Incision Care

Definition
Purpose
Description
Normal results

Definition

Incision care refers to a series of procedures and precautions related to closing a wound or surgical incision; protecting the cut or injured tissues from contamination or infection; and caring properly for the new skin that forms during the healing process. Incision care begins in the hospital or outpatient clinic and is continued by the patient during recovery at home.

Purpose

There are several reasons for caring properly for an incision or wound. These include:

• lowering the risk of postoperative complications, particularly infection
• avoiding unnecessary pain or discomfort
• minimizing scarring
• preventing blood loss

Description

Types of wound or incision closure

Proper care of an incision begins with knowing what material or technique the surgeon used to close the cut. There are four major types of closure used in Canada and the United States as of 2003.

SURGICAL SUTURES. Sutures, or stitches, are the oldest method still in use to close an incision. The surgeon uses a sterilized thread, which may be made of natural materials (silk or catgut) or synthetic fibers, to stitch the edges of the cut together with a special curved needle. There are two major types of sutures, absorbable and nonabsorbable. Absorbable sutures are gradually broken down in the body, usually within two months. Absorbable sutures do not have to be removed. They are used most commonly to close the deeper layers of tissue in a large incision or in such areas as the mouth. Nonabsorbable sutures are not broken down in the body and must be removed after the incision has healed. They are used most often to close the outer layers of skin or superficial cuts.

Sutures have several disadvantages. Because they are made of materials that are foreign to the body, they must be carefully sterilized and the skin around the incision cleansed with Betadine or a similar antiseptic to minimize the risk of infection. Suturing also requires more time than newer methods of closure. If the patient is not under general anesthesia, the surgeon must first apply or inject a local anesthetic before suturing. Lastly, there is a higher risk of scarring with sutures, particularly if the surgeon puts too much tension on the thread while stitching or selects thread that is too thick for the specific procedure.

SURGICAL STAPLES. Surgical staples are a newer method of incision closure. Staples are typically made of stainless steel or titanium. They are used most commonly to close lacerations on the scalp or to close the outer layers of skin in orthopedic procedures. They cannot be used on the face, hand, or other areas of the body where tendons and nerves lie close to

KEY TERMS

Catgut— The oldest type of absorbable suture. In spite of its name, catgut is made from collagen derived from sheep or cattle intestines. Synthetic absorbable sutures have been available since the 1980s.

Dehiscence— Separation or splitting open of the different layers of tissue in a surgical incision. Dehiscence may be partial, involving only a few layers of surface tissue; or complete, reopening all the layers of the incision.

Drainage— The withdrawal or removal of blood and other fluid matter from an incision or wound. An incision that is oozing blood or tissue fluids is said to be draining.

Dressing— A bandage, gauze pad, or other material placed over a wound or incision to cover and protect it.

Incision— The medical term for a cut made by a surgeon into a tissue or organ.

Laceration— A type of wound with rough, torn, or ragged edges.

Suture— A loop of thread, catgut, or synthetic material used to draw together and align the edges of a wound or incision. Sutures may be either absorbable or nonabsorbable.

the surface. Staples are usually removed seven to 10 days after surgery.

Staples are less likely to cause infections than sutures, and they also take less time to use. They can, however, leave noticeable scars if the edges of the wound or incision have not been properly aligned. In addition, staples require a special instrument for removal.

STERI-STRIPS. Steri-strips are pieces of adhesive material that can be used in some surgical procedures to help the edges of an incision grow together. They have several advantages, including low rates of infection, speed of application, no need for local anesthesia, and no need for special removal. Steri-strips begin to curl and peel away from the body, usually within five to seven days after surgery. They should be pulled off after two weeks if they have not already fallen off. Steri-strips, however, have two disadvantages: they are not as precise as sutures in bringing the edges of an incision into alignment; and they cannot be used on areas of the body that are hairy or that secrete moisture, such as the palms of the hands or the armpits.

LIQUID TISSUE GLUES. Tissue glues are the newest type of incision closure. They are applied to the edges of the incision and form a bond that holds the tissues together until new tissue is formed. The tissue glues most commonly used as of 2003 belong to a group of chemicals known as cyanoacrylates. In addition to speed of use and a low infection rate, tissue glues are gradually absorbed by the body. They are less likely to cause scarring, which makes them a good choice for facial surgery and other cosmetic procedures. They are also often used to close lacerations or incisions in children, who find them less frightening or painful than sutures or staples. Like Steri-strips, however, tissue glues cannot be used on areas of high moisture. They are also ineffective for use on the knee or elbow joints.

Dressings and drainage devices

After the incision is closed, it is covered with a dressing of some sort to keep it dry and clean, and prevent infection. Most dressings consist of gauze pads held in place by strips of adhesive tape or ACE bandages. An antibiotic ointment may also be applied to the gauze. A newer type of dressing, called OpSite, is a thin transparent membrane made of polyurethane coated with adhesive. It keeps disease organisms out of the wound while holding a layer of moisture close to the skin. This moist environment keeps scabs from forming and speeds up healing of the incision. OpSite can also be used to hold catheters or drainage tubes in place. It cannot, however, be used for severe (third-degree) burns or deep incisions.

Some surgical procedures, such as a mastectomy or removal of a ruptured appendix, require the surgeon to insert a drainage device to remove blood, pus, or other tissue fluids from the area of the incision. It is important to prevent these fluids from collecting under the incision because they encourage the growth of disease organisms. The drain may be left in place after the patient leaves the hospital. If so, the patient will need to check and empty the drain daily in addition to general incision care.

Home care of incisions

Guidelines for home care of an incision vary somewhat depending on the material that was used for closure, the location and size of the incision, and the nature of the operation. The following section is a general description of the major aspects of incision care.

Patients should ask their doctor for specific information about caring for their incision:

• the type of closure used
• whether another appointment will be needed to remove any sutures or staples
• the length of time that the incision should be kept covered, and the type of dressing that should be used
• whether the incision must be kept dry, and for how long
• any specific signs or symptoms that should be reported to the doctor

Most hospitals and surgery clinics provide patients with written handouts or checklists about incision care; however, it is always helpful to go over the information in the handout with the doctor or nurse, and to ask any further questions that may arise.

BATHING AND SHOWERING. Incisions should be kept dry for several days after surgery, with the exception of incisions closed with tissue glue. Incisions closed with nonabsorbable sutures or staples must be kept dry until the doctor removes the sutures or staples, usually about seven to 10 days after surgery. Incisions closed with Ste-strips should be kept dry for about four to five days. If the incision gets wet accidentally, it must be dried at once. Patients with incisions on the face, hands, or arms may be able to take showers or tub baths as long as they are able to hold the affected area outside the water. Patients with incisions in other parts of the body can usually take sponge baths.

It is usually safe to allow incisions closed with tissue glue to get wet during showering or bathing. The patient should, however, dry the area around the incision carefully after washing.

PHYSICAL ACTIVITY AND EXERCISE. Patients should avoid any activity that is likely to pull on the edges of the incision or put pressure on it. Walking and other light activities are encouraged, as they help to restore normal energy levels and digestive functions. Patients should not, however, participate in sports, engage in sexual activity, or lift heavy objects until they have had a postoperative checkup.

MEDICATIONS. Patients are asked to avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after surgery, because aspirin interferes with blood clotting and makes it easier for bruises to form in the skin near the incision. The doctor will usually prescribe codeine or another non-aspirin medication for pain control.

Patients with medications prescribed for other conditions or disorders should ask the doctor before starting to take them again.

SUN EXPOSURE. As an incision heals, the new skin that is formed over the cut is very sensitive to sunlight and will burn more easily than normal skin. Sunburn in turn will lead to worse scarring. Patients should keep the incision area covered for three to nine months from direct sun exposure in order to prevent burning and severe scarring.

SPECIAL CONSIDERATIONS FOR FACIAL INCISIONS. Patients who have had facial surgery are usually given very detailed instructions about incision care because the skin of the face is relatively thin, and incisions in this area can be easily stretched out of alignment. In addition, patients should not apply any cosmetic creams or makeup after surgery without the surgeon’s approval because of the risk of infection or allergic reaction.

GENERAL HYGIENE. Infection is the most common complication of surgical procedures. It can be serious; of the 300,000 patients whose incisions become infected each year in the United States, about 10,000 will die. It is important, therefore, to minimize the risk of an infection when caring for an incision at home.

Patients should observe the following precautions about general cleanliness and personal habits:

• Wash hands carefully after using the toilet and after touching or handling trash or garbage; pets and pet equipment; dirty laundry or soiled incision dressings; and anything else that is dirty or has been used outdoors.
• Ask family members, close friends, and others who touch the patient to wash their hands first.
• Avoid contact with family members and others who are sick or recovering from a contagious illness.
• Stop smoking. (Smoking slows down the healing process.)

Normal results

As an incision heals, it is normal to experience some redness, swelling, itching, minor skin irritation or oozing of tissue fluid, or small lumps in the skin near the incision. At first, the skin over the incision will feel thick and hard. After a period of two to six months, the swelling and irritation will go down and the scar tissue will soften and begin to blend into the surrounding tissue.

Risk factors for abnormal results

Some patients are more likely to develop infections or to have their incision split open, which is known as dehiscence. Risk factors for infection or dehiscence include:

• obesity
• diabetes
• malnutrition
• a weakened immune system
• taking corticosteroid medications prescribed foranother disorder or condition
• a history of heavy smoking

Warning signs

Patients who notice any of the following signs or symptoms should call their doctor:

• fever of 100.5°F (38°C) or higher
• severe pain in the area of the incision
• intense redness in the area of the incision bruising
• bleeding or increased drainage of tissue fluid

Resources

BOOKS

Khatri, VP and JA Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Townsend, CM et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Farion, K., M. H. Osmond, L. Hartling, et al. “Tissue Adhesives for Traumatic Lacerations in Children and Adults.” Cochrane Database Systems Review 2002: CD003326.

Mattick, A., G. Clegg, T. Beattie, and T. Ahmad. “A Randomised, Controlled Trial Comparing a Tissue Adhesive (2-octylcyanoacrylate) with Adhesive Strips (Steri-strips) for Paediatric Laceration Repair.” Emergency Medicine Journal 19 (September 2002): 405–407.

Selo-Ojeme, D. O., and K. B. Lim. “Randomised Clinical Trial of Suture Compared with Adhesive Strip for Skin Closure After HRT Implant.” BJOG: An International Journal of Obstetrics and Gynaecology 109 (October 2002): 1178–1180.

Takahashi, K., T. Muratani, M. Saito, et al. “Evaluation of the Disinfective Efficacy of Povidoneiodine with the Use of the Transparent Film Dressing OpSite Wound.” Dermatology 204 (2002), Supplement 1: 59–62.

OTHER

Higgins, Robert V., Wendel Naumann, and James Hall. “Abdominal Incisions and Sutures in Gynecologic Oncological Surgery.” eMedicine, December 21, 2007. http://www.emedicine.com/med/topic3397.htm [accessed April 22, 2008].

Rebecca Frey, Ph.D.