THIS WEEK'S ARTICLES
Patient-Centered Wound Care
The importance of properly treating incision sites ramps up after discharge.
Post-op providers should focus on more than treating postoperative nausea and vomiting (PONV) and managing pain. “Patients and their caregivers are responsible for managing wounds, but there’s very little help available to guide them,” says Kathleen Heneghan, PhD, MSN, RN, PN-C, assistant director of surgical patient education at the American College of Surgeons (ACS).
With that in mind, surgical facilities must implement these pointers and protocols to ensure incisions heal properly when patients are on their own at home:
- Early information. Educating patients on how to care for surgical wounds should begin as soon as they schedule procedures, when they’re more receptive to processing the information. “They’re dealing with so much emotional stress and physical strain on the day of surgery, so it’s not a great time for learning or remembering,” says Nancy Strand, MPH, RN, manager of surgical patient education at ACS. She says it’s also important to tailor the instructions to individual patients. For instance, smokers should be told to stop smoking, which can delay wound healing.
- Show and tell. Providers should demonstrate proper ways to change dressings and clean wounds. Detailed informational packets and hands-on demonstrations performed well in advance of surgeries give patients and their caregivers the base knowledge they need to clean and prepare incision sites when the time comes.
- Clear instructions. It’s never safe to assume patients fully comprehend even the most basic care instructions, says Dr. Heneghan. Written directives about wound care — and the supplies needed to properly dress incision sites — should therefore be included in discharge packets. Providing this information in a convenient and easy-to-understand format provides patients with a handy reference during the critical stages of their recoveries.
- Contact phone numbers. It’s important for patients to reach a member of their care team if they’re concerned about the condition of their wound or the possibility of infection. Being able to call a provider to sort out if their cause for concern requires follow-up care or is part of the natural wound healing process can mean the difference between needed follow-up care and unnecessary trips to the clinic.
Giving patients the information they need to manage their wounds well in advance of their procedures will ensure they head home with the confidence to take ownership in their care and contribute to their own successful recoveries.
Is Scarless Surgery Possible?
Researchers discover a common eye medication can prevent scars from forming.
Verteporfin, a medication often used to treat macular degeneration, could be the key to performing surgery that doesn't leave a mark, according to a study published in the journal Science.
Scars are the body's natural response to covering and protecting openings in the skin. They form more quickly than normal skin can grow to prevent infections and bleeding. Surgery results in 50 to 80 million scars each year, according to Michael Longaker, MD, the Deane P. and Louis Mitchell Professor in the School of Medicine at Stanford (Calif.) Medicine. He says no one likes the look of scars, but the health risks they pose are far greater than cosmetic concerns: Scar tissue is absent of hair follicles and sweat glands, is weaker than healthy skin, and can inhibit movements or the body's ability to adapt to changing temperatures. There's no way to prevent scars from forming — at least not yet.
Skin tension plays a critical role in the formation of scars because mechanical stress activates a gene called engrailed, which creates a protein found in fibroblasts — the type of skin that causes scarring. Dr. Longaker's team discovered that applying tension to healing wounds on mice increased the number of fibroblasts that expressed engrailed, resulting in the generation of thicker scars.
When the team applied verteporfin to the wounds, the drug interfered with the molecular signals that activate engrailed. As a result, the regenerated skin looked completely normal to the naked eye and it also resembled normal skin at the microscopic level. Additionally, hair and glands appeared in the healed wounds, and the regenerated skin was just as strong as the normal skin around it.
"These results are exciting because we have shown that we're able to intervene and stop fibroblasts from sensing mechanical force when healing a skin wound," says study co-author Geoffrey Gurtner, MD. "Now we need to see if the same approach will work in preventing other kinds of scarring."
Check out the complete study here.
Primary Wound Closure Device Improves Surgical Outcomes
Nine steps to wound closure in a variety of surgical procedures.
Orthopedic and trauma surgeons, among other surgeons, use a special device (DERMACLOSE) to help them achieve primary closure, avoid skin grafts and donor sites, and also help them improve surgical outcomes. Included in the types of orthopedic surgeries that benefit from this continuous external tissue expander are:
- Large, tissue loss injuries
- Open fractures
- Fasciotomy repair
- Amputation wound closure
- Post-surgical wound infections
- Infected hardware removal
- Wound dehiscence
- Post trauma (non-closable wounds)
The DERMACLOSE Continuous External Tissue Expander reduces time to closure with no need to re-tighten or readjust. It provides delayed primary closure of full thickness wounds. Surgeons use it as an alternative to split thickness skin grafts or when there are large skin deficits, such as on fasciotomies, tumor excisions, and trauma.1
The DERMACLOSE Continuous External Tissue Expander is indicated for use in assisting with the closure of moderate to large surgical or traumatic acute full thickness wounds of the skin by approximating and reducing the size of the wound. The DERMACLOSE Continuous External Tissue Expander should not be used on ischemic, infected or acute burned tissue. It should not be used on fragile tissue at the edges of a wound.
Nine steps are indicated for the proper use of this device in a variety of surgical procedures. These include:
1. Undermine wound edges. Undermine or elevate wound margins on a supra-fascial plane by approximately half the width of the wound.
2. Close wound ends. Prior to applying the DERMACLOSE device, close as much of the distal and proximal wound ends as possible.
3. Position skin anchors. Space skin anchors a maximum of 2 cm apart from each other. Position the tips of the skin anchors approximately 0.5 - 1 cm from the wound edge. The DERMACLOSE device is intended to be used with three skin anchors per side of wound and one tension controller for each 10 cm of length of wound. Use multiple devices for longer wounds. Pearl: Some surgeons put a strip of Ioban™ or thin DuoDERM™ along wound edges and place anchors through the Ioban or DuoDERM.
4. Staple skin anchors in place. Affix each skin anchor with a minimum of two skin staples. Press stapler firmly against each anchor and staple between each of the staple guide tabs found on the skin anchors.
5. Protect the wound bed. Protect the wound bed with petrolatum impregnated or similar non-adhering wound dressing, such as prior to applying the tension line to the anchors. The Xeroform or Adaptic can be extended under the elevated wound margins to prevent tissue adherence during the tissue expansion process.
6. Lace the line around the skin anchors. Seat the distal end of the bridge tubing on the center anchor by firmly pressing the lumen of the tubing into the top of the skin anchor tab.
7. Wind tension controller. Apply tension to line by turning tension controller knob clockwise (approximately 22 rotations) until multiple audible clicking sounds are heard. A built-in clutch automatically prevents over-tensioning. At this point the spring motor is fully engaged and no additional tightening is required.
8. Push in the lock button. Lock the device to prevent accidental tension line release by pushing in the locking button at the rear of the tension controller.
9. Post op follow-up. Evaluate tissue movement after 48 to 72 hours. Typically, wounds are re-approximated to within 1 cm in 3 to 7 days and can then be sutured or stapled closed. Use standard wound therapy.
1. Dermaclose IFU. Synovis Micro Companies Alliance, Inc.
Note: For more information, go to https://www.synovismicro.com/html/products/dermaclose_external_tissue_expander.html
New Looks Nerve-wracking for Some
Cosmetic surgeons can do a better job of calming patients before surgery.
Many plastic surgeons don't assess the level of anxiety their patients experience before surgery, but are willing to help those in their care feel more comfortable before they undergo cosmetic procedures. That's according to a recent surgery conducted by Arif Musa, a medical student at Wayne State University School of Medicine in Detroit.
The survey, published in Aesthetic Plastic Surgery, says 63% of 100 plastic surgeons who responded did not manage patient anxiety. A majority (81%) said they'd prefer to provide additional education about the procedures patients were scheduled to undergo as a way to help reduce their pre-op jitters.
Nearly three-fourths of the surgeons (69%) believed having family members present during clinic appointments would help to reduce patient anxiety, while approximately half (54%) said having anesthesiologists meet with patients would be an effective calming measure. The surgeons believed several factors play into reducing patients' pre-op anxieties, but hold themselves and anesthesiologists as most responsible for easing their concerns.
Mr. Musa says physicians should always account for the feelings and well-being of their patients, especially before surgery. "Patients' anxieties often go unaddressed or unrecognized by providers," he says. "Not only is there research that shows that high anxiety before surgery can lead to negative outcomes for the patient, but I believe that addressing patient anxiety is necessary for both patient-centered and evidence-based care."
The Drawback of Shopping for Surgery on Social Media
Implicit biases impact how patients interpret Instagram posts of cosmetic surgeons.
Cosmetic surgeons who post videos and pictures on Instagram to market their practices and showcase their skills might be unwittingly recruiting patients who are attracted to the ethnicity of their name, not their surgical results. This reality is brought to light in a new study, which shows patient perceptions of plastic surgeons' skills may be affected by implicit bias.
The study's authors created a series of fake Instagram posts that showed identical before and after pictures of a breast augmentation. The only difference among the posts were the names of the surgeons who "performed" the procedure; male and female ethnically identifiable names — African, Caucasian or Jewish American, East or South Asian, Black, Latinx and Middle Eastern — were noted.
Approximately 3,000 participants in the study were surveyed about their perceptions of the surgeon's competence whose name appeared in the post and how likely they were to schedule a procedure with the physician. The overall competency ratings were not impacted by the ethnicity of the names, but Caucasian Americans and Latinxs assigned preferable ratings to surgeons in their own respective racial/ethnic groups. These two ethnicities comprise about 80% of U.S. cosmetic surgery patients, according to the study.
Additionally, Caucasian Americans comprise 70% of the aesthetic plastic surgery population, note the researchers, who say surgeons without classically Caucasian American names might be at a disadvantage when recruiting patients through social media.
The findings highlight the importance of combatting implicit bias in health care, although it's challenging to do so because the associations described in the study are subconscious and often go unacknowledged. "We need to look at new approaches to encourage patients to make decisions about plastic surgeons based on board certifications, qualifications and experience," says Ash Patel, MB, ChB, study lead author and a plastic surgeon at Albany (N.Y.) Medical Center. "The findings remind us that implicit bias plays a critical role in our day-to-day actions, whether or not we realize it."
The findings were published in the journal Plastic and Reconstructive Surgery.