POSTOPERATIVE CARE
Wound care and bandaging both play an important role in minimizing the risk of complications and in obtaining optimal cosmetic and functional results. Wound care removes surface debris and promotes re-epithelialization. A good bandage supports and stabilizes the wound in the closed position, wicks away excessive blood or tissue fluid, supplies pressure to the wound for hemostasis, and protects the wound from the dryness and bacterial contamination of the external environment.
A small shallow wound that is to heal by second intention is cared for by daily cleansing of the site with mild soap and water, application of petrolatum, and coverage with an adhesive bandage such as a Band-Aid® (with a central non-adherent area). There is little to no evidence that topical antibiotic ointments are better than petrolatum. In addition, bacitracin and Neosporin® (bacitracin, polymyxin B +/− neomycin) ointments are associated with a substantial risk of developing contact dermatitis. Topical mupirocin is also not recommended because of the high prevalence of antibiotic resistance. A liquid adhesive bandage was reported to be effective as well as easy to use in a trial focusing on minor cuts and abrasions. A large shallow wound that is to close by second intention may need a bandage fashioned specifically for that site, usually consisting of layers composed of petrolatum, Telfa®, gauze or cotton, and then tape or other means of adhering the bandage at the site.
A layered bandage is also required for a sutured wound. A liquid adhesive (e.g. Mastisol®) is applied to the skin surface surrounding the sutures. Petrolatum is applied in a thin line onto the wound edge. Sterile tapes such as Steri-Strips™ may be placed perpendicular to the line of closure. The final layer is rolled gauze or cotton, which is then taped in place with paper tape, Scanpor® tape, Kind Removal® Silicone Tape, or Hy-Tape® (“pink” tape). Elastic dressing (e.g. Coban®) can be used for compression, but should be released and reapplied if it is used circumferentially, so that vascular compromise distally does not occur.
Patients need oral and written instructions regarding the care the wound will require at home. Most simple wounds are cleansed daily with soap and water and redressed until the sutures are removed or the wound has completely re-epithelialized. Patients should understand that they need to remove any crusting or debris from the wound as they cleanse it and they may prefer to use cotton-tipped swabs or gauze. Instructions regarding bandages should likewise be clear. Leaving the wound open to the air or allowing it to become dry retards re-epithelialization and may compromise the final appearance or the scar.
Bandages that minimize the need for wound care are preferred by many patients. In addition, the stability and protection afforded by a bandage that stays in place for a week or more may further optimize the results, especially for wounds closed primarily. These bandages may be constructed in layers as discussed above and should be kept dry to prevent maceration of the covered skin. On the trunk and extremities, a bandage can be made of a polyurethane foam dressing (e.g. Cutinova Hydro®) covered by a water repellent film (e.g. Bioclusive®), precluding the need for any care and allowing ease of movement and a normal regimen for bathing.
Once the sutures have been removed and the wound cleaned, the use of liquid adhesive and sterile tapes for another week or two further stabilizes the wound. Many specialized bandaging systems are available for complicated wounds (see Ch. 145).