Practical Pearls for Managing Bleeding, Tension, and Closure in Mohs and Skin Surgery

Conclusions

• Effective bleeding control in dermatologic surgery often comes from simple mechanical tactics such as circumferential pressure, careful release to identify individual vessels, and targeted cautery.
• Tranexamic acid appears to be a practical, low-cost, and versatile hemostatic adjunct that can reduce bleeding and postoperative calls when used topically, intralesionally, or with anesthetic.
• TXA should not be used indiscriminately because thrombotic disease, pregnancy, and concurrent oral contraceptive use are important contraindications or cautions.
• Taking clinical photographs is valuable because it improves documentation, helps recognize recurrence, and supports planning for reconstruction and closure.
• Tissue creep and temporary offloading devices, such as towel clamps or similar tension-modulating methods, can increase tissue mobility and help achieve primary closure.
• Choosing the correct suture and closure strategy requires accounting for postoperative edema and the need for elasticity so that tension can be maintained without cutting through tissue.
• There is a Goldilocks balance in suture bites: too large can sacrifice elasticity and too small may fail to hold, so the optimal bite size is a trade-off.
• Undermining should be chosen based on the goal of the closure, since deeper bloodless planes reduce bleeding but may eliminate the elastic tissue needed for stretch.
• Surgery is fundamentally about trade-offs, and good outcomes depend on balancing tension relief, hemostasis, and preservation of tissue properties.
• Simple adjuncts like button-style offloading dressings and swab-based support can reduce tension on closures and improve healing.
• A pulley-style or single-sided tensioning technique can make deep dermal suturing easier, reduce hand fatigue, and speed up wound closure when working alone.
• More efficient hemostasis and closure techniques may ultimately reduce complications, postoperative bruising, patient anxiety, and after-hours phone calls.