WOUND DRESSINGS
The dressing or treatment of wounds, considered herein, embodies
particularly that practiced by the surgeon in the performance of plastic
operations.
The elasticity of the skin is especially serviceable in bringing about
desirable restorative results, but, owing to its extreme vascularity
and the infrequent supply of venous valves, as in the face, there
is considerable danger of infection, with rapidly spreading septic
inflammation.
=Sutured Wounds.=—Before the wound is closed all hemorrhage must be
arrested, either by catgut ligature, in exceptional cases, and by torsion
or pressure, as generally practiced. Gauze sponges dipped into hot
sterilized solution are most suitable for the latter purpose.
The edges of the wound must be coapted perfectly by cutaneous sutures
of sterilized silk of suitable thickness. Formaldehyd catgut is often
used because of its limited absorption. Ordinary catgut should not be
employed, as its early absorption interferes with obtaining the proper
union, and by becoming softened invites sepsis.
The wound, if small, may be powdered over with any of the antiseptic
powders, such as aristol or iodol. It must be remembered that such
powders form a hard crust with the serous oozing of wounds, which, by
reason of pressure from the dressing applied over it, is very liable to
separate the edges of the wound, thus increasing the width of the scar, a
very important factor in facial surgery.
Where perfect apposition has been made, the dusting powders may be used
and a covering of Lister’s protective silk plaster placed over it. The
edge of the strips of plaster must be incised at distances of about ⅛
inch, so as to snugly take on the curvature of the parts and at the same
time thoroughly seal over the area to prevent subsequent contamination.
The plaster is made of taffeta silk, preferably of flesh color, coated on
one side with copal varnish and a mixture prepared as follows:
℞ Dextrin ʒj;
Starch ʒij;
Carbolic acid ℥ij.
When applied, it should be moistened with an antiseptic solution only.
This can be applied only to dry surfaces, however, and should be rarely
used, since subsequent hemorrhage or oozing will raise the plasters,
inviting sepsis.
It is better, however, in all cases to employ several layers of an
antiseptic gauze, such as fifteen-per-cent iodoform or boric-acid gauze
to cover the wound, and back it with absorbent cotton, over which a
bandage or the silk protective is applied to retain it. The gauze absorbs
the secretions, at the same time rendering them harmless.
At no time should cotton be placed next to the wound, as it forms a hard
mass with the secretions, the removal of which requires enough force to
injure or hazard the union of a new wound. Nor should a plaster dressing
be pulled off without thoroughly moistening it first, withdrawing the
various layers one by one. The gauze, when moistened, readily leaves the
wound without injurious traction. An excellent dressing for small, dry
wounds, and one that causes little tension, is collodium, or, better,
iodoform-collodium painted over the surface. The latter may be prepared
as follows;
℞ Iodoformum 5j;
Collodium 5x.
[Küster.]
To this may be added oil of turpentine or castor oil, which permits of
greater flexibility. Boric lint, applied wet, is also good. It must be
moistened thoroughly before removal. Larger wounds should be dusted over
with one of the powders mentioned and covered with folds of gauze and
absorbent cotton, held in place with gauze bandages.
Such dressings are allowed to remain until the sutures are taken out,
unless there is sign of soiling. As these secretions readily decompose,
it is best to remove the cotton and upper layers of gauze and renew them
every day, or as often as is necessary. The wound, in this way, is not
disturbed whatever, and the antiseptic properties of the lower fold of
gauze is sufficient to keep the wound surface clean.
In most superficial wounds it is best to remove the sutures at the end of
forty-eight hours, unless there are reasons for retaining them longer,
as the coapted surfaces are then sufficiently united to permit of other
dressings, such as aseptic plaster, now extensively used. Before these
are applied the skin is washed with alcohol or ether to assure a dry
surface to facilitate adhesion.
Sutures drawn as stated leave no possibility of stitch scars and reduce
the occurrence of possible stitch abscess to a minimum. As there is
always slight oozing following their removal, aristol or iodol may be
powdered over them before applying the plasters. This brings us to the
rather late question of sutureless coaptation of superficial incisions.
=Sutureless Coaptation.=—This method, first practically demonstrated by
_Bretz_, may be used with considerable advantage in wounds about the
face, and overcomes the strain of individual sutures, besides avoiding
the possibilities of stitch infection.
[Illustration: FIG. 21. FIG. 22.
PLASTER SUTURES.]
The method involves the proper placing of strips of plaster at either
or opposite ends of the wound. The distance between the incision and
the edge of the plaster must not be less than ¼ inch or more, according
to the length of the wound and its position. In place of the strips of
rubber adhesive plaster, the aseptic Z. O. plaster should be substituted
to overcome the objections of the infections therefrom.
[Illustration: FIG. 23. FIG. 24.
ANGULAR PLASTER SUTURES.]
The inner edges of the plasters are raised slightly, and interrupted
sutures are inserted through them instead of the skin (see Fig. 21).
They are then tied as shown in Fig. 22. In angular incisions the plasters
are cut as desired to insure perfect coaptation, as in Figs. 23 and 24.
The advantages of this method, besides those already mentioned, are that
the wound is always open for inspection and permits of free drainage.
If thought best, a small strip of iodoform gauze may be placed over the
threads or even under them, if there is little tension.
Since the introduction of the aseptic Z. O. (Lilienthal) strips, the
above method may be discarded as unnecessary and requiring too much
time for their application. Strips of the antiseptic plaster are placed
across the wound at right angles, or, if the surface be a curved one,
obliquely to the wound. The plasters are furnished in strips of the width
desired, packed in two germ-proof envelopes. They are extremely adhesive
to dry surfaces. Besides being aseptic, they are slightly antiseptic and
nonirritating. The strips are placed in position, leaving an open space
between them while the assistant brings the edges of the wound into
position.
Where there is tension of the parts this method is not to be employed.
The wound may be dusted as when sutured and dressed in the same manner.
The plasters are removed about the sixth day _by drawing the ends of
the strips toward the wound_. Their second application is unnecessary,
regular dressings being substituted.
From the above it must not be inferred that all plastic wounds are
amenable to the above methods, because many require specific treatment,
as later described.
=Granulation.=—Wounds left open for granulation should be dusted over
with some stimulating antiseptic powder, such as aristol or boric acid,
and then covered with iodoform or borated gauze. The granulating surface
must be gently washed with a mild solution of peroxid.
Prolific hypertrophic granulations, that jut out over the surface, are
touched with a lunar caustic point, avoiding the epithelial edge of the
wound, where it causes considerable pain. Pale and loose granular points
should be scraped away with the sharp spoon curette to hasten better
growth.
If the skin edges are thickened and curled upon themselves, it may be
best to curette or to reduce them by cauterization, so stimulating
epitheliar spreading. Sterile gauze is then loosely laid upon the
surface, backed with a highly absorbing material, such at charpie
cotton (Burns), wood wool, and poplar sawdust, retained in gauze bags
(Porter). The absorbing layer should be light and pervious to the air,
to facilitate not only free absorption, but ready evaporation of the
secretions.
=Changing Dressings.=—All dressings must be absolutely sterile and all
precautions, as primarily carried out, must be followed in changing them.
It is rather infrequent to use permanent dressings in plastic surgery,
but where the wound appears aseptic, with a dry serous crust over the
line of healing, it should not be disturbed except for mechanical
reasons. The latter are caused by the coagulated mixture of the wound
secretion and the antiseptic powder used, often aggravated by the median
knotting of sutures or the careless disposition of the loose suture ends.
Not too much can be said of carefully folding the free silk suture ends
at right angles to the incisions. The ends, moistened subcutaneously,
are very liable to take on septic infection and communicate it to the
wound—crowded into the very wound. When becoming embodied in the coagula
of serum and antiseptic powder it prevents, by pressure, perfect union,
causing a wider scar at such point, as well as endangering the asepsis
of the wound by being pulled off accidentally, thus tearing it open and
bringing on hemorrhage.
The appearance of the resulting scar in facial surgery is often of as
much importance to the patient as the operation itself, therefore, all
care should be exercised in bringing about the very best result.
For this reason, a patient in poor health should not be operated upon,
and any erosion of the skin about the seat of operation should be
thoroughly healed before attempting plastic work. Aristol dusted on an
abrasion will heal it quickly.
If hemorrhage follows the dressings of a wound, the dressing should be
removed and the hemorrhage controlled by pressure, unless severe, and
be redressed. Moist blood decomposes readily and is a source of early
infection, unless careful drainage under antisepsis is established. At no
time should any part of the wound be unnecessarily exposed directly to
the air. For small wounds, silk protective plaster may be used to cover
the gauze dressing, while sterile gauze bandages should keep dressings of
large area in place.
Bandages, when changed, should be cut away with the aid of the
Lazarewitch angular bandage scissors and not be unwound. It is quicker
and the undue pulling of such, when glued by secretions, is liable to
disturb the healing of wounds and even result in the tearing out of
sutures.
The patient should never be intrusted to dress wounds himself. In cases
where the dressings cannot be changed frequently proper precautions for
drainage and comfort must be observed. The temperature of the patient
should be taken twice daily; any elevation thereof may indicate septic
infection and demand immediate attention.
When a portion of the ear, nose, or lip has been severed by injury, the
part may be put back into place and held by sutures and aseptic Z. O.
strips, powdered with aristol and properly dressed. Union usually takes
place, even in the most unexpected cases. None but incised wounds of
such nature should be covered hermetically with collodium or plaster,
as bruised surfaces so often in this kind of injury require perfect
drainage. The retention of secretions produces infection, generally
resulting in the entire loss of the part.
=Wounds of the Mucous Membrane.=—Wounds of the mucous membrane should be
carefully drained and cleansed freely at frequent intervals, especially
those about the mouth. Wounds of the cheek, if including the mucous
membrane, should be especially cared for, as there is here the increased
danger of infections from the secretions of the mouth.
=Pedunculated Flaps.=—When pedunculated flaps are left free of other
attachment, for reasons later mentioned, they must be dressed as
granulating wounds. Here it becomes necessary to support the loose
piece of skin in such a way as to overcome circulatory obliteration.
Unnecessary handling is always to be avoided. The following method has
been used with the best results by the author.
The flap is not dressed until all hemorrhage has ceased. A small pad
of sterilized or borated absorbent cotton is covered lightly with
ten-per-cent iodoform gauze—cigarette fashion. The surface of this roll
drain is powdered well with aristol or iodol and it is gently placed
beneath the flap so that it rests easily upon the same. A second and
somewhat larger pad or roll of like construction is placed next to the
skin surface of the flap. This is held in position by silk protective
plaster or several layers of gauze bandage, gently, though snugly,
applied.
The flap thus dressed should not be subjected to pressure, often
requiring considerable care on the part of the patient, especially during
the night. Undue pressure will induce sloughing and must be avoided, even
at the expense of comfort to the patient.
This dressing may be changed the second day, when the flap will appear
anemic. Signs of discoloration indicate gangrene, which is difficult to
overcome. In a short time the skin takes on a pale pink color, which
indicates a reëstablishment of circulation, and granulations begin to
show themselves on the reverse side, which, as they multiply, soon
thicken the flap sufficiently for the purpose desired.
The dressings are continued, as begun, if there be no indication for
interference, although the granulations may be stimulated if too
inactive. Gently irritating the granular surface with a 1-3,000 sublimate
solution, although rarely permitted by most surgeons, does no harm; in
fact, it is to be recommended before reapplying the dry dressing.
In removing the dressings the edges of the flap will be found to adhere
to the gauze; this may be gently lifted with the tenaculum, after
previous softening with a weak solution of hydrogen peroxid.
Pus (laudable) is the natural secretion from these flaps. Whatever
remains on the surface is easily removed by an antiseptic solution,
whereupon the powder is again dusted upon the part. When the flap has
thickened sufficiently it may be covered by skin grafts, but this is
rarely done until it has been properly implanted into the area for which
it was intended and only then when union between its sutured borders has
taken place. Ofttimes one part of a flap is left unattached, as, for
instance, the outer border of the ear, with the object of developing
a greater thickness. This must be cauterized along the edge with the
caustic pencil, keeping the granulations within the desired limit until
the opposite layer of skin has either cicatrized with it or has been
grafted near it for the same purpose. The surface is then antiseptically
treated, as any granulating surface, except as otherwise indicated.
=Foreign Bodies.=—Especial care must be exercised with wounds into which
foreign bodies have been implanted. Under favorable conditions many are
kindly received by the tissues, but often these rebel and even with
the greatest of care in dressing such wounds will often result in the
necessity for removal of the substance. Individual cases of such nature
are fully referred to later.