Proper Wound Care Promotes Improved Recoveries

From lavage to negative pressure therapy, here’s a look at what it takes to ensure proper healing and prevent SSIs.

Surgical site infections (SSIs), among the most common complications in health care, are responsible for delayed wound healing, hospital readmissions and other health ramifications.

A study recently published in JAMA Network found that 0.5% to 3% of patients undergoing surgery will experience an infection at or adjacent to the surgical site.

Proper, methodical wound care is your best defense against SSIs and other complications.

Expedited healing

Thanks to advanced wound care products such as dressings, topical agents and active wound care devices, surgical staff can now choose from a variety of options designed to speed up the healing process and minimize the risk of infection.

“To get the best results in wound healing, you must first consider your patient,” says Jay Calvert, MD, a board-certified plastic surgeon with offices in Beverly Hills and Newport Beach, Calif. “Look at their risk of wound breakdown, and consider factors such as whether they are physiologically stable and practice good nutrition.” Dr. Calvert also recommends assessing each patient’s wound healing ability through a detailed history, physical exam and laboratory examination of their blood chemistry, such as albumin and pre-albumin levels.

“Successful wound care involves a systemic attitude towards wound healing,” Dr. Calvert says. “It’s not just a local wound environment that makes a difference. There is absolutely no substitute for excellent surgical technique.”

Alternative closure devices

SMALL BUT MIGHTY Even the smallest incisions require proper postoperative care and attention.

Surgeons have long used sutures, surgical staples and skin glues as a means of closing surgical wounds, but wound closure devices now offer an alternative. While some of the devices continue to use sutures and staples that assist in closing wounds, others offer a needle-free alternative to sutures, medical staples and glue.

Dr. Calvert has found barbed sutures to be effective and efficient in closing wounds. Although barbed sutures were first introduced in 1964, Dr. Calvert notes they’ve evolved over the years and are now available as innovative wound closure devices that close wounds securely without the need to tie knots. Research has shown that two-layer wound closure with barbed sutures using a wound closure device was safer, faster and resulted in fewer postoperative complications than three-layer closure with conventional, non-barbed sutures. Although Dr. Calvert acknowledges that barbed sutures are more costly, he says they provide advantages such as more uniform wound closure, a lower incidence of postoperative bleeding, shorter closure times. They are available in both absorbable and non-absorbable monofilament materials.

Patients typically undergo skin closure after surgery using conventional sutures or skin closure devices. Closure devices provide equal efficacy when compared with standard closure methods such as sutures. At Cedars-Sinai Medical Center in Los Angeles, Randolph Sherman, MD, FACS, a plastic surgeon and chief of plastic and reconstructive surgery, says many patients prefer subcuticular sutures, or intradermal sutures that are placed immediately below the epidermal layer. The increased availability of natural materials that can be absorbed by the body have made them a popular option. “They’re absorbent, and dissolve as the body heals,” Dr. Sherman says. “They have less chance of reopening and patients experience less pain and discomfort.”

Levi Harrison, MD, APC, an orthopedic surgeon and owner of The Harrison Orthopedic Institute in Glendale, Calif., also uses plastic strips for wound closures that feature self-absorbing sutures. He notes high patient satisfaction.

“Although patients have a post-op appointment, it eliminates the need to remove sutures in 10-14 days,” he says.

Negative pressure wound therapy

Negative pressure wound therapy (NPWT), also known as vacuum-assisted closure (VAC), is a type of wound care treatment designed to speed up healing by applying sub-atmospheric pressure. While not every surgical wound requires a VAC, Dr. Calvert says they’re effective in treating plastic surgery conditions such as an infected abdominal wound or a thigh lift that broke down, rather than as a primary method for closing wounds. Compared to a normal saline dressing, VAC has been shown to decrease wound infection incidence and improve healing time.

Dr. Sherman says surgeons depend on VAC devices as part of a comprehensive wound management plan. “A wound VAC provides a healthy way of dealing with an open wound,” he says. “It decreases the frequency of dressing changes and also improves outcomes.”

NPWT has successfully been used in specialties including dermatology, podiatry, cardiology and orthopedics. “Wound vacuum systems are best used for large wounds, those that have extensive drainage, or to relieve pressure from the wound and to evacuate drainage and bacteria, while bringing the edges of the wound closer together,” says Dr. Harrison. “One of the goals of the wound vac is to promote healthy, rich granulation tissue at the wound site.”

Studies have also shown that using incisional NPWT after groin incisions for arterial surgery reduces the incidence of SSIs compared with standard wound dressings.

Venita Chandra, MD, a board-certified vascular surgeon with Stanford Medicine in Palo Alto, Calif., has found success treating patients at higher risk of incisional complications with an NPWT system designed specifically for the management of closed surgical incisions. “Both obesity and diabetes are growing healthcare issues and we know wound healing can be more challenging with this subset of patients,” says Dr. Chandra. “Obesity has been associated with an increased risk of SSIs, so it’s important to be proactive about preventing skin and wound complications.”

Antibacterial dressings

Both antibacterial and antimicrobial dressings work to accelerate wound healing and reduce the risk of infection. They can be paired with sponges, woven gauze and other dressing technologies and are available in different shapes, sizes and thicknesses. “Too much is not good, too little isn’t either, so finding the dressing that is just right is the key,” Dr. Calvert says. “If you’re dealing with a wound breakdown, then you’ll need to be more aggressive about how to keep it clean and support the wound for closure.”

In his plastic surgery practice, Dr. Calvert prefers using antimicrobial or antibacterial skin closures, non-adherent dressing pads that deliver a sustained release of antimicrobial agents to the wound. He says they are easy to use and have a decreased risk of resistance. “For facelifts, I use Xeroform gauze, which is a bismuth impregnated gauze to prevent infection,” Dr. Calvert says. “My patients also take oral antibiotics in addition to the wound care we provide.”

With high-risk patients, Dr. Chandra has found success using time-released absorbable antibiotic beads that deliver high doses of antibiotics directly to the surgical site. Like other wound care technologies, these antibiotic beads have evolved over the years, with newer versions offering reliable elution of antibiotics and effective protection against infections.

Wound lavage is essential

Irrigating the surgical site is a major part of wound care. It serves to remove debris and foreign material, while also reducing the risk of SSIs to patient. While some surgeons irrigate with antibiotic solution tailored to each patient, there also are readymade products available that go beyond traditional irrigation to also offer debridement and cleansing solutions that include antiseptics.

Dr. Calvert swears by his irrigation process, something he practices religiously in all of his operations. “I do mostly facelifts, rhinoplasty and cosmetic breast surgery, and I use antibacterial irrigation for each of those operations every single time to reduce the chance of infection,” he says. OSM