A practical guide to reducing preoperative and intraoperative patient anxiety in dermatologic surgery.

BACKGROUND: Dermatologists perform a variety of procedures including excisions, biopsies, and other minor surgical procedures. Patients can experience anxiety in anticipation of their surgeries or may develop anxiety during the procedure. Since most dermatologic procedures occur with the patient awake and alert, the physician can offer comforting methods to alleviate some of that anxiety. AIMS: We wanted to provide a review of available methods that dermatologists can use to reduce patient anxiety. MATERIALS & METHODS: In this paper, we review the current literature on methods that can be used in dermatology offices to reduce overall patient anxiety levels. RESULTS: In the preoperative stage, providers can offer educational content to explain the procedure to their patients. Whether it be through telephone calls, educational videos, or utilization of visual models, educating the patient regarding their procedure may reduce their anxiety. Intraoperatively, there are multiple methods that can be used such as music, guided imagery, coloring books, medications, hypnosis, and distraction techniques. DISCUSSION & CONCLUSION: There is a variety of approaches that can be easily implemented in the office and can help in reducing the anxiety of the patients to allow for a pleasant patient experience and an overall satisfactory procedure outcome.

Distinct Approaches to Perioperative Management of Anticoagulation and Antiplatelet Therapy among Providers Performing Cutaneous Surgery.

BACKGROUND: Despite increasing cross-collaboration between providers who perform cutaneous surgery, a disparity still exists in the current practices regarding perioperative management. This could lead to treatment delays, patient confusion, and increased morbidity, such as clotting, infection, and discomfort of patients. OBJECTIVE: To characterize the management practices of different providers in regards to perioperative anticoagulation and antiplatelet therapy for cutaneous surgery. METHODS AND MATERIALS: This study used an electronic survey to assess current perioperative management practices of dermatologic surgeons and plastic and reconstructive surgeons. RESULTS: 177 physicians (115 dermatologic surgeons and 62 plastic and reconstructive surgeons) responded to the survey. For all therapeutic agents, dermatologic surgeons were significantly more likely than their plastic and reconstructive surgery colleagues to continue all anticoagulant and antiplatelet agents perioperatively for cutaneous surgery (vitamin K antagonists, antiplatelets, LMWH, direct Xa inhibitors, direct thrombin inhibitors, NSAIDS: P<0.001; fish oil, vitamin E: P<0.01). CONCLUSION: Our data highlight the significant practice gaps that exist between dermatologic surgeons and plastic and reconstructive surgeons. Reducing this disparity will facilitate improved continuity of care, especially when patients are referred from dermatologic surgeons to plastic and reconstructive surgeons for more complex repairs, and potentially reduce morbidity and mortality associated with medication discontinuation. J Drugs Dermatol. 2022;21(7):766-772. doi:10.36849/JDD.6726.

Common Dermatologic Procedures and the Associated Complications Unique to Skin of Color.

BACKGROUND: The skin of color (SOC) population in the United States continues to grow, and these patients are undergoing various cosmetic and surgical procedures at increasing rates. There is a paucity of data on the potential complications associated with surgical and cosmetic procedures in this patient population. OBJECTIVE: We aim to educate dermatologic surgeons and clinicians on surgical and cosmetic procedures in patients of color and increase awareness of the potential complications unique to this patient population. MATERIALS AND METHODS: A thorough PubMed literature search was performed to conduct this review. RESULTS: There are a number of complications in SOC that require special attention, including keloids, postoperative infections, postinflammatory hyperpigmentation, and hypopigmentation. There are also various precautions to consider when performing cosmetic procedures, such as neurotoxin and filler injections, laser therapy, microneedling, and chemical peels. CONCLUSION: Dermatologists should be aware of the potential cosmetic and surgical complications of this growing patient population to provide optimal evidence-based medical care.

Pain-less injection: principles and pearls.

There has been an exponential growth in the number of dermatologic procedures performed over the past two decades. This surge in procedural volumes is accompanied by increasing utilization of local anesthetics. A proper technique in administering local anesthesia is necessary to minimize pain and promote comfort, as it is often regarded as the most painful part of cutaneous procedures. Pain is a psychophysiological phenomenon that involves attention, cognitive appraisal, and emotion. Sensory feedback and anxiety are two important aspects of pain perception. This article aims to introduce a novel way that minimizes pain and discomfort associated with local anesthetics. It is the authors' experience that painless injection is achievable by keeping syringes/needles out of sight, proceeding with injection without pre-procedure warning, and engaging patients in a conversation or simple tasks.

Influence of Topical Anesthesia on Superficial Sensitivity: A Double-Blind, Randomized, Placebo-Controlled Study on 48 Healthy Subjects.

BACKGROUND: Topical anesthetics are used in noninvasive transdermal anesthesia to decrease the superficial pain sensation threshold during dermatologic surgery. Combined pain relief and sensitivity loss can avoid discomfort during the surgery. OBJECTIVE: The aim of this placebo-controlled study was to compare the efficacy of 3 commonly used topical agents by collating loss of sensitivity over time. MATERIALS AND METHODS: Three topical anesthetic creams, a topical anti-inflammatory cream, and a moisturizing cream were applied on the left volar forearm of each of the 48 healthy Caucasian participants. Sensitivity was assessed with the dynamic 2-point discrimination and the Semmes-Weinstein test at 0, 60, 90, 120, 150, and 180 minutes after cream application. RESULTS: After 180 minutes, benzocaine showed a significantly lower 2-point discrimination reduction than lidocaine alone and a lidocaine and prilocaine mixture. Sensory threshold measurements by the Semmes-Weinstein test after 60 minutes revealed a significantly higher effect with lidocaine alone and with the lidocaine and prilocaine mixture than with benzocaine. CONCLUSION: The authors found a stronger skin sensitivity reduction by the eutectic lidocaine and prilocaine mixture and lidocaine alone compared with benzocaine. We suggest increased discomfort reduction in topical anesthetic supported dermatologic surgery by the eutectic mixture and lidocaine alone.

Postoperative Infections in Dermatologic Surgery: The Role of Wound Cultures.

BACKGROUND: Dermatologic surgery is associated with low postoperative infection rates, averaging from approximately 1% to 4.25%. Often, postoperative infections are treated empirically based on clinical diagnosis of infection, given it can take 48 to 72 hours for a wound culture to identify a pathogen. OBJECTIVE: We aimed to evaluate the efficacy of empiric antibiotics in dermatologic surgery postoperative infections and if wound cultures change postoperative antibiotic therapy. METHODS: A 7-center, retrospective analysis of postoperative infections, with culture data, in dermatologic surgery patients was performed. RESULTS: Of 91 cases of clinically diagnosed postoperative infection, 82.4% (n = 75) were successfully treated with empiric oral antibiotics (95% confidence interval [0.73-0.89], p < .0001). In 16 (17.6%) cases, initial empiric antibiotics were unsuccessful, and wound culture results altered antibiotic therapy in 9 cases (9.9%) with 6 (6.6%) of these cases requiring additional coverage for methicillin-resistant Staphylococcus aureus (MRSA). CONCLUSION: Empiric antibiotic treatment is usually appropriate for patients with postoperative surgical-site infections with wound cultures altering antibiotic management in a minority of cases. When empiric antibiotics fail, lack of MRSA coverage is usually the cause; therefore, providers should be aware of local MRSA prevalence and susceptibilities.

Optimizing Patient Safety in Dermatologic Surgery.

Overall, dermatologic surgery performed in the outpatient setting is very low risk to patients and safer than similar procedures performed under general anesthesia, and is also more cost-effective. There are several approaches to mitigating the risk of complications while optimizing patient outcomes. Strict oversight of the dermatology clinic helps to ensure team members all adhere to standards of care. Vial safety, strict hand hygiene, limiting the use of topical antibiotics, generally continuing all blood thinners perioperatively, and prebiopsy photographs are all examples of approaches to help maximize patient safety.

Pearls for Dermatologic Surgery in Pediatric Patients.

To achieve successful dermatologic surgery in a pediatric patient, several factors should be considered, including recognizing a child's inherent anxiety, ability to understand/comply with instructions, engaging their caregiver, and minimizing pain. Distraction techniques, including use of smart devices or classic play, have been shown to reduce anxiety, perception of pain, and increase overall satisfaction with the needed procedure. Customizing the child's need based on their stage of development and family preferences further improves how effectively the techniques are deployed. Because children are naturally playful, suturing techniques and dressing of surgical wounds may also require modification for best possible outcome.

Current Basal and Squamous Cell Skin Cancer Management.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Characterize basal and squamous cell carcinomas as low or high risk based on size, location, histology, and clinical features. 2. Understand appropriate surgical margins in low- and high-risk lesions, and other management options, including Mohs micrographic surgery, electrodissection and curettage, topical agents, cryotherapy, photodynamic therapy, and radiation therapy. 3. Discuss adjuvant therapies for locally advanced and metastatic disease, including radiation therapy, chemotherapy, and targeted therapies such as hedgehog pathway inhibitors. 4. Educate patients on preventive measures such as skin examinations, sun protection, oral retinoids, and oral nicotinamide (vitamin B3). 5. Devise a reconstructive plan once clear oncologic margins are obtained. SUMMARY: With the growing incidence of basal and squamous cell carcinoma, there is an increasing demand for appropriate oncologic management and aesthetic reconstruction. The goal of this CME article is to provide a foundation of knowledge to accurately diagnose, stage, and treat nonmelanoma skin cancers. In addition, it provides the practicing plastic surgeon alternate tools for managing these skin lesions, including topical agents, destructive therapies, and radiation therapy. Lastly, reconstructive plans for selected soft-tissue defects are discussed.

Photobiomodulation in the Postoperative of Bichectomy Surgeries: Case Series.

BACKGROUND: Several photobiomodulation (PBM) protocols with low-power lasers have been reported for pain control and tissue repair in the postoperative period of oral surgeries. However, there are still no reports of a protocol for bichectomy surgeries' postoperative period. OBJECTIVE: This article presents six reports of clinical cases in which bichectomy surgery was performed. METHODS: In the postoperative period, three patients were submitted to PBM with low-power lasers, while three patients did not receive it. Facial edema was evaluated using a millimeter tape. Pain was determined using the visual analog scale. RESULTS: Data of each clinical case were evaluated in a descriptive way and compared. CONCLUSIONS: The efficacy of the PBM protocol on the postoperative period of bichectomy surgeries was evidenced by the decrease of edema and pain.

Effectiveness and Safety of an Overnight Patch Containing Allium cepa Extract and Allantoin for Post-Dermatologic Surgery Scars.

BACKGROUND: An occlusive overnight intensive patch medical device (OIP) containing onion extract and allantoin has been developed for preventing and treating dermatologic scars and keloids. Here, we examined the efficacy and safety of the OIP for post-dermatologic surgery scars. METHODS: This was an intra-individual randomized, observer-blind, controlled study in adults with post-dermatologic surgery scars. Two scars per subject were randomized to no treatment or overnight treatment with the OIP for 12-24 weeks. Scar quality was assessed using the Patient and Observer Scar Assessment Scale (POSAS) and a Global Aesthetic Improvement Scale. RESULTS: A total of 125 subjects were included. The decrease in observer-assessed POSAS from baseline was significantly greater for treated than untreated scars at week 6 (p < 0.001) and 24 (p = 0.001). The decrease in patient-assessed POSAS was significantly greater for the treated scar than the untreated scar at week 12 (p = 0.017) and 24 (p = 0.014). Subject- and investigator-evaluated Global Aesthetic Improvement Scale scores were higher for the treated than the untreated scar at all visits. All subjects considered the global comfort of the OIP to be good or very good, and no safety concerns were identified. CONCLUSIONS: This study confirmed that the OIP safely promotes scar healing after minor dermatologic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Techniques for Optimizing Surgical Scars, Part 3: Erythema, Hyperpigmentation, and Hypopigmentation.

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. Part 3 focuses on scar revision for erythema, hyperpigmentation, and hypopigmentation. Scar revision options for erythematous scars include moist exposed burn ointment (MEBO), onion extract, silicone, methyl aminolevulinate-photodynamic therapy (MAL-PDT), pulsed dye laser, intense pulsed light (IPL), and nonablative fractional lasers. Hyperpigmented scars may be treated with tyrosinase inhibitors, IPL, and nonablative fractional lasers. Hypopigmented scars may be treated with needle dermabrasion, medical tattoos, autologous cell transplantation, prostaglandin analogues, retinoids, calcineurin inhibitors, excimer laser, and nonablative fractional lasers.

Assessing the outcomes, risks, and costs of local versus general anesthesia: A review with implications for cutaneous surgery.

BACKGROUND: There is a paucity of data providing direct comparison of outcomes, complications, and costs between general and local anesthesia in cutaneous surgery. OBJECTIVE: Analyze the literature from dermatologic and other specialties to compare outcomes, risks, and costs of general and local anesthesia. METHODS: A retrospective analysis of case comparison studies from other specialties comparing outcomes, risks, and/or costs in local versus general anesthesia was performed. A review of the literature from dermatology and other specialties was included. RESULTS: A total of 51 studies were selected; 41 of them directly examined outcomes in procedures performed under local and general anesthesia, and none found a significant difference in outcomes. A total of 41 studies measured adverse effects. Of these, 15 studies (36.6%) report significantly better outcomes between the 2 techniques. Only 2 studies (4.9%) report significantly improved outcomes with use of general anesthesia; 15 of 36 studies (41.7%) report fewer adverse events in local anesthesia. Of the 13 studies that examined costs, all (100%) found significantly decreased costs with use of local anesthesia. LIMITATIONS: These data cannot be seamlessly applied to all cases of cutaneous surgery. CONCLUSION: Local anesthesia techniques provide outcomes equal to or better than general anesthesia and with significantly lower costs.

Local anesthesia in pediatric dermatologic surgery: Evaluation of a patient-centered approach.

BACKGROUND/OBJECTIVES: A few studies have documented the effect of local anesthesia for minor dermatologic surgical procedures on children and their parents. Our objective was to evaluate the psychological effect and global satisfaction of a patient-centered approach to dermatologic surgery under local anesthesia. METHODS: Two self-administered questionnaires were used to evaluate the distress and global satisfaction of 388 children who underwent dermatologic surgery under local anesthesia, accompanied by oral and written therapeutic education measures (structured information and a cartoon brochure illustrating the procedure) addressed to children and parents. Distraction techniques were also used during the procedures. RESULTS: Although 54.5% of patients manifested some degree of fear, all other parameters analyzed (pain, surgery-related distress, surgical team-patient and -family relationship, global satisfaction) indicated that the procedures resulted in limited distress and that the large majority of children and parents tolerated them well. CONCLUSION: Specific measures for therapeutic pediatric patient education may be helpful in limiting discomfort, anxiety, and pain perception linked to procedures performed under local anesthesia. Further controlled studies are required to more precisely assess the benefits of specific therapeutic education measures.

Complicaciones y manejo de procedimientos dermatoestéticos: una actualización para el dermatólogo / Complications associated with cutaneous aesthetic procedures: an update for the dermatologist

En las últimas décadas se han desarrollado nuevas técnicas e indicaciones de los procedimientos estéticos mínimamente invasivos, presentando cada vez mejores resultados con un alto nivel de seguridad, sin embargo, estos no se encuentran exentos de complicaciones, las que pueden ser transitorias o permanentes. El conocimiento, abordaje, tratamiento y prevención de las distintas complicaciones son esenciales para los dermatólogos y cirujanos plásticos. Los procedimientos más utilizados son: administración de rellenos, peeling químicos, láser, luz pulsada intensa y ultrasonido de alta frecuencia. La siguiente revisión tiene como objetivo reconocer las principales complicaciones de estos procedimientos y su manejo.

In recent decades, new techniques and indications of minimally invasive aesthetic procedures have been developed, presenting increasingly better results with a high level of safety, however these are not exempt from complications, which may be transient or permanent. The knowledge, approach, treatment and prevention of the different complications are essential for the dermatologist and plastic surgeons. The most used procedures are the administration of fillers, chemical peels, lasers, intense pulsed light and high frequency ultrasound. The following review aims to recognize the main complications of these procedures and their management.