Dressing

The value of wound dressings has been debated for years. Studies indicate that an important component of wound repair is reepithelialization as the regenerating epithelial cells migrate across the moist exudate of a wound.1 A moist environment is crucial for this process, and epithelial repair is significantly impaired in desiccated wounds. Wound dressings that follow this basic principle of maintaining a moist environment for the first 24 to 48 h facilitate healing.

The simplest wound dressing is a layer of petrolatum-based ointment applied directly over the sutures. This approach is most useful to treat simple, uncontaminated lacerations of the face and scalp but should not be implemented when tissue adhesives are applied. These areas have an excellent vascular supply; they heal with little risk of infection and a good cosmetic result. The addition of an antibiotic to the petrolatum-based ointment reduces the risk of infection, particularly in extremity wounds.3 Available agents include bacitracin zinc, neomycin, and polymixin B, usually in combination. The ointment should be gently washed off and reapplied two or three times per day for the first 2 to 3 days and once a day thereafter until suture removal.3 This approach has been criticized as being unnecessary, time-consuming, and uncomfortable.4 Instead, the use of a topical antibiotic in a water-soluble base (such as mupirocin in polyethylene glycol) has been advocated, for abraded skin surrounding stellate lacerations. Topical antibiotic ointments, which contain povidone-iodine, should be avoided, since this antiseptic impairs wound healing. Application of ointment facilitates suture removal by preventing the exposed tails from becoming encrusted in a dried wound exudate.

Small lacerations can be dressed with self-adhesive elastic strips. These strips almost always have a nonadherent center that goes directly over the wound. Petrolatum-based antibiotic ointment can be placed either on the elastic strip or on the wound.

Most other wounds are commonly dressed; although there is little evidence that dressing reduces the risk of infection or improves ultimate cosmetic appearance. The less "scientific" but highly practical reasons for wound dressing include the following:

1. General cleanliness as the dressing absorbs exudate

2. Protection from external contamination when the patient returns home or work

3. Camouflage, so that the patient or others do not have to see the wound

4. Prevention of premature suture removal from spontaneous unraveling or the patient's curiosity

5. Prevention from excessive movement by providing a "soft" splint

6. Satisfying the patient's expectation that the repaired wound will be dressed

The basic wound dressing has four layers: (1) a nonadherent layer adjacent to the wound, (2) gauze sponges to absorb any exudate, (3) wrapping to hold the first two layers in place, and (4) tape or elastic bandage to secure the entire package ( TabJe. 41-1).

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