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POSTOPERATIVE MANAGEMENT
POSTOPERATIVE MANAGEMENT
Even the best surgical repair can be undone by less-than-optimal postoperative care. Clear written instructions on wound care are of vital importance, and should be reviewed verbally with the patient as well. For most linear repairs, only minimal postoperative management is required. For wounds closed without transepidermal sutures, a simple adhesive film dressing may be applied immediately postoperatively. This gas-permeable film will permit the wound to breathe while providing a moist environment for wound healing. Patients should be warned that a small amount of blood or serous fluid drainage is expected, and that this will typically become trapped beneath the film dressing. The film dressing may be left in place for the next 1 to 2 weeks,
depending on patient and surgeon preference. The advantage of this approach is that it requires no effort on the patientโs part, particularly useful for difficult-to-reach wounds or for patients living alone. Leaving the dressing in place for more than 2 weeks may increase the risk of maceration.
For wounds closed with transepidermal sutures, film dressings remain an option, though often a nonstick dressing is simply cut to size and placed over the wound after the application of a thin film of ointment.
A moderate pressure dressing is applied postoperatively and left in place for approximately 24 hours. When placing a pressure dressing over adherent film, the gauze should extend beyond the edge of the film so that the adhesive tape holding the pressure dressing in place does not touch the film, as otherwise the film may be inadvertently removed at the time of the first dressing change.
Pressure should be sufficient to mitigate the risk of oozing, but should not restrict blood flow to the wound. Additionally, downward and inward pressure should be exerted just lateral to the wound edges, resulting in a net effect of the wound edges being pressed together. Direct pressure over the surface of the sutured wound should be avoided, as this does not address potential space created laterally to the suture line and also serves as a distracting force against the sutures. This same principle should be emphasized to surgical assistants when they are asked to hold pressure on a partially sutured wound.
When needed, suture removal may be performed between postoperative days 3 and 10, depending on the anatomic site of the surgery and surgeon preference. For patients who are unable to return for suture removal, options include avoiding transepidermal sutures or placing the transepidermal sutures using fast-absorbing gut or fast-absorbing synthetic sutures.
For wounds covered with an adhesive film, no care is needed. For those covered with a nonstick pad, the wound may be gently cleaned once or twice daily and a thin film of petrolatum should be placed over the suture line using a cotton-tipped applicator. For wounds in dependent areas, patients should be advised to keep their legs elevated as much as possible for several weeks postoperatively.
Patients often ask about using over-the-counter scar healing aids. Most have little or no evidence of efficacy, and in general they should not be recommended. For patients with a history of true keloid formation, consideration may be given to intraoperative or immediate postoperative triamcinolone injection along the suture line, with repeat monthly treatments for maintenance, though risks, including delayed wound healing, atrophy, and telangiectasias, should be discussed with the patient. As noted above, patients should be told to expect dramatic wound eversion postoperatively, and be reassured that this is only temporary.18
CONCLUSIONS
The linear closure is the most useful and broadly applicable closure technique in dermatologic surgery. One of the great advantages of linear closures is their predictability; since the outstanding blood flow is maintained to the wound edge, these closures often result in fine-line nearly imperceptible scars when carefully designed and executed. Attention to detail and customizing approaches for each individual patient and anatomic location serves to create closures that will ultimately be difficult to detect from a conversational distance.