The long-term objective in wound repair is to restore the tissue to as nearly normal state as possible. Achieving this goal involves meticulous attention to technical details and appropriate pre-and postoperative care.

Many factors have a bearing on the final result, the two most important ones the surgeon can affect being the quality of the repair and the avoidance of infection. The entire procedure should be as painless as possible and the performance as expeditious as circumstances permit.

Hopefully, the patient and the family will be pleased with the outcome. Satisfaction of those concerned hinges not only on the surgeon’s technical skills but also on his competence in communication. An appreciation of the experience from the patient and family’ perspective is key to the rapport established. The recent emphasis on holistic trends in medicine is often touted as a new phenomenon. The experienced practitioner has been employing this approach for years, addressing both the emotional as well as the physical needs of the patient.

A time-honored way to attain proficiency in the technical nuances of wound repair is to adhere to sound procedural routines, making adjustments as circumstances dictate. The same strategy is applicable to the doctor-patient relationship. Verbal interaction with the patient and family may require modification to deal with idiosyncrasies of the moment but in general may be patterned along the same lines.

Most patients are cooperative and grateful for your services. A small, hopefully, minority may be disappointed with your personality and/or your skills. Obviously not every outcome will be so good as either the patient or surgeon would like. Even one’s best result may not meet the expectation of the patient. The reverse situation may also be true. What the surgeon would consider a mediocre or rather poor result may delight the patient and the family.

Explaining the probable result upfront, in an open and straightforward manner as possible, can go a long way toward allaying fears and generating reasonable expectations. Be certain that everyone concerned appreciates that there is no guarantee of the outcome. Never say “Everything will be all right” because sometimes it will not be.

These pre-and intraoperative (in the ER and the trauma bay) discussions become easier as one acquires more skills in sensing any particular concerns of the patient and family and more knowledgeable regarding probable outcomes.

The two most pressing concerns of the patient and family are almost always the amount of pain associated with the repair and the likely result in terms of scarring or deformity. Your stating that you can manage the problem with minimal discomfort may ameliorate much of the apprehension. You may want to acknowledge that the patient possibly has received similar assurance in the past only to experience significant pain later. A description of your anesthetic technique, topical anesthesia followed by infiltration with a tiny needle may further allay anxiety. Often angst in this regard will not be resolved until you “furnish proof of the pudding.”

Elicitation of an adequate history usually can be accomplished within a minute or two. How, when and where the injury occurred, general health, any routine doctor visits for chronic illness, routine medications, any drug allergies, history of increased bleeding tendencies or history of unusual scarring ordinarily suffices. Rarely the patient may state that they are allergic to all “caines.” A protocol for dealing with this quandary is outlined in the chapter on anesthesia.

Many patients and some physicians equate a plastic repair with the absence of a scar. A wound which goes completely through the skin always leads to a scar. The question thus becomes not whether one is going to have a scar but rather how conspicuous will the scar be.

A multitude of factors are involved in the prominence of scars. The three salient ones, assuming no infection, are usually the nature of the wound. The quality of the repair and the healing propensities of the patient. If the patient tends to form hypertrophic or keloidal scars, the other two considerations become much less relevant. The innate healing characteristics of the patient probably will prevail in spite of your best efforts. Occasionally such is not the case, however. You can assure the patient that she will do everything you can to minimize scarring but that their scarring eccentricities probably will control the outcome.

Wounds in some areas of the body almost routinely result in unsightly scars. Vertical incisions in the lower anterior neck, upper sternal area and deltoid region are notorious in this regard. Other major factors affecting the degree of scarring include the age of the patient, the amount of skin loss, the degree of blunt force involved and the bleeding status of the patient.

About one half of the patients seen in the emergency room for wound repair will have ingested an NSAID within the previous three weeks. Consequently, they will exhibit a prolonged bleeding time. Occasionally a referring physician in an outlining facility will have ordered such a medication for the patient prior to transfer. In such instances, it is good practice to have the facility contacted to explain that these types of medication are not advisable prior to wound repair. If the wound is small, clean and does not require significant debridement, the increased bleeding may be a minor irritation. On the other hand, if the wound is extensive and grossly contaminated, the excessive bleeding can be a nightmare.

Not infrequently a patient will be on Coumadin because of atrial fibrillation or DVT. The increased bleeding from Coumadin usually presents no more of a problem than that from an NSAID. The worst medication as far as causing challenging bleeding is clopidogrel.

The oozing and bleeding secondary to the medications referenced above not only can be difficult and time-consuming to control but almost always affect the quality of the repair. In my opinion, it is impossible to achieve the same meticulous debridement and closure when dealing with increased bleeding, particularly that from clopidogrel, as one can attain under normal circumstances. An appreciation and acceptance of this truism can go a long way towards decreasing the frustration of the surgeon dealing with the problem.

Intoxicated individuals, those under the influence of recreational drugs and persons suffering from mental disorders may initially refuse care for wounds which obviously need repair. Often these patients require observation for several hours in the emergency room or on the floor. During this timeframe, they almost always will have a change of heart regarding the desirability of wound repair. In the meantime, it is important to elevate the wounded area, cover the wound with a moist dressing, initiate antibiotic coverage and administer tetanus immunization, if the latter is indicated.

In the event all efforts to persuade the patient regarding the advisability of wound closure fail and the patient signs out against medical advice, they should be instructed in wound care, given a prescription for an antibiotic and an analgesic and instructed in follow-up. Obviously thorough documentation is mandatory.

Rarely, a patient or family member will request a wound care regimen that is blatantly suboptimal or even dangerous. You’re addressing the disadvantages and increased risks in such an approach usually leads to acquiescence of your recommendations. If not, you should explain, as diplomatically as possible, that you cannot be involved in such a plan and suggest that a different surgeon be contacted.

Factors beyond your control can be genesis of anger and frustration on the part of the family and patient. Difficulty in finding a parking spot, prolonged waiting time, remarks by a clerk, technician or nurse viewed as non-caring, long delays in analgesic or purely comfort issue requests can significantly charge the emotional atmosphere. Your prompt appearance after being contacted coupled with a calm, reassuring manner often can defuse a lot of the previous antagonism.

Patients with unusually low pain thresholds are almost always present or past alcoholics or drug addicts. With a little experience, it is easy to identify these individuals. Your awareness of the situation is helpful in managing the pre-and postoperative analgesics. These patients often require significantly more preoperative medication and one should avoid postoperative analgesics with increased addiction potential as well as limiting the quantity of their postoperative analgesic.