Preoperative Considerations for Cutaneous Surgery: Selecting Patients, Managing Medications, Antibiotics, and Anesthesia

Conclusions

• For many low-risk cutaneous lesions, especially superficial or nodular BCC on the trunk/extremities and low-risk SCC in situ or small well-differentiated SCC, non-surgical or less invasive management can be appropriate when paired with careful patient selection.
• Watchful waiting or biopsy-based removal strategies can be safe for selected basal cell carcinomas, with low-risk tumors growing slowly and deep shave removal often achieving clear margins without recurrence in follow-up.
• Topical or destructive therapies such as 5-fluorouracil plus calcipotriene and ED&C can provide high cure rates for selected superficial keratinocyte carcinomas while avoiding surgery.
• Moderately atypical nevi with positive margins can often be observed rather than re-excised, because long-term studies found no melanomas at the biopsy site and very low rates of repigmentation.
• If surgery is needed but the biopsy site is hard to find, a Woods lamp can help localize residual pigment and blood products for more accurate site identification.
• Most anticoagulants should be continued for dermatologic surgery, but ibrutinib is a notable exception because it carries a clinically important bleeding risk and should generally be held perioperatively.
• Routine preoperative antibiotics should be used very sparingly in dermatologic surgery because infection rates are usually low and prophylaxis does not reliably prevent infections, even on the lower leg.
• Antibiotic prophylaxis is mainly reserved for clearly higher-risk scenarios such as oral mucosal or infected skin procedures and certain endocarditis or joint-infection risk situations.
• Good local anesthesia practice relies on using both short-acting and long-acting agents, minimizing injection pain, and respecting dose limits.
• Patient comfort during dermatologic surgery can be improved by warming anesthetic, injecting slowly, using nerve blocks or vibratory distraction, and considering dilution strategies when appropriate.
• Reported lidocaine allergy should be questioned carefully, and uncertain cases are better referred for allergy evaluation than assumed to be true allergy.
• Listening to clinical intuition or the ‘voice’ of experience is presented as an important final safeguard against missing atypical or deeper pathology before operating.