Surgical Pearls for Hemostasis, TXA Use, and Tension-Reducing Closure Techniques

Conclusions

• Tranexamic acid appears to be a useful, cost-effective adjunct for controlling bleeding in dermatologic surgery, especially when used topically or intralesionally in selected patients.
• Simple mechanical measures such as circumferential pressure, instrument tamponade, and careful bandaging can effectively improve hemostasis in small or hard-to-visualize wounds.
• TXA should be used cautiously or avoided in patients with active or prior thrombotic risk, pregnancy, or concomitant oral contraceptive use, but short-term use may still be reasonable in some higher-risk situations.
• Photographing and carefully documenting wounds and lesions is important for optimizing surgical planning and outcomes.
• Managing wound tension is a central principle of successful closure, and strategies like temporary tissue stretching, offloading devices, and thoughtful undermining can improve closure.
• There is an optimal middle ground for suture bite size: too large a bite sacrifices elasticity, while too small a bite risks inadequate strength.
• Preserving and leveraging skin elastin helps reduce closure tension and improve the ability of wounds to stretch during healing.
• The level of undermining should be chosen based on the goal of the closure, because deeper bloodless planes may reduce bleeding but can also reduce tissue stretch.
• Using elastic sutures and anticipating postoperative edema can help maintain closure strength as swelling changes tissue tension.
• A pulley or sliding knot technique can make deep dermal suturing easier when operating alone and may reduce hand fatigue, needle sticks, and operative time.
• Hair management is important on the scalp because hair in the suture line can interfere with healing, so clipping, Vaseline, and assistance can help keep hair out of the wound.
• In many routine closures, especially on the trunk, layered closure with buried absorbable sutures plus short-term superficial support sutures can balance early strength with better cosmetic healing.