Elsevier

Dermatologic Clinics

Volume 16, Issue 1, 1 January 1998, Pages 25-47
Dermatologic Clinics

DRESSING THE PART

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Postoperative wound care is an ancient art with recorded evidence dating back at least 4000 years. Ancient documents reveal how wounds were initially bandaged to reapproximate them and aid in healing. Lint was used to pack and to fill open wounds. Grease or oil was used to decrease sticking of bandages to wounds because it did not spoil. Later, insect mandibles were used as clips to close disrupted tissue. Bodies preserved from as early as 2000 B.C. have revealed sutures used to close the wounds created during embalming. Infection was an invisible and insidious mystery that often complicated wound healing. Without understanding how they worked, ancient surgeons empirically employed various agents, such as honey, vinegar, wine, and metallic salts, to prevent infections and to aid in wound healing. Only in the late 1800s with the work of Pasteur, Koch, and Lister on the bacterial cause of infection did the systematic search for specific chemical therapies for wound management begin in earnest.13

Wound care is an important but still often misunderstood aspect of dermatologic surgery. Past practices, not supported by more recent research, were based on traditional methods inherited from our predecessors. This recent interest and research in wound healing have significantly advanced our understanding of the micromolecular processes involved, and produced an almost bewildering explosion of dressings and topical agents at our disposal. This article will review these newer dressings, topical agents, and methods of wound care as well as their specific roles in wound healing.

Section snippets

PHYSIOLOGY OF WOUND HEALING

Wound healing is generally thought to consist of four phases: hemostasis, inflammation, granulation, and tissue remodeling.* While these phases are discussed as distinct components later in this article, wound healing is more of a continuous, well-orchestrated sequence of events involving cell–cell and cell–matrix interactions. The four phases of wound healing often overlap and are regulated by growth factors that serve as messengers between the

Partial-Thickness Wounds

Partial-thickness wounds are produced when the epidermis and some portion of the dermis are lost. This type of wound is commonly created by shave excisions, curettage and electrodesiccation, dermabrasion, chemical peels, and CO2 laser surgery. Healing in partial-thickness wounds progresses relatively quickly with re-epithelialization by keratinocytes from wound edges and adnexal structures. The amount of granulation, wound contracture, and scarring in the wound depends on the depth of dermal

TOPICAL AGENTS

Topical agents are commonly used in postsurgical wound care. Topical antiseptics and antibiotic ointments are used in an attempt to reduce bacterial counts where they are applied, and subsequently to reduce the rate of wound infections. Hemostatic agents are also commonly used to control bleeding. Topical growth factors are relatively new products with some promising results reported for a future role in wound healing.

ANTIBIOTIC PROPHYLAXIS

Antibiotic prophylaxis in dermatologic surgery is usually used to prevent wound infection or the development of bacterial endocarditis. Although there is clear support for the use of antibiotics in some cases, dermatologic surgeons face scenarios every day in which evidence for their use is not so clear. Haas and Grekin have recently reviewed the literature as it pertains to this subject54 and their findings are the basis for most of this section.

WOUND DRESSINGS

Prior to the early 1960s, wounds were thought to heal more quickly and better if kept open to the environment and allowed to form a dry crust. Dressings had hardly advanced from the ancient times, consisting primarily of dry, nonocclusive gauze and nonwovens of cotton or wool. Their primary function was to fill open wound spaces or to cover and conceal closed wounds. In 1962, however, Winter142 published his landmark study of young domestic pigs that revealed that partial-thickness wounds under

WOUND CARE GUIDELINES

Once the appropriate dressing is applied in the office and the patient returns home, care of the acute postoperative wound relies on the patient's involvement and understanding of wound care instructions. Detailed information should be provided not only orally, but in written form as well for reinforcement. Telfer and Moy131 have recently reviewed the general subject of wound care after office surgery. Their review provides advice for specific wound types and anatomic locations.

For sutured

SUMMARY

Wound care after cutaneous surgery can play an integral role in wound healing. Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood. Foremost is the improvement in wound healing achieved by keeping the wound occluded and moist. This observation has led to an explosion of a whole new category of occlusive dressings at the surgeon's disposal in healing postoperative wounds. These dressings have numerous applications

References (148)

  • A.C. Halpern et al.

    The incidence of bacteremia in skin surgery of the head and neck

    J Am Acad Dermatol

    (1988)
  • T. Helfman et al.

    Occlusive dressings and wound healing

    Dermatol Clin

    (1994)
  • J.J. Hutchinson et al.

    Occlusive dressings: A microbiologic and clinical review

    Am J Infect Control

    (1990)
  • T.F. Imperiale

    Does prophylaxis prevent postdental infective endocarditis?

    Am J Med

    (1990)
  • M.H. Katz et al.

    Human wound fluid from acute wounds stimulates fibroblasts and endothelial cell growth

    J Am Acad Dermatol

    (1991)
  • W.Y. Lau et al.

    Randomized prospective trial of topical hydrogen peroxide in appendectomy wound infections

    Am J Surg

    (1981)
  • J.E. Lawrence et al.

    A comparison of calcium alginate and scarlet red dressings in the healing of split thickness skin graft donor sites

    Br J Plast Surg

    (1991)
  • V. Lees et al.

    A comparison of the use of polythene sheet and Jelonet as temporary dressing for excised wounds

    Br J Plast Surg

    (1991)
  • L.S. Leipziger et al.

    Dermal wound repair: Role of collagen matrix implants and synthetic polymer dressings

    J Am Acad Dermatol

    (1985)
  • J.G. Marks et al.

    North American contact dermatitis group standard tray patch test results (1992–1994)

    Am J Contact Dermatitis

    (1995)
  • P.M. Mertz et al.

    Occlusive dressings to prevent bacterial invasion and wound infection

    J Am Acad Dermatol

    (1985)
  • L.G. Phillips et al.

    Uses and abuses of a biosynthetic dressing for partial skin thickness burns

    Burns

    (1989)
  • D. Alexander et al.

    Analysis of strike-through contamination in saturated sterile dressings

    Clin Nurs Res

    (1992)
  • A.K. Armitage

    Effects of nicotine and tobacco smoke on blood pressure and catecholamines from the adrenal gland

    Br J Pharmacol

    (1965)
  • P.L. Bencini et al.

    Utility of topical benzoyl peroxide for prevention of surgical skin wound infection

    J Dermatol Surg Oncol

    (1994)
  • B. Bjorkner et al.

    Bacitracin: A cutaneous allergen and histamine liberator

    Acta Dermatol Venereol

    (1973)
  • L.L. Bolton et al.

    Occlusive dressings: Therapeutic agents and effects on drug delivery

    Dermatol Clin

    (1992)
  • P.I. Branemark et al.

    Tissue injury caused by wound disinfectants

    J Bone Joint Surg Am

    (1967)
  • C.D. Brown et al.

    A review of topical agents for wounds and methods of wounding

    J Dermatol Surg Oncol

    (1993)
  • G.L. Brown et al.

    Enhancement of wound healing by topical treatment of epidermal growth factor

    N Engl J Med

    (1989)
  • I.A. Buchan et al.

    Clinical and laboratory investigation of the composition and properties of human skin wound exudate under semi-permeable dressings

    Burns

    (1980)
  • M.D. Caldwell

    Topical wound therapy—an historical perspective

    J Trauma

    (1990)
  • A.J. Carmichael et al.

    The occurrence of bacteraemia with skin surgery

    Br J Dermatol

    (1996)
  • W.Y. Chen et al.

    Characterization of biologic properties of wound fluid collected during early stages of wound healing

    J Invest Dermatol

    (1992)
  • R.A.F. Clark

    Biology of dermal wound repair

    Dermatol Clin

    (1993)
  • R.A.F. Clark

    Fibronectin matrix deposition and fibronectin receptor expression in healing and normal skin

    J Invest Dermatol

    (1990)
  • I.K. Cohen et al.

    Topical application of epidermal growth factor onto partial-thickness wounds in human volunteers does not enhance re-epithelialization

    Plast Reconstr Surg

    (1995)
  • S. Craig et al.

    The effects of smoking on experimental skin flaps in hamsters

    Plast Reconstr Surg

    (1985)
  • M. Crossfil et al.

    The use of chlorhexidine antisepsis in contaminated surgical wounds

    Br J Surg

    (1969)
  • P.E. Cryer et al.

    Norepinephrine and epinephrine release and adrenergic mediation of smoking associated hemodynamic and metabolic events

    N Engl J Med

    (1976)
  • A.S. Dajani et al.

    Prevention of bacterial endocarditis

    JAMA

    (1990)
  • J.C. Dardour et al.

    The one-stage preauricular flap for male pattern baldness: Long-term results and risk factors

    Plast Reconstr Surg

    (1988)
  • D.T. Durack

    Prophylaxis of infective endocarditis

  • W.H. Eaglstein

    Occlusive dressings

    J Dermatol Surg Oncol

    (1993)
  • W.H. Eaglstein et al.

    Optimal use of an occlusive dressing to enhance healing: Effect of delayed application and early removal on wound healing

    Arch Dermatol

    (1988)
  • G. Eriksson

    Comparison of two occlusive bandages in the treatment of venous leg ulcers

    Br J Dermatol

    (1986)
  • V. Falanga

    Growth factors and wound healing

    J Dermatol Surg Oncol

    (1993)
  • V. Falanga et al.

    Electrical stimulation increases the expression of fibroblast receptors for transforming growth factor-beta

    J Invest Dermatol

    (1987)
  • M.S. Favero

    Iodine—champagne in a tin cup

    Infect Control (Thorofare)

    (1982)
  • C.K. Field et al.

    Overview of wound healing in a moist environment

    Am J Surg

    (1994)

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    Address reprint requests to Chang Y. Cho, MD, 9985 Sierra Avenue, Fontana, CA 92335

    *

    From the Department of Dermatology, Mohs Micrographic and Cutaneous Reconstructive Surgery Center, Southern California Permanente Medical Group, Fontana, California

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    Copyright © 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.