Plastics surgery

wound management – Dr. Stanley U. Kho

A wound can be classified as: o Treatment goals

o Remove deterrents to normal healing and eliminate
ACUTE complications

o Due to surgical causes MANAGEMENT

o Incisions
o Sterile wounds HISTORY
o Due to trauma
o Accidents o Mechanism of injury
o Unsterile wounds o Risk of infection
o More complications o Time of injury
o Involvement limited to integument and soft tissue o 5 hrs – 100,000 organisms/kg of tissue
o Laceration – most common o 100,000 organism count means the chance of infection is
very high
CHRONIC o Wound location
o Axilla, perineum – more prone to infection
o Pressure Ulcer o Patient factors
o Diabetic Foot Ulcer
o Venous Leg Ulcer EXAMINATION
o Arterial Ulcer
o Loss of function
WOUND HEALING o Involved structures
o Level of contamination
o Choice to close the wound or not
o Foreign bodies
o Viability
o Remove non-viable tissues
o Missing parts

PREPARATION

ANESTHESIA

o Do it early
o 25 – 30 guage needle
o Infiltrate slowly
o Inject through wound
o Nerves in intact skin causes pain
o Aim for subcutaneous (more malleable)
o 1 ml HCO3: 9 ml Lidocaine
o Inflammation o Max dose 7 mg/kg
o The body cleans the wound o Epinephrine to lessen the bleeding (do not use in
o Bioburden patients with heart problem)
o Warm the solution

EXPLORATION

o Wound contamination
o Diagnostic imaging
o X-ray
o Ultrasound
o CT scan
o Surrounding structures

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 CLEANSING WOUND CLOSURE

o “The solution to pollution is dilution” PRIMARY INTENTION

o Irrigating solution
o Safe, low allergic potential, broad spectrum, easy to o Mechanical apposition
use, effective, no resistance, removes dirt, debris, and o Suture
bacteria o For clean wounds
o Povidone iodine
▪ Antimicrobial
▪ Improve wound healing
▪ Cytotoxic
o Saline
▪ Glides over the wound
▪ No antimicrobial activity
▪ Does not improve wound healing
▪ Very low toxicity
o PHMB (polyhexanide)
▪ Contact lens solution
▪ Antimicrobial
▪ Improve wound healing SECONDARY INTENTION
▪ Very low toxicity
o Betaine o Spontaneous wound healing
▪ Reduces surface tension (detergent) o For infected wounds
▪ Antimicrobial
▪ Improve wound healing
▪ Very low toxicity
o Pressure
o Decreased pressure = ineffective
o 4 – 15 psi ideal pressure
o 19 gauge needle 35 mL syringe
o Asepto syringe – low psi
o Volume
o 50 – 100 ml/cm/cm2/cm3
o All visible debris should be removed
o Temperature
TERTIARY INTENTION/DELAYED PRIMARY
o Tissue cooling induce vasoconstriction  hypoxia
o Should be warm
o Ideal wound temperature 37 °C (34 – 41 °C) o Monitor 3 – 5 days

HEMOSTASIS

o Direct pressure
o 10 min straight, elevate the extremity
o Avoid clamping
o Might injure normal structures
o Use of tourniquet
o Deprive normal tissue of blood supply

DEBRIDEMENT
Dermis is the strongest layer of the skin. The ratio of dermis to epidermis is 5:95
o Removal of all necrotic tissues DO NOT close the subcutaneous fat
o Surgical
o Devitalized tissues TYPES OF SUTURES
o Foreign bodies
o Irregular, macerated or leveled wound edges o Absorbable sutures
o Dermal suture
SKIN PREPARATION o Non-absorbable sutures
o Superficial skin
o Povidone iodine o Non tissue reactive
o NO NOT SHAVE (causes microcuts) o Better looking scar
o Apply to the skin surrounding the wound

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 o Braided/Multifilament
o Easy to use
o Only need 3 closures
o Monofilament
o Can unravel (needs 5 – 6 rows)
o Non tissue reactive because the bacteria has no place to
hide
o Traumatic wound

o Staples
o Quick and easy
o More complex to remove
o Less biologically active
BRAIDED/MULTIFILAMENT MONOFILAMENT
o Lower infection risk
The smaller the number, the bigger the suture o Hair covered areas
o Long lacerations
o Resorption time: o Comparable cosmetic
outcomes

o Adhesives
o Cyanoacrylate
o Water resistant
o Superficial wound
o Sloughs off in 7 – 10 days
o Superior strength to tapes
o Linear wounds with little tension
o Children

o Size by location

SUPERFICIAL DEEP
Scalp, torso, 4-0 or 5-0 3-0 or 4-0
extremities
Face, Eyebrow, Nose, 6-0 5-0 o Skin tapes
Lip
o Alternative to adhesives
Hand 5-0 5-0
o Similar outcomes/infection
Foot or sole 3-0 or 4-0 4-0
Non-absorbable absorbable rates
o Fewer complications
o Better if with adhesives
REMOVAL OF SUTURES

Barrier is formed in 24 – 48 hrs in normal patients, if with comorbid conditions,

it will take 5 – 7 days.

Wounds are more susceptible to infection in the 1st 2 days.

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 SURGICAL SITE INFECTION CHRONIC WOUND

o Potential consequences
o Impaired healing
o Revision surgery
o Systemic illness (sepsis)
o Extended hospital stay
o Associated increased cost
o Death
o A chronic wound is basically an acute wound that did not heal
o Wet to dry (gauze)
o Left for 24 hrs then removed
o Mechanical debridement
o Painful and traumatic
WOUND BED PREPARATION

DRESSINGS o The management of a wound in order to accelerate endogenous

healing or to facilitate the effectiveness of other therapeurtic
o Polyurethane Film Dressing measures
o Waterproof, bacteria proof o How to make the wound heal faster
o 2 – 3 days o Treat the patient as a while, not just the hole in the patient
o Gauze o “TIME heals all wounds”
o Readily available o Tissue management
o Forms a scab ▪ Debridement
▪ Not good for wound healing ✓ Surgical
o No mechanical protection ✓ Mechanical
o Needs to be replaced everyday ✓ Enzymatic
o 65 layers needed for antimicrobial effect ✓ Biologic
o Properties of the ideal wound dressing ✓ Autolytic
o Promotes a moist wound environment o Inflammation and infection control
o Promotes wound healing ▪ Biofilm development (90% of all chronic wounds) –
o Provides mechanical protection 24 hrs to deform
o Allows for nonadherence to the wound
o Allows for removal without pain or trauma
o Capable of absorbing excess exudate
o Allows for gaseous exchange
o Non-cytotoxic to healthy tissue
o Antimicrobial/antifungal
o Acceptable to the patient
o Easy to use
o Cost-effective

TETANUS PROPHYLAXIS

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 ▪ Antimicrobial dressing (ionic silver, antibiotics, o Epithelial/Edge advancement
honey) ▪ Change dressing everyday to encourage epithelial
✓ Ionic silver – damages the cell wall, cells to migrate to close the wound
interferes with DNA synthesis, denatures ▪ To heal a wound, you need to stop touching it
protein and enzymes, inhibits protein
synthesis
▪ Proteases (helps you clean the wound)
✓ Modulation of MMP-2 and MMP-9 activity
by hydrofiber-foam hybrid dressing =
relevant support in the treatment of chronic
wounds

Proteases are supposed to disappear by day 5 (acute wounds), if persist, the

wound cannot heal properly.

o Moisture balance

▪ Scar formation – slow epithelial cell migration under

dry tissue
▪ Important to have moisture balance
✓ Necrotic wounds – dry
✓ Seaming wounds – less exudate
✓ Gaping wounds – more exudate

WOUND AIM ACTION

Dry Increase moisture level Add moisture with
hydrating gels
Moist Maintain Continue with current
dressings
Wet Reduce moisture level Use more absorbent
dressing

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