Dressing the part

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 as discussed previously. Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as graft donor sites and after dermabrasion, chemical peel, or laser treatment, and full-thickness wounds allowed to heal by secondary intention. Occlusive dressings may have greater benefit for the treatment of chronic ulcers of varying etiologies. The different categories of dressings share the common disadvantage of being relatively expensive. For routine sutured wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical antibiotic ointment. Topical antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery. Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice. However, antiseptics have been shown to be toxic to healing tissue, and should not be used on open wounds. In contrast, topical antibiotic ointments are safe to use on open wounds, effective in preventing wound infections, and promote wound healing by maintaining a moist wound environment. The authors prefer the combination antibiotic ointment Polysporin for routine postoperative wound care. Antibiotic prophylaxis in dermatologic surgery to prevent wound infection is appropriate in certain cases. Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of antibiotics. Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from antibiotic prophylaxis. The choice of antibiotics should be based on the organism most likely to cause wound infection at the particular surgical site. Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed. The risk of bacterial endocarditis after dermatologic surgery is not known. Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin. Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA). The antibiotic chosen should again cover the organism most likely to cause infection. One dose can be given 1 hour before surgery and repeated 6 hours postoperatively. Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office. Therefore, wound care instructions should be clear, detailed, and provided in both oral and written form. Information should also be provided about what to expect as the wound heals.