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Review
October 20, 2016

Addressing Practice Gaps in Cutaneous SurgeryAdvances in Diagnosis and Treatment

Author Affiliations
  • 1University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
JAMA Facial Plast Surg. Published online October 20, 2016. doi:10.1001/jamafacial.2016.1269
Key Points

Question  How can patient safety and comfort best be addressed when performing cutaneous surgery?

Findings  This review of evidence-based advances in cutaneous surgery demonstrates that large surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and/or antiplatelet medication should be continued during cutaneous surgery; music and anxiolytic medications are safe and effective ways to prevent patient anxiety; and postoperative opioids and topical antibiotics might cause harm to patients and should be avoided.

Meaning  Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

Abstract

Importance  Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making.

Objective  To present the newest and best evidence to close common practice gaps in cutaneous surgery.

Evidence Review  We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms “cutaneous surgery,” “Mohs micrographic surgery,” “plastic surgery,” in combination with “safety,” “cost,” “anesthesia,” “anti-coagulation,” “bleeding,” “pain,” “analgesia,” “anxiety,” or “infection,” among others. Bibliographies from these references, as well as meta-analyses, were also reviewed.

Findings  A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications.

Conclusions and Relevance  Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

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