Wound Care

The human body has many processes to help wounds heal and to fight infection. Learn ways that doctors, nurses, patients and caregivers can help.

Overview

In basic terms, a wound disrupts of the normal function and structure of the skin. Wounds can occur in a variety of ways, and include everything from a scraped knee, to a sliced finger, to a surgical operation. The human body has many processes in place to help wounds heal and to fight infection. However, doctors, nurses, patients, and caregivers can help out the body’s natural processes, thereby allowing surgical wounds to heal quickly and safely.

Following surgery for head and neck cancer treatment, patients will have wounds of varying sizes and locations, depending on the location of the cancer and the incision that was made during the operation. Some patients may have only one small incision on their neck, whereas other patients may have multiple incisions on their face, neck, and other parts of their body (in cases of regional and free flap reconstruction).

When the surgery is over, the surgeons most often close up all of the incisions with stitches (also referred to as sutures). Absorbable stitches are most often placed below the level of the skin in the deeper tissues in order to take the tension off of the skin closure. Skin closure may be accomplished in a variety of ways: sutures in the skin that need to be removed several days after surgery; subcuticular (below the skin) sutures that are placed in the layer immediately deep to the skin (dermal layer) which resorb spontaneously and do not need to be removed; or metallic staples which need to be removed several days to weeks after surgery.

Sometimes, the surgeons will cover the wound in which subcuticular stitches were placed with small tape strips (also called Steri Strips) during surgery. The incision, or wound, will then be covered up with a dressing (usually made of gauze), and secured in place with some kind of adhesive tape.

When Can Sutures Be Removed

Sutures that require removal are generally taken out at defined time periods after surgery depending on a number of variables.

  • Where the scar is located (face, neck, scalp or other part of the body).
  • Whether the area in question was previously radiated, which tends to slow the healing process and usually delays the removal of skin sutures.

Wounds generally heal from the inside out, so the dressing will help to absorb any fluid that may seep out as the wound is healing, as well as to protect the open surface of the wound from any outside bacteria that may cause infection. Dressings need to be removed and changed regularly, even once the patient has left the hospital and returned home. Doctors will tell their patients how often their dressings should be changed, but the general procedure for dressing changes remains the same.

Steps for Safe Wound Care

1) Hand Washing & Preparation

Before anyone touches a dressing or wound, their hands must be properly cleaned by washing with soap and warm water for 15-30 seconds. Make sure that all of the necessary supplies are ready, and that all nearby surfaces are sanitized and clean.

2) Remove the Old Dressing

The person removing the dressing should be wearing clean gloves. First, the tape securing the dressing should be carefully loosened from the skin. Then, the old dressing can be gently and slowly removed from the skin. If the tape is sticking, or if the dressing is hard to remove, they can be moistened with warm water.

If the incision has been covered with Steri Strips, do not remove them unless specifically instructed to do so by a doctor. Usually, these will come off when they are exposed to water with bathing. It is a good idea to ask your surgeon about the preferred management of the Steri Strips.

Dispose of the old dressing safely, and then wash hands again.

3) Clean the Wound

Using gauze or a soft cloth soaked in either saline (salt water) or mild soapy water, gently dab or wipe the skin around the wound. Carefully try to remove any dried drainage or blood but do not pull on or scrub the wound itself.

Never use any skin cleaners, alcohol, peroxide, iodine, or antibacterial chemicals, as these can slow healing.

If a doctor has given instruction to irrigate, or wash out, the wound, then spray the wound using a syringe filled with salt water or soapy water. Dry the wound with a clean cloth or piece of gauze.

4) Put on the New Dressing

Doctors will instruct their patients as to the proper type of dressing to use. After the wound has been cleaned and dried, place the new dressing onto the wound, following the doctor’s instructions. Secure the dressing with tape or adhesive, if necessary.

All supplies and old dressings should be disposed of in a sealed waterproof bag, and then thrown into the trash. Never reuse a dressing.

Wash hands again after the dressing change is complete.

Adhesive Plaster - Heart

Types of Dressings

Depending on the type of surgery and the resulting wound, patients may need to use different types of dressings.

For example, the standard incisional wound left after a thyroidectomy or neck dissection will likely be covered with Steri Strips and gauze. Doctors should always inform their patients about which kind of dressing to use and how often to change it. Some of the dressings commonly used to heal wounds of the head and neck include:

Wet to Dry Dressings

Wet to dry dressings are used specifically in cases of wound breakdown or infection. This type of dressing is intended to debride (or remove) any unhealthy tissue that may accumulate in an infection, and involves placing a wet gauze (soaked in saline) over the wound, wrapping it in dry gauze, and then allowing it to dry. Once the gauze has dried, it is then removed and replaced with a new wet gauze. These dressings are usually changed 2–4 times per day.

Petrolatum Dressing

This type of dressing is non-adherent (meaning that it won’t stick to the wound and cause painful removal) and occlusive (meaning that it doesn’t let air reach the wound, thereby retaining heat and moisture). It is made of an absorbent fine mesh gauze, and it molds to the body to make it more comfortable. There are additional components of the dressing that help to fight odor and infection. One common brand of petrolatum dressing is called Xeroform. 

Telfa

This is a type of dry gauze dressing that is non-adherent and sterile. These are best for lightly-draining wounds. Telfa pads do not stick to the wound, nor do they leave behind a residue. Some Telfa pads have an adhesive rim to help hold the gauze onto the wound area. If not, the pads can be secured with an additional bandage or adhesive.

Waterproof Dressings

Waterproof dressings, such as Tegaderm, are useful in covering and protecting wounds, while keeping out water, dirt, and infection-causing bacteria. These dressings allow patients to bathe without worrying about their wound. These dressings are often transparent, so that wounds can be watched and monitored as they heal. 

Ointments

In some cases, doctors may recommend applying ointment to a wound, underneath the dressing. This is usually done to help fight or prevent infection and to promote quicker healing. Doctors may suggest several different types of ointments, each of which has its own function and purpose.

  • Topical antibiotics, such as bacitracin and polysporin, help to keep infection at bay
  • Petroleum-based ointments, such as Aquaphor, help to keep wounds moist, thereby speeding up the healing process and minimizing the eventual appearance of a scar.

Drains

In some cases, surgeons may place a drain in the wound before they close up the incision. Surgical drains help to promote healing and prevent infection by removing and preventing the accumulation of any remaining blood or fluid in the wound. There are several different types of drains that are used often in head and neck surgery. The two main categories are passive drains and active drains:

  • Passive drains rely on gravity to remove fluids from the wound. In head and neck surgery, the most commonly used type of passive drain is called a Penrose drain.
  • Active drains use negative pressure (suction) to help promote the outflow of fluids. The most commonly used type of active drain is called a Jackson Pratt drain.

Patients generally do not need to worry about the maintenance of drains while they are in the hospital, as they will generally be managed by nurses or nurse practitioners. However, patients may be discharged with a drain in place. In these cases, patients and caregivers will need to learn how to manage the suction portion of the drain, as well as the dressings that will be placed around the point where the drain exits from the skin. Patients should follow the instructions of their doctors and nurses regarding how to care for their drains.

Negative Pressure Wound Therapy

Overview

Negative pressure wound therapy (NPWT) is a therapeutic technique that draws fluid from a wound to help it heal. NPWT in head and neck surgery is most often used to treat acute or chronic wounds resulting from extensive surgical resections or in the case of a failed reconstructive procedure. They may also be used for holding skin grafts in place while they heal. This type of therapy is often applied in patients whose wounds are not healing properly.

How Does it Work?

NPWT involves the placement of a microporous foam sponge into the depth of the wound, sealing the wound with a plastic drape, and then applying a suction tubing device into the wound to deliver controlled negative pressure to the wound bed. NPWT is most often used in the secondary setting, after a surgery has taken place and the wound has not been healing well.

NPWT in the Primary Setting

Additionally, in select cases, NPWT may be used as an alternative method of eliminating dead space in the primary setting, following ablative surgery. In this case, the NPWT helps to close larger defects, or wounds, that might not otherwise be able to close on their own. This prophylactic technique helps avoid wound healing problems and may help eliminate the need for additional flap transfers and reconstructive surgeries.

Bandage - Illustration

Wound Healing Precautions

While a wound is healing, patients should avoid the following activities:

  • Do not rub or scrub the wound.
  • Do not put lotions, creams, or powders on the incision.
  • Avoid exposing the wound to sunlight.
  • Be sure to keep the wound completely dry during baths and showers. If taking a bath, be sure to keep the wound out of the water. If showering, try to cover the dressing with a plastic bag to keep it dry, if possible.

Signs to Look Out For

When caring for a wound at home, patients and caregivers should always look out for warning signs that may indicate infection or impaired healing:

  • Redness, pain, or swelling at or around the incision.
  • Excessive bleeding from the wound.
  • A wound that appears to get larger or deeper, instead of healing and shrinking.
  • A wound that looks dried out or dark.
  • Thick, tan, green, yellow, or bad-smelling drainage from the wound.
  • Fever (temperature at or above 100.5 oF).

Patients and caregivers should call a doctor immediately if they notice any of these signs.

In Cases of Infection

If a doctor determines that a patient’s wound is infected, they may do a variety of things to help combat the infection.

  • Drainage
    If there is a collection of fluid (or an abscess) deep in the wound, doctors may place a drain (likely a penrose drain) to remove the fluid. This allows the wound to continue to heal safely from the inside out. Once the wound stops draining fluid, the drain can be removed.
  • Packing
    In some cases, doctors may pack dry dressing (such as iodoform) inside a wound to help facilitate healing. This type of dressing is absorbent and also contains antiseptic, so it is ideal for infected wounds and plays a role in the resolution of infection.
  • Antibiotics
    In cases of infection, doctors will prescribe antibiotics to kill off the dangerous bacteria.
  • Wet to Dry Dressings
    These dressings may be used in cases of open, infected wounds.

Doctor’s Instructions

Patients and caregivers should always carefully follow their doctor’s instructions, no matter what. If they have any questions, or if anything is unclear, patients and caregivers should call their doctor’s office immediately to clear up any confusion, so that they can continue to safely care for the wound.

References

https://medlineplus.gov/ency/patientinstructions/000040.htm

https://www.uofmhealth.org/health-library/tc4128spec