Blood Thinners and Skin Cancer Surgery: Why the "Just Continue Everything" Advice May Be Too Simple

The Most Striking Disagreement in Modern Surgery

If you take a blood thinner and need skin cancer surgery, you will receive contradictory advice. Your dermatologist will tell you to keep taking it. Your cardiologist may tell you to hold it. Your primary care doctor may say something different from both.

This is not a failure of communication. It is a genuine intellectual disagreement about how to interpret the same body of evidence, and it is one of the most striking areas of inter-specialty conflict in contemporary surgery.

Here is what makes it remarkable: Mohs surgeons and dermatologic surgeons routinely continue direct oral anticoagulants (DOACs) during procedures that are procedurally identical to operations performed by plastic surgeons, otolaryngologists, and general surgeons — all of whom routinely hold these medications. A rhombic flap performed by a Mohs surgeon and a rhombic flap performed by a plastic surgeon involve the same tissue handling, the same undermining, the same dead space. Yet the perioperative anticoagulation management is opposite.

That should bother you. It bothers me.

What the AAD Recommends — and Why It May Be Oversimplified

The AAD and the American College of Mohs Surgery (ACMS) have historically recommended continuation of anticoagulant therapy, including DOACs, during Mohs surgery and cutaneous procedures (Rao et al., 2023; Ireland et al., 2024). Their position applies uniformly to all cutaneous procedures — from a 5-minute shave excision to a multi-hour staged reconstruction with a paramedian forehead flap.

The AAD guideline for reconstruction after skin cancer resection, published jointly with the ASPS, reviewed six studies comparing aspirin, warfarin, and clopidogrel to placebo and concluded there was no difference in perioperative bleeding or hematoma rates (Chen et al., 2021). The guideline characterizes the risks of continuing medications as "minor inconveniences and costs," while the potential benefits are "reduction in the incidence of severe adverse events and death."

That framing sounds compelling. But there are two problems.

Problem 1: The evidence base is weak. The broader dermatologic surgery literature suffers from pervasive methodological limitations. Adalsteinsson and colleagues performed a critical review of Mohs surgery and staged excision studies for melanoma using ROBINS-I criteria — the standard tool for assessing bias in non-randomized studies — and found that 97.9% of studies had serious or critical bias (Adalsteinsson et al., 2023). None were randomized controlled trials. While that review focused on melanoma outcomes rather than anticoagulation specifically, it exposes a structural problem: the same study designs, the same institutions, and the same methodological shortcomings pervade the anticoagulation literature in dermatologic surgery. Alam and colleagues separately found that the median Jadad score for RCTs in dermatologic surgery was only 1–2, indicating poor reporting of randomization, blinding, and sample size determination (Alam et al., 2014).

Problem 2: The recommendation does not stratify by procedural risk. A simple excision with primary closure has a fundamentally different bleeding risk profile than an interpolation flap or a full-thickness skin graft. Treating them identically is clinically convenient but intellectually indefensible. The AAD's failure to differentiate between a 1-cm primary closure and a paramedian forehead flap with an 8.4% active bleeding rate is inconsistent with the approach of every other major guideline body.

What Every Other Major Guideline Body Recommends

Seven major international guideline bodies — the American College of Chest Physicians (ACCP), the American College of Cardiology/American Heart Association (ACC/AHA), the European Society of Cardiology (ESC), the American Society of Plastic Surgeons (ASPS), the British Society for Dermatological Surgery (BSDS), the National Comprehensive Cancer Network (NCCN), and the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee (ISTH SSC) — all recommend a risk-stratified approach to perioperative DOAC management (Douketis et al., 2022; Thompson et al., 2024; Doherty et al., 2017; Shaw et al., 2026).

That is not a typo. Seven against one. The AAD stands alone.

The ACCP guideline categorizes procedures into three tiers based on expected 30-day major bleeding rates:

• Minimal bleeding risk (expected major bleeding ~0%): Continue DOACs or omit/delay morning dose. This includes simple excisions, primary closures, and small local flaps.
• Low-to-moderate bleeding risk (expected major bleeding 0–2%): Hold DOACs for 1 day (24 hours) preoperatively, resume ≥24 hours postoperatively. This includes larger flaps and full-thickness skin grafts.
• High bleeding risk (expected major bleeding ≥2%): Hold DOACs for 2 days (48 hours) preoperatively, resume 48–72 hours postoperatively. This includes extensive reconstructions.

This framework is grounded in the PAUSE trial — the largest and highest-quality prospective study on perioperative DOAC management ever conducted.

How the Guidelines Actually Compare, Side by Side

Before we examine the PAUSE trial itself, it is worth putting every major guideline body in one place. The table below summarizes how each society recommends managing perioperative DOACs for skin surgery. Notice how the AAD sits alone.

Every body except the AAD stratifies management by procedure complexity. Several — NCCN, ACCP, ACC/AHA, ISTH SSC — stratify further by agent and renal function. One guideline body recommends continuation regardless of procedure: the AAD.

The ISTH SSC guideline deserves special attention. Published in 2026 in the Journal of Thrombosis and Haemostasis by Shaw and colleagues, it represents the most current international consensus on perioperative DOAC management (Shaw et al., 2026). The ISTH SSC explicitly endorses a three-tiered procedural bleeding risk classification — minimal, low-to-moderate, and high — with DOAC- and creatinine-clearance-specific interruption protocols. This is not a peripheral specialty society weighing in on a topic outside its expertise. The ISTH is the international authority on thrombosis and hemostasis. When the people who define the science of blood clotting tell you to risk-stratify, that should carry weight.

The AAD-ASPS Divergence: The Same Guideline, Two Different Conclusions

This is the part that should make every Mohs surgeon pause and think.

In 2021, the AAD and the American Society of Plastic Surgeons (ASPS) published a joint evidence-based clinical practice guideline on reconstruction after skin cancer resection. The same authors, the same evidence review, the same working group. It was published simultaneously in two journals: the Journal of the American Academy of Dermatology (Chen et al., 2021) and Plastic and Reconstructive Surgery (Chen et al., 2021 PRS).

Here is what is remarkable: the two versions are not identical.

The Plastic and Reconstructive Surgery version — the version read by plastic surgeons — explicitly acknowledges that "when complex reconstructive procedures involving flaps or grafts are planned in the facility setting, bleeding risk potentiates complications and possible failure of the reconstruction" (Chen et al., 2021 PRS). That language concedes a critical point: complex procedures carry different bleeding risks than simple excisions, and that difference matters for perioperative medication management.

The JAAD version — the version read by dermatologists — omits this language.

Same guideline. Same authors. Same evidence base. But the version published for plastic surgeons acknowledges procedural risk stratification, while the version published for dermatologists does not. Ask yourself why.

In real-world practice, this divergence plays out in a way that most dermatologists never see. Plastic surgeons routinely hold blood thinners when performing advancement flaps, bilobed flaps, interpolation flaps, and full-thickness skin grafts — the same procedures Mohs surgeons perform daily. They do this because their training, their guidelines, and the facility-based protocols they operate under all support risk stratification. The AAD's blanket continuation recommendation was written for office-based dermatologic procedures, but the procedures Mohs surgeons perform have grown far beyond what "office-based dermatologic procedure" traditionally described.

Here is the question that deserves an honest answer: if a plastic surgeon is justified in holding a blood thinner before performing a bilobed flap at an ambulatory surgery center, on what basis is a Mohs surgeon unjustified in doing the same thing for the same flap in the office? The tissue does not know the setting. The bleeding risk of a bilobed flap is a property of the flap — not of the building it is performed in.

The fact that the same joint guideline was published with different language for different audiences suggests that even the guideline authors recognized this tension. They just resolved it differently depending on which journal they were writing for.

The NCCN Classification: Where Dermatology Sits and Why That's Odd

The National Comprehensive Cancer Network (NCCN) publishes a Perioperative Management of Anticoagulation and Antithrombotic Therapy guideline that categorizes every common invasive procedure by bleeding risk. Here is how the relevant categories break down (NCCN Guidelines v3.2025):

Now look at this carefully. NCCN classifies reconstructive plastic surgery and head and neck surgery as moderate bleeding risk — triggering a 2-day DOAC hold for most agents. NCCN classifies minor dermatologic procedures — specifically listed as skin biopsies, BCC and SCC excisions, actinic keratoses, and nevi — as very low risk, where continuation is appropriate.

That classification is defensible for what it literally describes: a shave biopsy, a small simple excision closed primary, an actinic keratosis destruction. Those procedures are very low bleeding risk by any standard. The problem is what NCCN's list does not include.

Mohs micrographic surgery on the face is not, in practice, a "minor dermatologic procedure." It ends with a reconstruction — frequently a flap, a full-thickness skin graft, or occasionally an interpolation flap on the nose, ear, or lip. That reconstruction is, anatomically and technically, identical to the procedure a plastic surgeon or otolaryngologist would perform on the same defect. NCCN itself places "reconstructive plastic surgery" and "head and neck surgery" in the moderate-risk tier. The same operation, performed by a different specialty, moves two categories up.

The data on who performs these reconstructions is unambiguous. In the Medicare population, Mohs surgeons performed 75.3% of all cutaneous reconstructions at cosmetically and functionally sensitive (head and neck) sites in 2019, up significantly from 2013 (Tan et al., 2023). In 2014, Mohs-performing dermatologists billed Medicare for 52.85% of all flaps, 59.65% of all full-thickness skin grafts, and 67.56% of all complex repairs (Kantor, 2020). Donaldson and Coldiron found dermatologic surgeons accounted for 55.5% of local tissue rearrangements and 57.5% of full-thickness skin grafts in Medicare (Donaldson & Coldiron, 2013).

Put the pieces together. NCCN says reconstructive plastic surgery and head and neck surgery are moderate bleeding risk — hold the DOAC. In the real world, Mohs surgeons — dermatologists — perform the majority of those exact reconstructions in the United States. If a 2-day DOAC hold is appropriate when a plastic surgeon closes a forehead defect with a paramedian flap, what evidence supports the claim that no hold is appropriate when a Mohs surgeon closes the same defect with the same flap?

The tissue does not know who is wielding the scalpel. The bleeding risk of a paramedian forehead flap is a property of the flap, not the credentials of the surgeon. NCCN's categorization of "minor dermatologic procedures" as very-low-risk is correct for the procedures it names. It becomes misleading only when it is extrapolated — as the AAD guideline extrapolates — to every cutaneous procedure a dermatologist performs, including the interpolation flaps and large grafts that NCCN itself would classify as moderate risk in any other specialty's hands.

The PAUSE Trial: 3,007 Patients, the Gold Standard

In 2019, Douketis and colleagues published results from the PAUSE trial in JAMA Internal Medicine — a prospective management study of 3,007 patients with atrial fibrillation on apixaban, dabigatran, or rivaroxaban undergoing elective surgery (Douketis et al., 2019). It is important to note that PAUSE was a single-arm study without a continuation comparator group — it cannot directly compare interruption versus continuation. What it does provide is the largest prospective dataset showing that standardized DOAC interruption produces acceptably low rates of both bleeding and thromboembolism.

The PAUSE protocol used a simple, standardized approach: DOACs were interrupted for 1 day before low-bleeding-risk procedures and 2 days before high-bleeding-risk procedures. No heparin bridging. No coagulation function testing.

The results:

• Major 30-day postoperative bleeding, by DOAC cohort: 1.35% (apixaban), 0.90% (dabigatran), 1.85% (rivaroxaban)
• Major bleeding stratified by procedural risk: 0.9% (95% CI, 0–1.32%) for low-to-moderate-bleeding-risk procedures; 2.48% (95% CI, 0–3.43%) for high-bleeding-risk procedures
• Arterial thromboembolism: 0.16–0.60%
• Residual anticoagulant levels (<50 ng/mL threshold): At procedure time, 90.5% of apixaban patients, 95.1% of dabigatran patients, and 96.8% of rivaroxaban patients had residual DOAC levels below 50 ng/mL (Douketis et al., 2022). In the high-bleeding-risk subgroup undergoing a 2-day interruption, 98.9% had levels below 50 ng/mL, and 94.7% had levels below 30 ng/mL — essentially no clinically meaningful anticoagulation remaining (Douketis & Spyropoulos, 2024)

These are remarkably low complication rates. And they were achieved with a standardized interruption protocol — not blanket continuation.

Compare this to the dermatologic surgery literature: Ireland and colleagues' 2024 systematic review found an average hemorrhagic complication rate of 1.74% with DOAC continuation (Ireland et al., 2024). The PAUSE trial achieved comparable bleeding rates (0.9–1.85% across drug cohorts) with interruption — while also demonstrating thromboembolic rates below 1%.

One caveat on that comparison: the Ireland review pooled studies using heterogeneous definitions of "hemorrhagic complication," while PAUSE used standardized ISTH major-bleeding criteria. So these numbers are approximations, not a head-to-head comparison. The broader point — that standardized interruption produces very low bleeding rates in a large, prospective, well-characterized cohort — stands regardless of how the denominators are defined.

What 806 Patients at a Mohs Surgery Practice Showed

The question of whether brief DOAC interruption is safe specifically in dermatologic surgery was directly addressed by Siscos, Neill, Singh, and Hocker in a 2021 study published in the Journal of the American Academy of Dermatology (Siscos et al., 2021).

The study retrospectively reviewed 806 dermatologic operations — 750 Mohs procedures and 56 excisions — in patients with atrial fibrillation or a history of deep vein thrombosis who underwent perioperative DOAC interruption. The 30-day outcomes:

• Thrombotic complications: 1 patient (0.14%) sustained a transient ischemic attack
• Bleeding complications: 2 patients (0.25%) had minor bleeding

Those numbers deserve emphasis. In 806 operations with DOAC interruption, the thromboembolic rate was 0.14% and the bleeding rate was 0.25%. Both were minor and self-limited. No strokes. No pulmonary emboli. No life-threatening hemorrhage.

This study is important because it demonstrates that brief DOAC interruption in dermatologic surgery — the very practice the AAD recommends against — produces outcomes that are indistinguishable from the outcomes reported in studies of DOAC continuation.

The Pharmacokinetic Logic Behind Risk Stratification

The risk-stratified approach is not arbitrary. It is grounded in the pharmacokinetics of DOACs — specifically, how long these drugs stay active in your body.

Factor Xa inhibitors have elimination half-lives that vary by agent: rivaroxaban 5–9 hours in younger adults (extending to 11–13 hours in the elderly), apixaban approximately 12 hours, and edoxaban 10–14 hours. Dabigatran has a half-life of 12–17 hours in patients with normal kidney function (CrCl ≥80 mL/min), extending to approximately 15 hours with CrCl 50–79 and 18 hours with CrCl 30–49 (Douketis & Spyropoulos, 2024; Douketis et al., 2022).

Here is why those numbers matter:

• A 1-day (24-hour) hold corresponds to approximately 2–3 half-lives depending on the specific DOAC and patient factors. After 3 half-lives, more than 87% of the drug is eliminated. This achieves minimal residual anticoagulant effect — sufficient for low-to-moderate bleeding risk procedures.
• A 2-day (48-hour) hold corresponds to 3–5 half-lives depending on the agent. In the PAUSE trial, 94.7% of patients undergoing high-bleeding-risk procedures had drug levels below 30 ng/mL after a 2-day interruption — essentially no clinically meaningful anticoagulation remaining.

For patients with impaired kidney function — particularly those on dabigatran, which is 75–80% renally cleared — the interruption interval must be extended. The ACCP recommends 3–4 days before high-bleeding-risk procedures for dabigatran in patients with CrCl below 50 mL/min (Douketis et al., 2022).

A 2026 study by Camilleri and colleagues in JAMA Network Open adds another layer of nuance. Measuring preoperative DOAC levels in patients undergoing elective surgery after standardized interruption, the authors found that apixaban patients had a markedly higher proportion of elevated (≥30 ng/mL) residual levels at surgery compared with dabigatran or rivaroxaban (Camilleri et al., 2026). The implication: a one-size-fits-all 24-hour or 48-hour interruption protocol may be adequate for rivaroxaban and dabigatran but insufficient for some apixaban patients undergoing high-bleeding-risk procedures. Agent-specific management — longer holds for apixaban in higher-risk cases — may become the standard of care as this evidence base matures.

The rapid onset of action of DOACs (peak effect 2–3 hours after intake) is equally important for postoperative management. Resuming a DOAC too early after surgery is like turning on a faucet while you are still trying to secure the plumbing. The ACCP recommends waiting at least 24 hours after low-to-moderate risk procedures and 48–72 hours after high-risk procedures before restarting (Douketis et al., 2022).

The Risk-Stratified Framework: Matching the Hold to the Procedure

Bringing together the ACCP framework with procedure-specific bleeding data from the dermatologic surgery literature, the evidence supports the following approach:

The procedure-specific bleeding data supports this stratification. Bordeaux and colleagues prospectively showed that compared to intermediate (layered) closure, the odds ratio for hemorrhage was 5.80 for complex repair, 7.58 for graft repair, and 11.93 for flap repair (Bordeaux et al., 2011). That gradient is real, clinically significant, and should inform anticoagulant management.

For interpolation flaps specifically — paramedian forehead flaps, melolabial flaps, retroauricular flaps — Perz and colleagues reported a 5.33% bleeding rate after flap placement (95% CI: 2.83–9.82%) (Perz et al., 2023), and Newlove and Cook found 8.4% active bleeding requiring physician intervention across 653 staged interpolation flaps (Newlove & Cook, 2013). Freeman and colleagues' 2023 cohort of interpolation flap repairs found a 28.7% bleeding event rate without perioperative tranexamic acid, falling to 4.8% with TXA (Freeman et al., 2023). The 28.7% figure uses a broader definition (any unplanned bleeding-related contact) than Perz's physician-intervention definition, but all of these rates exceed the ACCP's ≥2% threshold for high-bleeding-risk classification — by a considerable margin.

For full-thickness skin grafts, the critical concern is not just bleeding volume but what a hematoma does to graft survival. Bordeaux and colleagues reported that partial graft necrosis occurred in 8.6% of grafts overall, 20% on the scalp, and 10% on the nose (Bordeaux et al., 2011). A hematoma under a graft prevents revascularization and can kill the graft entirely — making the clinical significance of even modest bleeding greater than raw hemorrhage rates suggest.

The largest prospective dataset on Mohs complications comes from Alam and colleagues' multicenter cohort of 20,821 cases across 23 centers (Alam et al., 2013). That study found that while flaps and grafts represented only about 37% of repair types, they accounted for one-half to two-thirds of bleeding, infection, and wound-healing complications. The disproportionate burden of flaps and grafts — the same procedures NCCN and the ACCP classify as moderate-to-high bleeding risk — is not an artifact of small single-center series. It is a pattern that holds across 23 academic and community practices.

Aspirin and Antiplatelet Agents: The Easier Question

For aspirin and single antiplatelet agents, the evidence more clearly supports continuation. The AAD guideline found no difference in perioperative bleeding or hematoma rates in patients on aspirin undergoing skin flaps and grafts (Chen et al., 2021). Bordeaux and colleagues prospectively evaluated 1,911 patients and found an overall hemorrhage risk of 0.89%, with all complications resolving without sequelae (Bordeaux et al., 2011). Isted and colleagues' systematic review found no increase in hemorrhagic complications with aspirin monotherapy and no increase in wound dehiscence, graft failure, or cosmetic outcome issues (Isted et al., 2018).

The ACCP and ASPS agree: continue aspirin and, where possible, clopidogrel, given the low absolute bleeding risk and potentially catastrophic consequences of interruption.

Dual antiplatelet therapy (typically aspirin plus clopidogrel, often prescribed after coronary stenting) is a different situation. Höper and colleagues found severe bleeding was significantly more frequent with dual antiplatelet therapy (11.76%, P = 0.0166), though no life-threatening events occurred (Höper et al., 2023). Bordeaux found patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications (Bordeaux et al., 2011). Dual antiplatelet therapy warrants individualized assessment — never stop these medications without coordinating with the prescribing cardiologist.

Bridging Anticoagulation: The One Thing Everyone Agrees On

If there is a single point of consensus across all specialties and all guidelines, it is this: do not bridge with heparin.

The BRIDGE trial (1,884 patients) demonstrated that perioperative interruption of warfarin without heparin bridging did not increase thromboembolic risk (0.4%) but did reduce bleeding complications compared to bridging (Douketis et al., 2015). Höper and colleagues found that bridging of either warfarin or DOACs was associated with significantly more severe bleeding in dermatosurgery (9.09% for warfarin bridging, 15.38% for DOAC bridging) (Höper et al., 2023). The Koenen DESSI study — a prospective multicenter cohort of 9,154 dermatosurgical procedures — reported that phenprocoumon-to-LMWH bridging carried the highest postoperative bleeding rate of any management strategy at 9.26%, and recommended DOAC discontinuation 24 hours prior to surgery (Koenen et al., 2017). Bridging, in short, is the most reliably harmful thing a clinician can do with these medications.

The ACCP explicitly recommends against perioperative bridging anticoagulation for DOACs. The rapid onset and offset of DOACs makes bridging unnecessary — these drugs can be stopped and restarted on a predictable schedule, unlike warfarin, which takes days to reach therapeutic levels (Douketis et al., 2022).

For warfarin, the ACCP recommends continuation for minor dermatologic procedures, with interruption (hold 5 days, resume 12–24 hours postoperatively) reserved for higher-risk procedures. Bridging with low-molecular-weight heparin should be considered only in patients at high thromboembolic risk — mechanical heart valves, recent stroke, or very high CHA₂DS₂-VASc scores (Douketis et al., 2022).

The Methodological Problem That Nobody Talks About

This is the part of the article that matters most, because it explains why the disagreement exists.

The dermatologic surgery evidence base is built almost entirely on retrospective, observational studies. Adalsteinsson and colleagues, reviewing Mohs surgery and staged excision studies for melanoma, found that 97.9% had serious or critical bias by ROBINS-I criteria, with zero randomized controlled trials (Adalsteinsson et al., 2023). While that review assessed melanoma outcomes rather than anticoagulation management, the methodological weaknesses it identified — lack of randomization, poorly defined outcomes, absence of prospective design — are equally prevalent throughout the dermatologic surgery literature on perioperative anticoagulation. Alam and colleagues found the median Jadad quality score for RCTs in dermatologic surgery was only 1–2 (Alam et al., 2014).

By contrast, the ACCP and ACC/AHA guidelines are grounded in large-scale prospective studies — the PAUSE trial (3,007 patients) and the BRIDGE trial (1,884 patients) — which employed standardized protocols, prospective enrollment, and rigorous outcome definitions.

The GRADE approach to evidence evaluation, used by both the ACCP and the AAD, rates observational studies as low-quality evidence and recommends downgrading certainty when most relevant studies suffer from high risk of bias. By the AAD's own evidence assessment framework, the data supporting blanket continuation should be rated low certainty.

This does not mean the dermatologic surgery data is worthless. It means we should be honest about what it can and cannot tell us. The observational data is adequate to support continuation for simple excisions and small closures — where absolute bleeding rates are very low regardless of anticoagulation status. But extrapolating that data to complex reconstructions, where bleeding rates approach or exceed 2%, is a stretch that the ACCP, ACC/AHA, ESC, ASPS, BSDS, NCCN, and now the ISTH SSC have all declined to make. Seven guideline bodies have looked at the same evidence and reached the same conclusion: risk-stratify. The AAD looked at the same evidence and said: continue everything.

What This Means for Your Surgery

If you are reading this because you have skin cancer surgery coming up and you take a blood thinner, here is the practical bottom line:

For simple excisions and primary closures — the most common dermatologic procedures — continuing your blood thinner is well-supported by the evidence. The absolute bleeding risk is very low, bleeding is manageable with local measures, and the risk of a thromboembolic event from stopping is real and potentially devastating. Your dermatologist is on solid ground here.

For larger flaps, grafts, and complex reconstructions, the evidence supports a risk-stratified approach. A brief 1–2 day hold of your DOAC, timed to the pharmacokinetics of your specific medication and your kidney function, produces bleeding and thromboembolic rates that are both very low. This is the approach endorsed by seven major guideline bodies — including the ACCP, ACC/AHA, ESC, ASPS, BSDS, NCCN, and the ISTH SSC — and validated in the 3,007-patient PAUSE trial.

For aspirin and single antiplatelet agents, continue unless your surgeon and prescribing physician jointly decide otherwise. The evidence clearly supports continuation for these medications across all procedure types.

Never stop any blood thinner on your own. This decision should always involve your surgeon and the physician who prescribed the medication. The goal is not to choose between bleeding and clotting — it is to minimize both risks simultaneously, and that requires coordination.

Never bridge with heparin for DOACs. Every guideline agrees on this.

Frequently Asked Questions

1. Should I stop my blood thinner before skin cancer surgery?

For most dermatologic procedures — simple excisions, biopsies, small closures — the evidence supports continuing your blood thinner. For larger procedures involving complex flaps or grafts, a brief 1–2 day hold may be appropriate depending on the procedure, your specific medication, and your kidney function. Never make this decision on your own — always discuss with both your surgeon and the doctor who prescribed your blood thinner.

2. Why does my dermatologist say to continue but my cardiologist says to hold?

This reflects a genuine inter-specialty disagreement — and the score is currently 7 to 1. Seven major international guideline bodies (ACCP, ACC/AHA, ESC, ASPS, BSDS, NCCN, and the ISTH SSC as of 2026) recommend risk-stratifying blood thinner management based on procedural complexity. Only the AAD recommends blanket continuation for all procedures. The risk-stratified approach — continue for simple excisions, brief hold for complex reconstructions — is supported by the PAUSE trial (3,007 patients) and reconciles both perspectives.

3. What blood thinners are safe to continue during simple skin cancer surgery?

Aspirin, warfarin, DOACs (Eliquis/apixaban, Xarelto/rivaroxaban, Pradaxa/dabigatran), and antiplatelet agents (Plavix/clopidogrel) are routinely continued during simple excisions and small closures. For more complex procedures, DOACs specifically may warrant a brief pharmacokinetically timed hold.

4. What is bridging anticoagulation, and should I get it?

Bridging means taking injectable heparin while your oral blood thinner is held. For DOACs, bridging is never recommended — every guideline agrees. The BRIDGE trial showed that bridging increases bleeding without reducing clotting risk. DOACs can be stopped and restarted on a predictable schedule, making bridging unnecessary.

5. Why do plastic surgeons hold blood thinners for the same procedures dermatologists continue them for?

This is one of the most revealing inconsistencies in the current guideline landscape. The 2021 joint AAD/ASPS guideline was published in two versions: the JAAD version (read by dermatologists) and the PRS version (read by plastic surgeons). The PRS version explicitly acknowledges that complex reconstructive procedures in facility settings carry bleeding risks that can compromise outcomes. In practice, plastic surgeons routinely hold blood thinners when performing the same advancement flaps, bilobed flaps, and interpolation flaps that Mohs surgeons perform in the office. The difference is not the procedure — it is the practice setting and specialty culture. The tissue and the bleeding risk are the same regardless of who is wielding the scalpel.

6. What is the ISTH SSC guideline, and why does it matter?

The International Society on Thrombosis and Haemostasis (ISTH) Scientific and Standardization Committee published updated perioperative DOAC management guidance in 2026 (Shaw et al., J Thromb Haemost). The ISTH is the international authority on blood clotting science. Their guideline endorses three-tiered procedural bleeding risk stratification with DOAC- and kidney-function-specific interruption protocols — the same approach the ACCP, ACC/AHA, and ESC already recommend. This makes it seven major international guideline bodies supporting risk stratification versus one (the AAD) recommending blanket continuation.

7. What happens if I bleed more during surgery because of my blood thinner?

Bleeding during skin surgery — even on blood thinners — is manageable with direct pressure, electrocautery, and hemostatic agents. Studies show that while blood thinners modestly increase bleeding risk, the complications are virtually always minor and self-limiting. No life-threatening bleeding events have been reported in prospective dermatosurgery studies. The more important concern is hematoma under flaps or grafts, which can compromise the repair — this is why complex procedures may warrant a brief hold.

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