Update and Review of Bleeding Considerations in

Dermatologic Surgery: Hemostatic Techniques and

Treatment Strategies for Bleeding Complications
Sanjana Iyengar, MD,* Danielle G. Yeager, MD,† Joel L. Cohen, MD,‡x and
David M. Ozog, MD†

BACKGROUND There are many intraoperative and postoperative techniques to aid hemostasis in derma-
tologic procedures. An updated understanding is critical for the surgeon.

OBJECTIVE To provide an updated review of methods for hemostasis and therapies for postprocedural
purpura and ecchymosis applicable to dermatology.

MATERIALS AND METHODS A review of Ovid MEDLINE was performed to review the English-language
medical literature of hemostatic options and their use in cutaneous surgery. All available publication years
were included from 1946 to present.

RESULTS A comprehensive and current list of hemostatic options used in the intraoperative and post-
operative period is provided along with traditional and emerging therapies for postprocedural purpura and
ecchymosis.

CONCLUSION A myriad of options exist for minimizing and treating bleeding complications. The appropriate
use and updated knowledge of hemostatic options is provided.

The authors have indicated no significant interest with commercial supporters.

E ffective hemostasis is important to optimize

surgical outcomes and prevent complications
such as hematomas, dehiscence, and infection.1
Methods

A review of the English-language medical literature

Several techniques and hemostatic agents may be used
to manage bleeding complications both
intraoperatively and postoperatively.
In this review, we discuss current and proper tech-
niques to deal with bleeding complications, includ-
ing hemostatic options that can be used
intraoperatively and postoperatively. Updated
therapies to manage postprocedural purpura,
ecchymosis, and expanding hematomas will also be
discussed.
was performed using Ovid MEDLINE. Search terms
included “dermatologic surgery procedures,” “der-
matologic surgery,” “cutaneous surgery,” “hemosta-
sis,” “hemostasis, surgical,” “hemostatic techniques,”
“electrosurgery,” “sutures,” “bone wax,” “throm-
bin,” “fibrin tissue adhesive,” “fibrin sealant,”
“fibrillar collagen,” “hydrophilic polymer,” “micro-
porous polysaccharide hemosphere,” “aluminum
chloride solution,” “ferric subsulfate solution,” “zinc
chloride paste,” and combination thereof. The search
reviewed all relevant publications from 1946 to

*Department of Dermatology, West Virginia University, Morgantown, West Virginia; †Department of Dermatology,
Henry Ford Hospital, Detroit, Michigan; ‡AboutSkin Dermatology and DermSurgery, Greenwood Village,
Colorado; xDepartment of Dermatology, University of California Irvine, Irvine, California

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2019;00:1–13 DOI: 10.1097/DSS.0000000000002138

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 HEMOSTATIC AGENTS AND TECHNIQUES
August 3, 2018, and yielded 1,241 publications. These
were limited to the English language and 1,087
remained, whose abstracts were reviewed.
Results
A summary of the results and hemostatic methods can
be seen in Table 1.
Discussion
Pressure
Direct pressure over a bleeding vessel can stimulate
platelet aggregation and the resultant coagulation
cascade. Uninterrupted manual compression should
be held for 15 to 20 minutes to effectively cease
bleeding.1 Smaller wounds may require a shorter time,
anywhere from 1 to several minutes of direct pressure.2
Intraoperatively, the use of surgical instruments, such
as a hemostat (or even a needle-driver), can prevent
bleeding by clamping the involved vessel and facili-
tating electrocoagulation of the vessel or tying-off the
vessel with the suture. In the case of severe bleeding,
applying pressure to the supplying artery further
upstream can help control blood loss and slow the
pressure in the vessel enough to allow visualization to
clamp. For difficult-to-reach areas, such as the nasal
ala, long cotton tip applicators may also be used for
hemostasis. On digits, a tourniquet may be applied for
up to 20 minutes to control and help identify
bleeding.1
Electrosurgery
Electrosurgery is the most commonly used method for
hemostasis by dermatologic surgeons.1 Electricity
from the instrument induces thermal damage to the
tissue leading to the coagulation cascade and blockage
of the vessel. Forms of electrosurgery include electro-
coagulation, electrodessication, electrofulguration,
and electrosection. Electrocoagulation is the most
commonly used of these modalities in dermatologic
surgery and is a type of biterminal electrosurgery using
high-amplitude, low-voltage electric currents.
Although electricity is not lost to the surrounding tis-
sue, the current in electrocoagulation is actually
interrupted to promote vessel wall sealing.
2 DERMATOLOGIC SURGERY
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Electrosurgery can damage surrounding tissue and
impede wound healing.1 In addition, there is a minimal
risk of fire if the surgical area is prepped with alcohol
or aluminum chloride.3 Caution should be taken in
patients with implantable electronic devices due to the
risk of electromagnetic interference. Defibrillators
may incorrectly identify electrosurgery as a cardiac
arrhythmia and discharge a shock.4 The use of a
bipolar tip, however, has been reported to minimize
electromagnetic interference and avoid cardiac
complications.5
Suture Techniques
If bleeding from larger vessels does not respond to
electrocoagulation, suture techniques (vessel liga-
tion) are often used in place to provide proper
hemostasis. A figure-of-eight suture can be used to
ligate vessels to tamponade bleeding.1 This is per-
formed most commonly with an absorbable braided
suture.6 For patients with bleeding from the incision
site, purse-string sutures can be used to apply tension
to the wound edges and compress vessels in the
dermis.7
Hemostasis can also be accomplished with horizontal
mattress sutures or running locked sutures. Multiple
variations of horizontal mattress sutures include
interrupted, buried in dermal closure, running, and
finally modified locking horizontal mattress sutures.8
A potential risk of horizontal mattress sutures is tissue
strangulation and wound edge necrosis if tied too
tightly.9,10 When using running locked sutures, it is
best to use monofilament sutures to minimize track
marks and foreign-body reactions.
Additional techniques are helpful in certain loca-
tions. If a planned excision is close to the branches of
the superficial temporal artery, percutaneous ligature
of vessels with the suture near the superficial tempo-
ral artery may be considered.11 Before the procedure,
the course of the artery is palpated and traced. After
excision, severed ends of the artery can be ligated or
coagulated with subsequent removal of the percuta-
neous sutures.11 For the scalp, an effective technique
termed “hemostatic enclosure” has been described in
which simple stitches with 2-0 nylon are placed side
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

TABLE 1. Summary of Hemostatic Methods Based on Wound Type*2,30,47

Wound Hemostatic Approximate Use in

Type Method Name Cost† Dermatology Advantages Disadvantages
Deep/ Pressure — — Yes Inexpensive, May not adequately control severe,
active quick, easily persistent bleeding alone
bleeding performed
Electrosurgery — — Yes Widely Can damage surrounding tissue and
available, decrease wound healing if used in
effective excess, risk of fire if near alcohol or
aluminum chloride
Suture — — Yes Effective, inexpensive Excess pressure could cause
techniques strangulation and necrosis
Bone wax — Affordable ($4–$7/ Rare, may be Easily handled, quick application, Possible complications include foreign
2.5-gm wax) used if near effective on bony surfaces, body granulomas, local infection, and
bone nonabsorbent, malleable interference of osteogenesis
Physiologic Thrombin Expensive (range of Rare due to Useful for diffuse bleeding Postcoagulopathy
agents (Thrombostat, $46/unit–$300/ expense
Thrombin-JMI, 20,000 units; spray
Evithrom) more costly)
Fibrin sealants Expensive ($100/1 Rare due to Effective clot formation, may enhance Hypersensitivity reactions,
(Tisseel, Evicel) mL) expense wound healing neurotoxicity, and expense
Platelet gels Expensive ($100–150/ Rare due to Effective hemostatic meshwork Expense
(Vitagel, 1-mL kit) expense
Costasis)
Tranexamic acid Expensive (tablet is Limited Effective antifibrinolytic drug, May not be readily accessible, lack of
(Lysteda tablet) $50–150) (solution reversibly binds to plasminogen and high-quality trials
(Cyckloparon IV is $20–50 per 100 prevents dissolution of fibrin clots
solution) mg/mL vial)
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IYENGAR ET AL
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4
DERMATOLOGIC SURGERY

HEMOSTATIC AGENTS AND TECHNIQUES

TABLE 1. (Continued )

Wound Hemostatic Approximate Use in

Type Method Name Cost† Dermatology Advantages Disadvantages
Oozing Pressure — — Yes Same as above Same as above
Electrosurgery — — Yes Same as above Same as above
Noncaustic Gelatin Relatively affordable Limited Nonreactive, nonantigenic, ideal for Infection, neurovascular compression,
agents (Gelfoam, ($11–20/square). oozing, malleable, promotes healing giant-cell granuloma, can stick to
Surgifoam) Square sizes: 12, 50, by second intention, absorbed by instruments, should not be used in
100, and 200 square body in 4–6 wk closure of skin incisions as it may
cm affect healing74
Oxidized Relatively affordable Limited Easy application, conforms to wound, Inflammation, delayed wound healing
cellulose ($12/square, $25–40 left on wound to heal by second and coagulation necrosis, allergic
(Surgicel, for pad). intention, absorbed by body in 1–2 contact dermatitis
Oxycel) Variable sizes from weeks.
0.5 · 2 inches to 2 ·
14 inches
Microfibrillar Expensive ($132– Limited Ideal for large surface areas, minimal Rare granuloma or foreign body
collagen $170/1oz) swelling and risk of compression, reactions
(Avitene, hemostasis occurs in about 1–5 min
Helistat)
Hydrophilic Affordable ($2/use) Limited Inexpensive, easy to handle, 96% Only used on open wounds that heal by
polymer with success rate in treating lacerations, second intention
potassium salts skin tears, and abrasions, hemostasis
(WoundSeal) is quick and may be achieved in less
than 15 s
Microporous Expensive ($107/1 g) Limited Effective Could increase glucose levels,
polysaccharide within minutes, absorbed by body in expensive
hemospheres 24–48 hours, can be used on open or
(Arista, closed wounds, alternative to
Vitasure) electrocoagulation
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

TABLE 1. (Continued )

Wound Hemostatic Approximate Use in

Type Method Name Cost† Dermatology Advantages Disadvantages
Superficial Caustic Aluminum Inexpensive ($10–20/ Yes Less pigmentation risk, effective, Irritation, pain, delayed wound re-
Agents chloride, 20%– 37.5 mL) inexpensive epithelialization
40% soln
(Drysol, Xerac
AC)
Ferric subsulfate, Inexpensive ($0.10– Yes Inexpensive, used on Pigmentation (tattoo effect), erythema,
20% soln 0.60/mL) small wounds infection, dermal fibrosis, delayed re-
(Monsel’s epithelialization, postinflammatory
solution) hyperpigmentation
Silver nitrate Inexpensive ($0.15/ Yes Inexpensive, used on Pigmentation risk, argyria, burning
stick) small wounds
Trichloroacetic Relatively Yes Less pigmentation risk Irritation
acid, 35% inexpensive ($46/
solution 500 mL bottle)
Zinc chloride, Not widely available Rare Good for friable tissues like skin Irritation, pain
45% paste metastasis from breast
(Moh’s paste) cancer

*If the patient is on anticoagulant or antiplatelet therapy, reversal agents may be used to tamponade bleeding or oozing (e.g., vitamin k on warfarin). However, caution should be taken to
determine the benefit of reducing postprocedural bleeding versus the risk of discontinuing the anticoagulant based on the clinical scenario.
†Currency listed as United States dollars as of 2018; prices were obtained from online resources: QuickMedical, MedExSupply, eSutures, and Drugs.com.
00:00:MONTH 2019

IYENGAR ET AL
5
 HEMOSTATIC AGENTS AND TECHNIQUES
by side encircling the surgical margin to provide
hemostasis.12 Pulley sutures also place significant
positive pressure on wound edges, eliminating
bleeding. Bolster dressings have been used for
second-intention healing sites.13 The bolster, formed
of nonstick dressing such as petrolatum gauze, is
applied firmly over the wound with silk sutures
radially placed around the dressing. The constant
pressure has shown to successfully reduce bleeding
and prevent manipulation near the wound. If possi-
ble, scalp wounds should not be undermined,
reducing the possibility of a hematoma.
Epinephrine
Epinephrine, both an alpha- and beta-adrenergic
agonist, is added to local anesthetics for its vaso-
constrictive activity and prolongs the anesthetic
effect. Surgeons use varying combinations of amide
anesthetics with epinephrine, including 0.5% or 1%
lidocaine with epinephrine at a concentration of
1:100,000 or 1:200,000.14,15 Blanching of the skin
signifies vasoconstriction and occurs several minutes
after anesthesia. Tumescent anesthesia is less com-
monly used in dermatologic surgery, but if used,
surgeons should wait 20 to 30 minutes after injection
for full hemostatic effect.1 Side effects include
tachycardia, flushing, and anxiety—but are more
likely to be associated with much higher dosing of
epinephrine such as that in dental dosing (1:50,000)
than the traditional dermatologic 1:100,00 or
1:200,000.
Caution should be exercised when using higher dosing
of epinephrine in patients on beta blockers.16 Several
studies have shown that patients on nonselective
betablockers have an elevated blood pressure response
after receiving epinephrine.17,18 Nonselective beta-
blockers (such as propranolol) do not have the pro-
tective effects of B2-adrenergic and alpha-adrenergic
vasodilation seen in selective beta blockers. However,
small amounts of epinephrine combined with local
anesthetics is believed to be safe in patients on non-
selective beta blockers with the real risk limited to
those receiving systemic doses.17,19 When trying to
achieve pain control and vasoconstriction, it is rec-
ommended to use the lowest effective concentration of
epinephrine.18
6 DERMATOLOGIC SURGERY
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Physical Agents
Acrylates
Acrylates, such as 2-octyl cyanoacrylate (Dermabond;
Ethicon Inc., Somerville, NJ), are most commonly
used for small lacerations in patient populations
unsuitable for suture placement, such as the pediatric
population. Acrylates have also been used successfully
in wounds left to heal by second intention.20 These
agents rapidly polymerize and cause tissue adhesion,
which may help provide hemostasis for smaller
wounds with minimal tension.1 They are popular in
the outpatient setting due to their accessibility. With
the widespread use of acrylates, dermatologists should
surely be aware of possible contact dermatitis.21–23
Examples of acrylates include Krazy Glue (Elmer’s
Products Inc., Columbus, OH), Dermabond (Ethi-
con), and Band-Aid Liquid Bandage (Johnson &
Johnson, Somerville, NJ).2
Bone Wax
Bone wax is a paste composed of mainly beeswax and
isopropyl palmitate.2 It is a biologically inert material
used to tamponade bleeding, especially on bony sur-
faces. Because it is malleable, bone wax is advanta-
geous in areas such as the ear, nose, or medial canthus
of the eye, where it may be difficult to apply pressure to
the wound. Bone wax has been used successfully for
second-intention healing in patients with basal cell
carcinoma on the nose and medial canthus of the eye.24
Chemical Agents
Chemical hemostatic agents function by damaging the
surrounding tissue, leading to the coagulation cascade
and thrombus formation.2
Monsel’s solution, a 20% compounded ferric sub-
sulfate solution, causes occlusion of vessels by pre-
cipitating proteins in tissues due to its acidic pH. It is
effective postpunch biopsy for wounds healing
through second intention. Soaked cotton swabs or
gauze pads are applied to the wound after the der-
matologic procedure.25 Side effects include infection,
erythema, dermal fibrosis, delayed re-
epithelialization, and potential permanent pigmenta-
tion. Pigmentation of the skin seems to be the more
 IYENGAR ET AL

common issue, so many dermatologic surgeons prefer

to use this product in noncosmetically sensitive
areas—and often avoid the central face. Kuwahara
and colleagues26 suggests leaving the container of
Monsel’s solution open to the air to create a thick
paste, which is more advantageous for coagulation.

“Mohs paste,” composed of zinc chloride, was described

by Frederic E. Mohs in 1941.27 It causes tumor
destruction and is an effective hemostatic agent of friable
tissues, such as metastatic skin lesions from breast can-
cer. Disadvantages of the paste include pain and irrita-
tion during application.2 Silver nitrate, another caustic
hemostatic agent, is easy to use but may cause a tem-
porary gray to gray-black discoloration. Care should be
taken to avoid cosmetically sensitive areas. There is also a
very rare report of localized cutaneous argyria from
topical application of silver nitrate.28

A more commonly used topical hemostatic agent is alu-

minum chloride, which is formulated in a vehicle of
water, alcohol, ether, or glycerol.2 It is often used after
shave or punch biopsies with a cotton-tipped applicator.1
It has also been used successfully after nail biopsies when
combined with an absorbable gelatin sponge.29 Its
mechanism of action results from the hydrolysis of alu-
minum chloride.30 Side effects include pain at the site of
application, tissue irritation, and delayed wound healing.
Care should be taken to avoid application near the eyes.
Although TCA is most commonly used in dermato-
logic offices as an aesthetic chemical peel agent, it can
also serve as a topical hemostatic agent. Thirty-five
percent trichloroacetic acid can function as a hemo-
static agent by causing tissue necrosis and eschar for-
mation.31 Similar to aluminum chloride, but more
effective, trichloroacetic acid has little pigmentation
residue and may be preferred to silver nitrate or ferric
sulfate, which stain the skin. However, it can cause
more irritation and should be avoided in sensitive
areas, such as around the eyes. Figure 1 illustrates the
use of 35% TCA for hemostasis.
Noncaustic Agents
Physical noncaustic hemostatic agents promote clot
formation and can be used as an adjunct to electro-
coagulation. These agents work by propagating the
Figure 1. Dermabrasion site on the nose treated with 35%
TCA to achieve hemostasis (A) initial bleeding site; (B)
application of 35% TCA with the use of a long Q-tip; (C)
partial hemostasis achieved during midapplication of 35%
TCA; (D) complete achievement of hemostasis
within minutes after application. Photograph courtesy: Dr.
David M. Ozog.
phases of hemostasis and creating a physical mesh that
aides in platelet aggregation and coagulation.32
Wounds treated with gelatin, such as Gelfoam (Pfizer,
New York, NY), have successfully healed through
second intention by creating a matrix that promotes
granulation tissue and clot formation.2 Gelatin
products can also swell and double their volume,
providing mechanical hemostasis. They are absorbed
by the body in approximately 4 to 6 weeks. Caution
should be taken when using this product near nerves
or confined spaces due to the concern for compressive
complications.33 Gelatin is available in several

00:00:MONTH 2019 7

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 HEMOSTATIC AGENTS AND TECHNIQUES
different vehicles, including powders, sponges/foam,
and sheets/films. It has been reported to improve
cosmesis and hemostasis.34 However, for surgeons,
gelatin can be difficult to use because it can adhere to
surgical instruments. There is also a higher chance of
infection, and hence, it should not be used for skin
closures.
Collagen, marketed as Avitene (Davol, Cranston, RI)
and Helistat (Integra LifeSciences, Plainsboro, NJ), is
available in powder, sponge, and pad forms.2 When
platelets aggregate on the collagen surface, they
degranulate and stimulate the coagulation cascade.2
When applying collagen to the surgical wound, the
agent is kept dry and applied on the wound bed with
direct pressure. Compared with gelatin products, there
is minimal swelling. Absorption occurs in 8 weeks. Of
note, these agents can disrupt skin healing.35 Because it
is bovine derived, it has the potential for allergic and
foreign body reactions.36
Oxidized cellulose, such as Surgicel (Ethicon) and
Oxycel (Becton Dickinson, Franklin Lakes, NJ),
tamponades vessels with absorption varying between
1 and 6 weeks.2 It is derived from plant fiber and
serves as a physical meshwork for hemostasis.
Although its acidity creates a bactericidal environ-
ment, it prolongs the inflammatory phase and delays
wound healing.37 It is used more commonly in car-
diothoracic and gastrointestinal surgeries.38,39 Firm
pressure over the cellulose strips achieves hemostasis
and occupies space in the surgical field. Once placed
on the wound bed, cellulose should not be removed as
bleeding can occur. Side effects include granuloma-
tous reactions and swelling. Curad Bloodstop
Hemostatic Gauze (Medline Industries, Mundelein,
IL) and BloodSTOP (Life Science PLUS, Mountain-
view, CA) are examples of over-the-counter cellulose
options for patients.
Hydrophilic polymer with potassium salt, such as
WoundSeal (Biolife, Sarasota, FL), is left on open
wounds to heal by second intention.40,41 The potas-
sium salt binds to the positively charged red blood
cells, and an eschar forms in less than 60 seconds. The
topical hemostatic powder is inexpensive, easy to
apply, and is available over-the-counter. BioSeal and
8 DERMATOLOGIC SURGERY
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StatSeal (Biolife) are trade names of WoundSeal used
in the hospital. A study of Mohs patients found faster
hemostasis and greater reduction in wound size when
treated with topical hydrophilic polymer with potas-
sium compared with compressed surgical foam
sponge.42 There are reports, however, of foreign body
reactions after the use of these products after derma-
tologic surgery.41
Purified plant starch powder, composed of micropo-
rous polysaccharide hemispheres, is used when closing
wounds.40 Mechanistically, it works by dehydrating
the blood and concentrating platelets and clotting
factors, which helps accelerate the clotting process.
Marketed as AristaAH (Bard, Muray Hill, NJ), the
powder is expensive but can be used as an alternative
to those contraindicated to receive electrocoagulation.
It is sprinkled over wounds healing by second inten-
tion or before repair by primary closure. It has been
found to achieve hemostasis in less than 5 minutes
without affecting wound healing.43 Compared with
electrosurgery, however, it is less effective and more
expensive. Thus, its use is limited to when electrosur-
gery is contraindicated.44 Caution is advised in dia-
betic patients as the agent could theoretically increase
glucose levels.1
Physiologic Agents
Thrombin products, such as topical bovine thrombin
and human recombinant thrombin, enhance the
fibrinolytic cascade by converting fibrinogen to
fibrin. They are most useful when there is diffuse
bleeding. The solution is either sprayed into the
wound bed, applied with a nonstick gauze
pad/gelatin sponge, or directly applied as a powder.2
Postoperative coagulopathy is a side effect of bovine-
derived thrombin due to antigenic effects. Patients
with decreased fibrinogen levels should not use
thrombin products. Thrombin is marketed as
Thrombostat (Parke-Davis, Ann Arbor, MI) or
Thrombin-JMI (King Pharmaceuticals, Briston, TN).
FloSeal (Baxter Health Care, Deerfield, IL) is a com-
bination product containing gelatin and thrombin. It
is most effective for patients with platelet dysfunc-
tion.45 The use of these products in dermatology and
in outpatient settings is limited because of the cost
and concern for potential adverse events.

Fibrin sealants, a mixture of thrombin and fibrinogen,
form an insoluble fibrin and result in clot formation.42 It
is applied as a foam or by spraying on the wound. Fibrin
sealants are marketed as Tisseel (Hemaseel; Baxter) and
Evicel (Johnson & Johnson). The use of human-derived
fibrin sealants, such as Evicel, decreases the risk of
neurotoxicity.1 Disadvantages of fibrin sealants include
hypersensitivity reactions, neurotoxicity, and expense.
A study of 14 dermatologic patients in Brazil found a
significant reduction in time for hemostasis in the group
receiving fibrin glue.46 The use of fibrin glue for recur-
rent cheek hematoma after Mohs micrographic surgery
has also been recently reported.47
CoStasis (Ortovita, Malvern, PA) is a combination of
bovine collagen and bovine platelets.48 The thrombin
from the bovine platelets converts the patient’s
fibrinogen to fibrin. The collagen forms a hemostatic
meshwork. Expense is a major drawback.
Tranexamic acid (TXA) competitively inhibits the
activation of plasminogen. It is available in the United
States as either a 650 mg tablet or 100 mg/mL intra-
venous solution, which can be compounded into
3.25% solution or 5% solution. The solution is used to
soak sponges and then applied to the surgical site.
Overall, physiologic agents are less likely to be used
due to cost and are rarely used in an outpatient set-
ting. Thrombin is used more in reconstructive plastic
surgery than in dermatology for flaps and grafts due
to its ease of application via modalities such as
sprays, pads/sponges, and powder.2,49 Fibrin seal-
ants are more commonly used in cardiothoracic
procedures but have been used for skin grafts.
Platelet gels, such as Costasis, have been used for fat
grafts after liposuction and as an adjunct to laser
resurfacing. Operator experience, however, makes
fibrin sealants and platelet gels less desired in cuta-
neous surgery.
Topical Brimonidine
Topical brimonidine 0.33% gel, approved for the treat-
ment of rosacea, may have anticoagulant properties. Its
effectiveness in causing complete hemostasis of a bleeding
wound in 20 minutes was first reported in 2015.50
Brimonidine, a selective alpha-2 adrenergic agonist,
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IYENGAR ET AL
causes direct vasoconstriction of cutaneous vessels. It
should be applied to an open wound/vessel to be effective
and achieve high concentrations in the bloodstream. Side
effects include burning, contact dermatitis, and more
recently, central nervous system depression. In 2017, 2
patients on topical brimonidine 0.33% gel for hemostasis
developed altered mental status.51 Results from this
report discourage the use of brimonidine as a hemostatic
agent until its safety is further studied. Another alpha
agonist, Rhofade, has recently been approved by the FDA
but has yet to be examined as a hemostatic agent. It is
likely to also result in altered mental status due to a similar
mechanism of action to brimonidine.
Postoperative Care
Postoperative bleeding is most likely to occur within
the first 48 hours following the procedure.1,15
Ecchymosis is defined as 1 cm or greater patch of
purple-black discoloration appearing as a result of
blood extravasation from a vessel. Purpura is the
name for a smaller version of the lesion between 0.3
and 1 cm. Ecchymosis is a temporary side effect,
lasting from a few days to 2 weeks.40 Hematomas
present as fluctuant masses often accompanied by
ecchymosis on the skin surface. Expanding hemato-
mas occur within the first 24 to 72 hours post-
operatively and present with an expansive mass with
increase pressure, throbbing, ecchymosis, and fluc-
tuation of tissues. If bleeding is uncontrollable and a
hematoma is expanding, the patient should receive
immediate treatment by opening the surgical wound
and ligating or cauterizing the necessary vessel.14
During this procedure, consider using local anesthe-
sia without epinephrine as the latter can cause tem-
porary vasoconstriction and make it difficult to
identify the bleeding vessel. If untreated, hematomas
may cause infection, dehiscence, and tissue necrosis.
Hematomas in the periorbital and cervical locations
are a medical emergency due to the potential for mass
effect on vital structures.
Pressure Dressings
A pressure dressing should be applied for at least 24
hours after the procedure.14 Ideally, they should be left
in place for 48 hours as the risk of postoperative
bleeding complications is highest during this time.52
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 HEMOSTATIC AGENTS AND TECHNIQUES
These dressings are intended to theoretically compress
dead space and prevent hematoma formation by pre-
venting vascular blood loss and exudate. Dressing
normally consists of a topical nonadherent petrolatum
jelly, a nonadherent dressing pad, and a layer of gauze
that is secured by an adhesive tape. Patients should
limit physical activity during the first 48 hours (to
several days) after the procedure to allow vessels to
remain coagulated. If the patient notices increased
bleeding, pressure and ice should be applied directly to
the bandage without removing it for 20 minutes.
Dressing should be changed daily to allow for better
absorption and compression of tissues.
Topical Vitamin K
Vitamin K has been used to both prevent and accelerate
the clearance of bruising by an unknown mechanism.
Topical vitamin K in higher concentrations (5%) rather
than lower concentrations (0.5%) has been shown to
effectively treat postprocedure ecchymosis severity.53,54
Cohen and Bhatia55 showed vitamin K oxide gel has-
tened the resolution of pulsed-dye laser-induced pur-
pura as early as the second day post-treatment
compared with placebo in subjects being treated for
bilateral facial telangiectasia. A combined cream of
0.3% retinol (a low concentration) and 1% vitamin K
has also been shown to be effective in reducing bruising
postlaser treatment as early as Day 3.56
Oral Arnica
Arnica, which is derived from a native plant (Aster-
aceae) in the mountains of Europe and western North
America, may be used to treat ecchymosis. It is pos-
tulated arnica aids in the treatment of ecchymosis by
inhibiting thromboxane B2 (TXB2) formation and
nuclear factor kappa B (NF-kb).40 Topical and oral
formulations exist. Studies, however, suggest topical
arnica is ineffective for preventing or treating post-
procedural ecchymosis. A study by Alonso and col-
leagues57 showed no statistically significant difference
in ecchymosis between topical arnica and placebo
when used after pulsed dye laser (PDL) treatment for
facial telangiectasias. Although oral arnica is consid-
ered safe by the FDA, studies show mixed results
regarding its efficacy after the procedure.58–61 A study
10 DERMATOLOGIC SURGERY
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
by Seeley and colleagues58 noted oral arnica had a
statistically significant smaller area of ecchymosis on
postoperative Day 7 after rhytidectomy. However,
another study by Kotlus and colleagues61 reported no
significant difference with oral arnica on postoperative
Day 7 after blepharoplasty. Owing to these conflicting
results, more studies are needed to fully evaluate oral
arnica’s efficacy for patients with ecchymosis.
Bromelain
Oral bromelain, arising from the pineapple plant
(Ananas comosus), is hypothesized to treat ecchymosis
through its anti-inflammatory effect by reducing pros-
taglandin E2 and TXB2 along with inhibition of inter-
leukin 8–induced neutrophil migration and adhesion.62
A few randomized controlled trials documented posi-
tive outcomes of bromelain in preventing or treating
postprocedure ecchymosis, edema, and hematomas
after surgical and nonsurgical trauma to the face.62–64
However, one study by Howat and Lewis65 reported no
difference in ecchymosis or edema with oral bromelain
postepisiotomy. Of note, oral bromelain at low doses is
considered to be a procoagulant; however, at higher
doses, bromelain has antiplatelet effects and could
exacerbate bleeding.53,66 Its antithrombotic properties
work by increasing the mean platelet volume, inhibiting
Cox-2, and inactivating NF-kb.53 More trials evaluat-
ing oral bromelain are warranted.
Laser Therapy
Various lasers have been used to treat postprocedure
purpura. Pulsed dye laser has been shown to be
effective in treating postoperative purpura after facial
cosmetic procedures.67 Pulsed dye laser causes selec-
tive photothermolysis of hemoglobin and is commonly
used for cutaneous vascular lesions.68 Studies differ
regarding the optimal timing of laser treatment. De
Fatta and colleagues suggest delaying PDL treatment
(fluence: 6 J/cm2, 30-ms pulse duration, 10-mm spot
size) 5 to 6 days after surgery allows for extravasated
hemoglobin to migrate superficially for the laser to
target.67–69 By contrast, a study by Karen and col-
leagues70 suggests early PDL treatment (fluence: 7.5
J/cm2, 6-ms pulse duration, 10-mm spot size) is needed
to target the hemoglobin (absorption 595 nm) before

its conversion to bilirubin (absorption 460 nm). The
study found optimal bruise resolution with PDL
between 48 and 72 hours of ecchymosis formation but
reported accelerated bruise reduction as soon as 6
hours after laser treatment. On the other hand, a study
at Mayo found no difference in bruise reduction after
treatment with PDL and noted the bruises took sta-
tistically longer to resolve than controls.68 This was
attributed to fact that the ecchymosis was artificially
induced by the PDL laser and not by a cosmetic pro-
cedure like the previous studies.
Long-pulsed 1,064-nm Nd:YAG (fluence: 60 J/cm2,
40-ms pulse duration, 10-mm spot size) has also been
used with success to treat bleeding 1 to 2 days after the
procedure.69 Intense pulse light (fluence: 15–20 J/cm2)
initiated on Day 5 postoperative is another option
shown to be effective in reducing the severity of
ecchymosis after eyelid surgery.71
Miscellaneous
Other options to treat ecchymosis include cryotherapy,
vitamin E, and hydrogen peroxide. Vitamin E is anti-
inflammatory and helps with wound healing. Cryo-
therapy induces vasoconstriction and, hence, minimizes
localized hemorrhage72—but risks significant pigment
alteration, plus it is quite painful during the procedure
itself. Hydrogen peroxide 3% is an over-the-counter
topical antiseptic that decreases ecchymosis by causing
lysis of extravasated red blood cells. A stronger con-
centration of hydrogen peroxide 15% carbamide gel has
been reported as a novel treatment for ecchymoses.73
Conclusion
The risk of bleeding can be minimized by intra-
operative and postoperative hemostatic techniques,
pressure dressing, and close follow-up. Hemostatic
agents that are safe, cost-effective, and easy to use are
preferred when deciding which agent or method to
use. Although several hemostatic options exist, elec-
trosurgery seems to be the mainstay during the intra-
operative period.1 Aluminum chloride is preferred in
smaller cases where electrosurgery is not needed, such
as postbiopsy. Physicians should continue to be aware
of updated hemostatic options available for their use.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IYENGAR ET AL
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Address correspondence and reprint requests to: Sanjana
Iyengar, MD, Department of Dermatology, West Virginia
University, 1 Medical Center Drive, PO Box 9158,
Morgantown, WV 26506, or e-mail:
sanjana.iyengar@hsc.wvu.edu
00:00:MONTH 2019 13