Nicholas Golda, MD Shares Pearls to Manage Bleeding in Mohs Surgery

Nicholas Golda, MD, FACMS, and Mohs surgeon at Dermatology and Skin Cancer Centers in Lees Summit, Missouri provided pearls on managing bleeding during procedures based on research he has conducted. He was 1 of 3 presenters during the session “Evidence-Based Perioperative Care: Improving Satisfaction, Outcomes, and Efficiency” at the 2023 American College of Mohs Surgery Meeting in Seattle, Washington. Golda had the opportunity to catch up with Dermatology Times® and explained the take home messages from the session.

Dermatology Times: What are your best pearls on the topic of pain management and topical hemostasis in perioperative care?

Golda: There were 3 of uspresenting about pain management postoperative, intraoperative bleeding, and antibiotic use. My main section was about managing bleeding before, during, and then after the procedure. Basically, the big take home message from my part of the presentation was [that] we need to leave patients on aspirin, anticoagulant, and antiplatelet agents. Don'tmodify those regimens becauseyou're trying to make it easieron the patient from a bleeding standpoint. You want to keep them on it because the complications that can have from stopping those medications are far more difficult to deal with than the complications that you mightencounter, just over the course of standard skin surgery, even with some of the advanced techniques that we use intraoperatively.

Basically, preoperatively make sure that you're maybe checking a level for warfarin, checking in INR, making sure it's not super therapeutic or too high, a level below 3.5. Then, know that you can reverse some of these agents if you need to, butthat's more academic and really, not as practical from a day-to-day practice standpoint. Intraoperatively, know that you can use electrosurgery on patients, even with implanted defibrillators if you just are able to deactivate those defibrillators temporarily while you're doing a procedure. In some techniques, such as using a magnet over that, that defibrillator that we discussed and just taking the extra time,maybe modifying your reconstructive techniques to select something that might involve less tissue disturbance, less undermining. If an option like that exists, you know, you can choose between the most beautifuloption, ormaybe the option that presents your patient withless challenges with respect to bleeding. And of course, you need to make that decision in the moment, butdon't feel bad about, you know, swiping something that might be less of a risk of bleeding for your patient.

And then afterwards, know that you can use ibuprofen without running a risk of increased bleeding. And there are other things that you can use, such as placing drains, using cyanoacrylate over wounds that are seeming to be a little bit oozy. These are more patient comfort things. Basically, before, during, and after, there are things that we can do to try to make bleeding a little bit less of a problem. One of the big things I'm excited about is using tranexamic acid, topically and wounds that are left to heal on their own. I did research with a resident of mine, who's a Mohs fellow now, looking at just using a dilute like a 3 to 1 dilute tranexamic acid on a telfa as part of the wound dressing, it dropped in our study, at least it dropped bleeding to 0 in those granulated wounds. So now what I'm looking at what I'm hearing some people were doing, there's good data in the plastic surgery literature, the facial plastics literature, that we can inject tranexamic acid, and those studies were done at a 1 to 10 dilution injected. We're looking forward to studies that'll substantiate that.

Dermatology Times: What is your rule of thumb for prescribing antibiotics?

Golda: With respect to antibiotics, really, the take home message with that is to try not to prescribe them. The indications that that really mandate the use of antibiotics, before or after Mohs surgery are pretty narrow. It's, you know, working on an infected site with someone who has either a joint replacement or a risk for infective endocarditis. So, those indications are quite a bit less than they were when I trained quite some time ago. Then postoperatively, you know, there aren't any strong indications about when you shouldn't use it definitely between you as the physician and your patient. But there really aren't any notable indications that you really ought to always give antibiotics after surgery. People will make their own decisions, but I think people should feel reassured that the risk of infection is really,low and those antibiotics probably aren't necessary, even though they make us feel good. With respect to the anticoagulation, we're not prescribing that, so we just want to make sure that the patient is taking their medication appropriately. If they're taking something that requires laboratory monitoring that we check and make sure it's not too high and INR less than 3.5 is what we're shooting for generally. With respect to pain control, nationally, we're trying to reduce the amount of narcotics in circulation and Mohs surgeons prescribe the most narcotic analgesia.

There are ways that we can try to anticipate pain, which cases are going to have the highest risk of having pain. Can we use something like a injected anesthetic that has a longer duration of action, like bupivacaine, safely? Vanessa Voss, MD presented on this and presented her research on this topic that we conducted at Mizzou a couple of years ago, showing that indeed, doing that does reduce the need for narcotic pain medication use, as well as decreases pain scores in the immediate postoperative period. So again, there are things that we can do. And really, I think the big take home message is that we don't need to prescribe quite as much as we are of anything.

Dermatology Times: What keeps you coming back to the annual ACMS meeting?

Golda: This is where I recharge my battery every year at the Mohs college meeting. And for those of us that have part or for most of us, most of our practice is dedicated to, you know, cutaneous oncology, and really being at the leading edge of that. It's not just about the surgical procedure, but it's about how we manage the totality of the skin cancer and care for our patients. Mohs surgeons are really leading on that. Socially, it's an opportunity where we get to get together and exchange ideas. Those of us that are in geographically disparate places and lots of different practice settings, have a lot that we can learn from each other, even, you know, as we get a little bit more gray like I am. It's a huge opportunity for us to just, you know, recenter and norm ourselves against each other. I take something away from this meeting, every year. I used to run a fellowship program, and, even as a teacher, I come away from this meeting with pearls every year. I'm learning from people that are younger than me, people that are a lot older than me. There's tremendous opportunity, and we've got a lot of vitality in this organization right now. I'm excited to see it continue to flourish.

Transcript edited for clarity