Pathophysiology, Risk Factors, and Prevention of Wound Dehiscence Following Dermatologic Procedures

Main Article Content

Andrew Armenta
Frank Winsett
Richard Wagner


wound dehiscence, dermatologic procedures, prevention


Skin cancer is the most common malignancy in the United States and has been increasing in incidence, affecting approximately one in five Americans. As the number of skin cancers have increased, so have the number of dermatologic procedures including biopsies and excisions. Behind surgical site infection, wound dehiscence is the second most common postoperative complication of dermatologic procedures. There are many preoperative, intraoperative, and postoperative risk factors for wound dehiscence. The current literature on the risk factors of dehiscence within the field of dermatology is scarce. To our knowledge, there have not been any comprehensive reviews on this topic. Our research article aims to serve as a comprehensive and concise review with the goal of educating providers and increasing awareness of the risk factors associated with wound dehiscence.


1. Guy GP, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. Feb 2015;48(2):183-187.

2. Wang DM, Morgan FC, Besaw RJ, Schmults CD. An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015. J Am Acad Dermatol. 2018. 78(1):47-53.

3. Rosen R, Manna B. StatPearls. Wound Dehiscence. StatPearls Publishing; 2020.

4. Basu P, Goldenberg A, Cowan N, Eilers R, Hau J, Jiang SIB. A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery. J Am Acad Dermatol. Jun 2019;80(6):1594-1601.

5. Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. Dec 2013;149(12):1378-85.

6. Steinman HK, Clever H, Dixon A. The characteristics of Mohs surgery performed by dermatologists who learned the procedure during residency training or through postgraduate courses and observational preceptorships. Proc (Bayl Univ Med Cent). Apr 2016;29(2):119-23.

7. Wallace H, Basehore B, Zito P. StatPearls. Wound Healing Phases. StatPearls Publishing; 2020.

8. Gonzalez AC, Costa TF, Andrade ZA, Medrado AR. Wound healing - A literature review. An Bras Dermatol. 2016 Sep-Oct 2016;91(5):614-620.

9. Ireton JE, Unger JG, Rohrich RJ. The role of wound healing and its everyday application in plastic surgery: a practical perspective and systematic review. Plast Reconstr Surg Glob Open. 2013;1(1):e10-e19.

10. Carlson MA. Acute wound failure. Surg Clin North Am. Jun 1997;77(3):607-36.

11. Gabrielli F, Potenza C, Puddu P, Sera F, Masini C, Abeni D. Suture materials and other
factors associated with tissue reactivity, infection, and wound dehiscence among plastic surgery outpatients. Plast Reconstr Surg. Jan 2001;107(1):38-45.

12. Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol. Dec 2012;67(6):1302-9.

13. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol. Feb 2003;139(2):143-52.

14. Falland-Cheung L, Scholze M, Lozano PF, et al. Mechanical properties of the human scalp in tension. J Mech Behav Biomed Mater. 08 2018;84:188-197.

15. Buka B, Uliasz A, Krishnamurthy K. Buka's Emergencies in Dermatology. Springer; 2013.

16. Paul SP. Biodynamic excisional skin tension lines for surgical excisions: untangling the science. Ann R Coll Surg Engl. Apr 2018;100(4):330-337.

17. Maranda EL, Heifetz R, Cortizo J, Hafeez F, Nouri K. Kraissl Lines—A Map. JAMA Dermatol. 2016;152(9):1014.

18. Stasko T, Roenigk H, Jr RH. Complications of cutaneous procedures. In: Dermatologic Surgery: Principles and Practice, 2nd ed,. New York: Marcel Dekker; 1996. p. 149.

19. Berens AM, Akkina SR, Patel SA. Complications in facial Mohs defect reconstruction. Curr Opin Otolaryngol Head Neck Surg. Aug 2017;25(4):258-264.

20. Alghamdi KM. The gliding stitch. Dermatol Surg. Jun 2008;34(6):803-5.

21. Giandoni MB, Grabski WJ. Surgical pearl: the dermal buried pulley suture. J Am Acad Dermatol. Jun 1994;30(6):1012-3.

22. Casparian JM, Monheit GD. Surgical pearl: the winch stitch-a multiple pulley suture. J Am Acad Dermatol. Jan 2001;44(1):114-6.

23. Coldiron BM. Closure of wounds under tension. The horizontal mattress suture. Arch Dermatol. Sep 1989;125(9):1189-90.

24. Breuninger H, Keilbach J, Haaf U. Intracutaneous butterfly suture with absorbable synthetic suture material. Technique, tissue reactions, and results. J Dermatol Surg Oncol. Jul 1993;19(7):607-10.

25. Clayton A, Stasko T. Dermatology. 3rd ed. vol 2. Surgical Complications and Optimizing Outcomes Elsevier; 2012.

26. Wahie S, Lawrence CM. Wound complications following diagnostic skin biopsies in dermatology inpatients. Arch Dermatol. Oct 2007;143(10):1267-71.

27. Sandy-Hodgetts K, Carville K, Leslie GD. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J. Jun 2015;12(3):265-75.

28. Delpachitra MR, Heal C, Banks J, Divakaran P, Pawar M. Risk Factors for Surgical Site Infection in Minor Dermatological Surgery: A Systematic Review. Adv Skin Wound Care. May 2019;32(5):217-226.

29. Gantwerker EA, Hom DB. Skin: histology and physiology of wound healing. Facial Plast Surg Clin North Am. Aug 2011;19(3):441-53.

30. Reimer A, Has C. [Syndromes with skin fragility]. Hautarzt. Jul 2019;70(7):481-489.

31. Libby P, Buring JE, Badimon L, Hansson GK, Deanfield J, Bittencourt MS, Tokgözoğlu L, Lewis EF. Atherosclerosis. Nat Rev Dis Primers. 2019 Aug 16;5(1):56.

32. Barchitta M, Maugeri A, Favara G, et al. Nutrition and Wound Healing: An Overview Focusing on the Beneficial Effects of Curcumin. Int J Mol Sci. Mar 2019;20(5).

33. Guzik TJ, Touyz RM. Oxidative Stress, Inflammation, and Vascular Aging in Hypertension. Hypertension. 10 2017;70(4):660-667.

34. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. Jun 2012;255(6):1069-79.

35. Siasos G, Tsigkou V, Kokkou E, et al. Smoking and atherosclerosis: mechanisms of disease and new therapeutic approaches. Curr Med Chem. 2014;21(34):3936-48.

36. Anderson K, Hamm RL. Factors That Impair Wound Healing. J Am Coll Clin Wound Spec. Dec 2012;4(4):84-91.

37. Wilson JA, Clark JJ. Obesity: impediment to wound healing. Crit Care Nurs Q. 2003 Apr-Jun 2003;26(2):119-32.

38. Wagner IJ, Szpalski C, Allen RJ, et al. Obesity impairs wound closure through a vasculogenic mechanism. Wound Repair Regen. 2012 Jul-Aug 2012;20(4):512-22.

39. Casey G. Nutritional support in wound healing. Nurs Stand. 2003 Feb 19-25 2003;17(23):55-8.

40. Russell L. The importance of patients' nutritional status in wound healing. Br J Nurs. Mar 2001;10(6 Suppl):S42, S44-9.

41. Anderson B. Nutrition and wound healing: the necessity of assessment. Br J Nurs. 2005 Oct 27-Nov 9 2005;14(19):S30, S32, S34.

42. Shigematsu T, Tajima S. Modulation of collagen synthesis and cell proliferation by retinoids in human skin fibroblasts. J Dermatol Sci. Mar 1995;9(2):142-5.

43. Aksoy HM, Aksoy B, Çalikoglu E. Systemic Retinoids and Scar Dehiscence. Indian J Dermatol. 2019 Jan-Feb 2019;64(1):68-70.

44. van Anholt RD, Sobotka L, Meijer EP, et al. Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition. Sep 2010;26(9):867-72.

45. Brewer JD, Otley CC, Christenson LJ, Phillips PK, Roenigk RK, Weaver AL. The effects of sirolimus on wound healing in dermatologic surgery. Dermatol Surg. Feb 2008;34(2):216-23.

46. Shanmugam VK, Fernandez SJ, Evans KK, et al. Postoperative wound dehiscence: Predictors and associations. Wound Repair Regen. 2015 Mar-Apr 2015;23(2):184-90.

47. Zhao-Fleming H, Hand A, Zhang K, et al. Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis. Burns Trauma. 2018;6:25.

48. Goren I, Lee SY, Maucher D, et al. Inhibition of cyclooxygenase-1 and -2 activity in
keratinocytes inhibits PGE. Int Wound J. Feb 2017;14(1):53-63.

49. Otley CC, Fewkes JL, Frank W, Olbricht SM. Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol. Feb 1996;132(2):161-6.

50. Billingsley EM, Maloney ME. Intraoperative and postoperative bleeding problems in patients taking warfarin, aspirin, and nonsteroidal antiinflammatory agents. A prospective study. Dermatol Surg. May 1997;23(5):381-3; discussion 384-5.