Evaluation and Management of Hypertension in the Perioperative Period of Mohs Micrographic Surgery: A Review Rebecca J. Larson, MD,* and Juliet Aylward, MD†

BACKGROUND While patients’ hypertensive problems are usually actively and effectively managed by their primary physician, the dermatologic surgeon can still be affected by hypertension where the condition is unrecognized or uncontrolled. Hypertension is an important contributor to both bleeding and hematoma formation during and after surgery, ultimately affecting functional and cosmetic outcomes. OBJECTIVE To extensively review the literature on perioperative management of the hypertensive patient as relates to the dermatologic surgeon. MATERIALS AND METHODS An updated and comprehensive literature review, focusing on current diagnostic guidelines, practice by specific dermatologic surgery groups and management recommendations, was conducted. RESULTS Review of the literature does support generalized guidelines for the management of hypertensive patients in the Mohs Micrographic Surgery (MMS) setting; however data on implementation and outcomes by specific dermatologic surgery groups is variable and lacking. CONCLUSIONS The treatment of nonmelanoma skin cancers with MMS is now routine, and fortunately can be performed quite safely. There are still improvements to be made however, in managing perioperative hypertension—both in making patients aware of their condition and in treating it effectively. Practicing these measures can promote patients’ overall health and the efficiency of the dermatologic surgeon’s practice. The authors have indicated no significant interest with commercial supporters.

Mohs Micrographic Surgery and Hypertension in the United States


t is estimated that the number of persons older than 65 years in the United States will increase by 25% to 35% over the next 30 years. This is the same age group in which the highest number of surgical procedures is performed. Thus, it is possible that the number of noncardiac surgical procedures performed in older persons will increase from the current 6 million to nearly 12 million per year.1 Currently, the United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from

approximately 1 million in 1994 to approximately 4 million per year in 2011. Presently, approximately 1 in 5 skin cancers are treated with Mohs micrographic surgery (MMS); therefore, a significant number of those noncardiac surgical procedures performed in older persons will be MMS.2 Hypertension affects 50 million people in the United States,3 a number that is also increasing. People who are 55 years old, who are currently normotensive, have a 90% lifetime risk of developing hypertension4; however, a significant number of affected individuals

*Department of Dermatology, Southern Illinois University School of Medicine, Springfield, Illinois; †Department of Dermatology, West Clinic, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin


© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:603–609 DOI: 10.1111/dsu.0000000000000012



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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.


are receiving no or insufficient treatment.5 The National Health and Nutrition Examination Surveys from 1999 to 2000 were used to evaluate adults with hypertension, in particular, those who were aware of their condition, receiving treatment, and achieving control. In this group of people with hypertension, 30% were not aware that they had hypertension, only 59% were being treated, and just 34% had their hypertension under control.3 The impact of undiagnosed, untreated, or controlled hypertension is not fully elucidated. Results from a recent review of randomized controlled trials suggest that medically treating mild hypertension in individuals with no previous cardiovascular events or cardiovascular disease may not reduce mortality or morbidity. In a metaanalysis of 3 of the 4 randomized controlled trials involving 7,080 asymptomatic individuals with mild hypertension, Cochrane researchers found that antihypertensive drugs as compared with placebo did not reduce the incidence of coronary heart disease or stroke, or total cardiovascular events. In addition, 9% of the patients enrolled in these trials discontinued medical treatment because of adverse effects.6 Despite these discouraging statistics, patients’ hypertensive problems often are managed actively, and often effectively, by their family physicians or internists. However, unrecognized or uncontrolled hypertension can present problems for dermatologic surgeons. Hypertension is an important contributor to both bleeding and hematoma formation during and after surgery. In addition, high intravascular pressure may inhibit adequate blood supply to flaps

TABLE 1. Blood Pressure Classification Systolic, mm Hg and/or Diastolic, mm Hg


Evaluation and management of hypertension in the perioperative period of Mohs micrographic surgery: a review.

While patients' hypertensive problems are usually actively and effectively managed by their primary physician, the dermatologic surgeon can still be a...
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