Gentle pressure applied to wounds of the breasts, scalp, face and neck during extubation can significantly decrease the chance of hematoma formation. The increase in both systolic and venous pressure during extubation can be counteracted by gentle pressure.

If the surgery was done under local anesthesia have the patient or a family member whole gentle pressure with a 4 x 4 gauze over the wound for about 30 minutes, after elevating the wound higher than the heart. If the patient’s bleeding time was prolonged. Continue the pressure for one hour. The pressure should be gentle, essentially the weight of the hand, to avoid reactive hyperemia when the pressure is discontinued elevation of the wound as much as possible during the first few postoperative days cannot be over emphasized. Elevation not only decreases pain but improves healing by improving the circulation. Patients with hand injuries should be fitted with a sling which holds involved hand on the opposite shoulder crutches should be obtained for patients with any but small lacerations of the feet or legs and weight-bearing should be avoided on the involved extremity for six weeks. The patient should be advised to stay supine with the involved extremity elevated is much as possible during the first 2 to 3 postoperative days. As noted previously, the different implications of similar sized wounds of the scalper face and those of the feet and legs are not widely appreciated. The difference to the patient as far as pain and inconvenience is significant.

Most wounds do not require dressings except to avoid spotting clothing. Ice water compresses to larger wounds of the head and neck are beneficial. A washcloth is preferable to gauze for the face and scalp compress. It stays in position better and also if the patient is hospitalized there is no cost. Immerse the washcloth and ice water, wring it out and apply it completely unfolded to the involved area. When the compress warms up, repeat the process. A cool compress does three things-- it keeps the wound clean, decreases pain and causes vasoconstriction and hence less edema. Patients can shower the first postoperative day.

Repaired wounds of the trunk and extremities usually can be left exposed. Most emergency room physicians recommend a dressing for two days or so but in my experience such dressings are unnecessary except to avoid soiling clothing.  Dressings are a particular nuisance as far as minor hand wounds are concerned. Hand wounds may be immersed in water briefly after 4 to 6 hours and the patient can shower by the first postoperative day after repair of most drunken extremity wounds.

When using addressing on the trunk or extremity to avoids soiling clothing, use a single layer of greasy gauze next to the wound before applying the rest of the dressing. This approach will make removal of the dressing essentially painless.

As noted previously thorough documentation regarding description of wounds, what you did, prescriptions and postoperative instructions is mandatory, either on the chart or in the dictated note.

If the patient is hypertensive, labile hypertensive or elderly, he or she should be advised to take pain medication as soon as they begin experiencing discomfort. A wound, particularly of the head and neck, which was not bleeding at the time of closure when the systolic pressure was 125 may well bleed at a postoperative systolic pressure of 160, especially if the wound is sizable.  Some patients seem to have an innate aversion to pain medication and in the instances noted above it is important to explain the desirability of early, good analgesia.

As noted earlier, I place every postoperative wound repair patient on an antibiotic for two days. In my experience, this routine is significantly more effective than a single IV dose. If the wound was markedly contaminated, I extend the antibiotic coverage for three or four days. I realize that many wounds would not become infected with no antibiotic coverage, but routine prophylactic antibiotics constitute a cheap insurance against infection, after thorough debridement. An infection usually results in a bad scar and the main purpose of a plastic repair is to attain the best scar possible.

Most patients appreciate a narcotic for pain for a day or so. I routinely use Vicodin (hydrocodone) and almost never prescribe oxycodone. The latter has far more addiction potential.

I like to see most patients and follow-up within two or three days to check on the wound. Provide the patient with your card and request that he or she contact you if they have any concerns about the wound prior to the office visit. Your home number as well as your office phone should be on your card.

Review your instructions with the patient and family regarding wound care, medication, problems to watch for, anticipated edema and discoloration (particularly if they have been on an NSAID). Also ask if they have any questions. Document all of the above.

If the patient is a child, it is important to request that two adults accompany the child at the time of the office visit for suture removal. Removing sutures from young children is another skill that is almost an art form in itself. It requires three adults to adequately restrain a child who is uncooperative, for safe suture removal. One adult holds the knees of the child against the table, one holds the child’s hands on the child’s chest and another adult is required to study the involved area, usually the head. Most children under age 2 will require restraint. From age 2 on, a remarkable number will be fairly cooperative if you explained to them that the procedure will involve a little pain and that the less they move, the less pain there will be. Also tell them that you will be as careful as possible to keep the pain at a minimum. Loopes with 3 ½ times magnification and a plastic needle nosed forceps and suture removal scissors are recommended. A few children will scream rather loudly during suture removal. I keep a pair of earplugs nearby for such occasions as the decibels can get rather high.

I routinely do nerve blocks for suture removal from distal digits both in children as well as in adults. The digital block can be done almost painlessly whereas suture removal from a distal digit can be quite painful.

A drop or two of ¼% tetra cane in the before removing sutures from the eyelid margin can appreciably decrease the pain. General anesthesia may be required for suture removal from eyelids and infants and toddlers.

Abraded areas should be left open as soon as this option is convenient for the patient. The sooner the abraded areas are left exposed, the faster they will dry. Freshly abraded areas which will be in contact with clothing should be covered with a single layer of greasy gauze and a wet to dry dressing, changed every other day or so, until they are dry enough to be left open.

Patients and their families are often concerned regarding the degree of scarring which will follow abrasions. Superficial abrasions may lead to increased pigmentation whereas deeper ones may cause the pigmentation. Most minor abrasions result in minimal or no pigment discrepancies. As noted previously, it is very important that contaminated abrasions be adequately debris did to avoid permanent pigmentation.

If a circular dressing has been used, such as around the head or an extremity. Advise the patient to loosen or even remove the dressing if it feels too tight.

Repaired paper-thin flaps usually require a snugly fitting dressing for 10 to 14 days. Change the initial dressing on the second postoperative day and then redress the wound every 2 to 3 days. Again, a single layer of greasy gauze should be applied next to the wound with each dressing change. Also, emphasize that the wound should be kept higher than the heart as much as possible. If the wound is on the leg or foot, weight-bearing should be avoided on that side for six weeks and crutches should be used during that period.

Cover split-thickness donor sites with a single layer of greasy gauze and a wet-to-dry dressing. Ask the patient to change the dressing about every eight hours, leaving the greasy gauze in place. The wound will usually heal within 7-10 days and can be left exposed at that time. The greasy gauze will separate spontaneously as the area becomes reepithelialized.

In applying a circular bandage around the brow or extremities, it is important not to have a localized thinker dressing over the wound itself. To the inexperienced, this localized thickening of the dressing may seem reasonable to prevent oozing or excessive edema but such an arrangement can easily lead to pressure necrosis in the wound area itself.