The aim of good postoperative treatment is to prevent haematoma, provide restfor healing, and pre» vent suture marks. In practice this is achieved by the dressing, care in suture removal, and later support of the wound. The dressing In the past, the use of pressure dressings was standard, with or without a drain.
The pressure dressing, apart from preventing haematoma, cre-ated the immobility and splinting which were considered to provide the best conditions for rapid, uneventful healing. With the increased use of suction drainage there has been a marked reduction in the use of dressings generally, with exposure of the wound site increasingly stan-dard practice in combination with suction drainage if necessary.
When a dressing is used, the wide mesh of a single layer of tulle gras –tulle fabric impregnated with petroleum jelly –allows the passage of any discharge, and this combined with the petroleum jelly base make it a particularly good dressing, permitting its removal with the minimum of trauma from sticking. Over the tulle gras, gauze and wool followed by a crepe bandage will give adequate, cushioned pressure and immobility.
Elastoplast may replace the crepe bandage in suitable circumstances. An alternative dressing which can be applied directly to the suture line is an adhesive ‘paper’ tape such as micropore or steristrips. It does not macerate the skin, supports the wound well and yet, peeled off slowly, sticks neither to suture nor hair.
Applied directly over the wound, its adhe-siveness encourages the wound edges to lie flush, a useful attribute when flap tips are tend-ing to lie a little proud of the wound as a whole. If no undermining has been used, such tape can provide the sole dressing. Apart from its role in the sutured wound, it can also on occasion be used to coapt wound edges and obviate the need for sutures at all, a considerable virtue when the young child with a laceration is being treated.
When applying Elastoplast or adhesive paper strips, the surgeon should avoid placing the dressing with the skin under undue tension, either by stretching the Elastoplast or by putting the paper strip on one side of the wound and then pulling the skin closer to the other side of the wound. This creates a reaction in the under-lying skin which is similar in appearance to dermatitis.
Patients who have experienced this problem frequently, but erroneously, describe themselves as having an allergy to the dressing materials. When the wound is exposed it is desirable to keep the suture line free of blood until the fibrin clot covering the line of the wound is firm and dry. A mild degree of reaction at the site of the sutures is not uncommon, settling when they are removed and seeming not to affect the final result adversely.
The severity of the reaction seems to parallel the degree of sebaceous activity in the particular area of the face and in the indi-vidual patient. The use of chloramphenicol oint-ment, conveniently applied from the small tube designed for ophthalmic use, has been found to eliminate this reaction to a considerable extent, and it has the incidental virtue of softening any minor discharge around the individual sutures and facilitating their removal.
Rarely, chloram-phenicol sensitises to sunlight, under which cir-cumstances other ointments such as mupirocin or Polyfax (polymyxin and bacitracin) can be used as alternatives. Suture removal Set days are apt to be laid down for the removal of sutures in various sites and under varying circumstances, but this approach is quite wrong.
The principle is to remove at the earliest time judged safe, and this depends on so many factors -degree of tension, site, line of wound, etc. -that it is quite impossible to lay down hard and fast rules. In any case clinical experience soon tells the surgeon when a suture may be removed safely. In removing the suture it must be remembered that the tensile strength of the wound is minimal, and dehiscence is liable to occur on the slightest provocation. Where most care is needed, the sutures are usually smallest, and prerequisites for safe removal are a good light, fine, sharp scissors which cut to the point, and fine dissecting forceps which grip properly.
The technique of removal is not radically different from suture removal in other surgical contexts, except for the degree of gentle-ness which is necessary and the fact that the suture, once cut, must be pulled out towards the wound, not away from it. In removal, as in inser-tion of the suture, the surgeon should have his elbows well supported, and work from wrist and fingers to give smooth movements without tremor.
The patient should also be carefully sup-ported so that the suture line stays absolutely still. Scissors are not invariably sharp, nor do they always cut to the point, and a good alternative method is to use the triangular tip of a No. 11 scalpel blade to cut the suture.
In a dif-ficult situation its sharp point will often cut the suture with less disturbance of the wound than scissors.
1. Subsequent support of the wound
Early suture removal leaves the wound devoid of strength, and a sudden ill-judged tension strain may cause it to dehisce. For this reason the wound is best supported or at very least pro-tected for up to a week after suture removal, and micropore skin tape works well in this role.
It is seldom practicable to support the wound much beyond this, and indeed attempts to prevent later stretching of the wound by prolonged sup-port are of little avail.