspirin, and warfarin had significantly more males, were older, and had significantly more comorbid medical conditions. There was no significant difference in the incidence of any of the complications in any of the groups. This study shows that patients taking clopidogrel before skin surgery, though older and with more associated medical conditions, do not experience a greater rate of complications. We conclude that patients undergoing minor excisional cutaneous surgery should continue taking clopidogrel because there is no apparent risk for increased complications when good meticulous surgical techniques are used.