Addressing infection, bleeding in lower extremity dermatologic surgeries

Key takeaways:

• Surgical sites on the lower extremities tend to have a higher complication rate than other dermatologic surgery sites.
• Infection, bleeding and wound healing are complications that can occur in these procedures.

CHICAGO — Addressing post-operative complications in the lower extremities can be a difficult task that needs nuanced care, according to a speaker at the American Society for Dermatologic Surgery annual meeting.

“This can be a pretty challenging site,” Frances Walocko, MD, assistant attending physician at Memorial Sloan Kettering, said during her presentation. “These wounds are at a higher risk of complication because [it’s a] poorly vascular site, there’s limited skin laxity, it’s fragile skin and the legs are dirty, to say the least. They can be frequently colonized by bacteria.”

While dermatologic surgery complication rates are low at less than 1%, those in the lower extremity are generally around 2%, with some reports saying it could be up to 16%.

In order to address this issue and to limit complications, practitioners can begin with antibiotic prophylaxis, which is recommended for high-risk surgery sites; however, according to Walocko, most Mohs surgeons do not do so.

More complex repairs such as flaps or grafts can have higher infection rates on the leg, with staphylococcus aureus and pseudomonas being the most common.

“It can be difficult because the lower extremity can be colonized by these bacteria as well and that might not necessarily mean it’s infected,” Walocko said.

Treating infection can be done using white vinegar soaks, topical antibiotics, intra-incisional antibiotics and pre- or post-operative oral antibiotics.

In addition to infection, bleeding and wound healing can often be complications of lower extremity surgery.

“People need to complete their activities of daily living. It’s very difficult to activity restrict someone,” Walocko said.

Pressure, elevation and hematoma aspiration can address bleeding issues; however, wound healing can be a harder issue to combat.

“For wound healing it’s very challenging because the lower leg is a dependent site. It’s collecting a lot of fluid and this kind of edema can prolong the healing process,” Walocko said.

Using compression socks or wraps and elevating the legs are the current standards to expedite healing in the lower extremities. The use of timolol 0.5%, red light therapy and ablative laser are all options that can be used, according to Walocko, although there is limited research into these methods.