Questioning Surgical Incision Myths

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The practices we learn during our surgical training can set the stage for what we do during our careers, but how rooted in evidence are all of those practices? In this blog I will question the received podiatric wisdom on skin closure, incisions, and wound dressing selection, and take a close look at the evidence on each.

Do You Need to Evert the Skin Edges on Closure?

Many times during training, I had attendings stress the importance of good eversion for wound closure. From what I gathered at the time, it apparently was one of the most important parts of a good incision. There are 2 purported main benefits I heard: everted wound edges appropriately close the surgical wound, and they provide an excellent cosmetic outcome. Is this idea really rooted in evidence, though? Or, is this just another dogmatic teaching that continues to be reinforced without data to support it?
 
The origins of this teaching apparently predate evidence-based medicine. The theory is that there are contractile forces present during wound healing, and if there is no eversion, the scar will become depressed and not cosmetically pleasing.^1,2 Kappel and colleagues in 2015 sought answers by performing a randomized trial in a dermatology clinic.³ They had two groups. The first had wounds closed with eversion techniques and the second had planar closure. At 3 and 6 months, the wounds/scars were no different, using patient outcome scores as well as objective measurements in height, width, and depth.
 
While this was a single dermatology center and did not involve deeper surgical wounds, the results are enticing. Why do we keep teaching wound eversion when it doesn’t seem to matter? The evidence is further bolstered by the fact that repair techniques don’t seem to make a huge difference either—surgical glue and wound closure strips, which do not evert the wound edges, have identical outcomes to suture.^4-7

Do You Need to Keep Incisions Dry for 14 Days?

After surgery, most podiatrists will tell their patients to keep the dressing intact and the incision completely dry for at least 14 days (or until sutures get removed). Why? While there is not great literature specifically around foot and ankle surgery, there does not seem to be any evidence to support this trend. The American College of Surgeons and the National Institute for Health in the United Kingdom offered recommendations to allow patients to shower 48 hours after surgery. These organizations state that the wound re-epithelializes around 24 hours after the surgery, which creates an external watertight seal.^8,9 Of note, the World Health Organization has no position on this topic in its recommendations for decreasing surgical site infections.¹⁰
 
There have been various trials all reiterating the fact that uncovering wounds and minor washing of the wounds is at least non-inferior and possibly decreases the risk of infections versus conventional postoperative dressings.^11-13 This makes logical sense, as even in the most sterile operating room, skin will never be completely sterile after the procedure and surgical wounds drain non-sterile fluid, which just builds up and collects over and on top of the incision.
 
Hsieh and colleagues in 2016 performed a prospective randomized trial with various face and extremity surgical wounds.¹⁴ They had two groups. The first changed their dressings every 1–2 days with routine washing. The other group did not shower/kept the area dry for 14 days. There were fewer infections in the shower group and patients were more satisfied with their method of wound care as well.
 
There was a systematic review in 2013 by Dayton and colleagues that reviewed 9 studies with 2,150 patients.¹⁵ While all the studies were heterogeneous and of questionable bias and validity, there ended up being no difference between groups of patients who showered early (between day 2 and 5 postoperatively) and those who kept incisions dry until suture removal. If results are equivocal or even favoring light rinsing of the surgical site, why do we stress to patients to keep things as clean and dry as possible (which can be very challenging)?
 
There needs to be more evidence and more foot and ankle-specific research, but as the research currently stands, it is likely prudent to allow the patients you trust to wash their feet lightly after surgery and utilize a clean dressing that they may apply themselves.

Do Surgical Dressings Make a Difference?

Many surgeons I have met are very particular with their postoperative protocols, including their dressings. Most surgical dressings involve a non-adherent base, plain gauze, a rolled gauze or cotton layer, and some compressive wrap to hold it on the foot. This raises the question: is there any evidence to support dressing a surgical wound one way versus another?
 
Dressings are used to keep wounds clean, manage moisture, and provide patient comfort, but it seems like based on available human data (of which there is not much), it doesn’t really matter what you do or don’t use.^16,17 Turns out, a Cochrane review in 2016 found “no clear evidence to suggest that one dressing type was better than any other at reducing the risk of surgical site infection, nor that covering wounds with any dressing at all reduced the risk of surgical site infection. Additionally, there was no clear evidence that any dressing type improves scarring, pain control, patient acceptability, or ease of removal.”¹⁸ Granted, this is one review, and is therefore subject to bias; however, there have been other randomized controlled trials with similarly murky conclusions.^19,20
 
Based on what is available, there is very little support for one sort of dressing versus another and until more research is done, it seems plausible to use what you are comfortable with if you’ve had well-healing wounds and low infection risk.
 
Dr. Ehlers is in private practice in Arvada, CO, and is an attending at the Highlands-Presbyterian/St. Luke’s Podiatric Residency Program. He finds interest in debunking medical myths and dogma.
 
References
1)    Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol. 1992 Sep;18(9):785-95. doi: 10.1111/j.1524-4725.1992.tb03036.x. PMID: 1512311.
2)    Zide MF. Scar revision with hypereversion. J Oral Maxillofac Surg. 1996 Sep;54(9):1061-7. doi: 10.1016/s0278-2391(96)90160-3. PMID: 8811815.
3)    Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015 Apr;72(4):668-73. doi: 10.1016/j.jaad.2014.11.032. Epub 2015 Jan 23. PMID: 25619206; PMCID: PMC4950516.
4)    Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002;2002(3):CD003326. doi: 10.1002/14651858.CD003326. PMID: 12137689; PMCID: PMC9006881.
5)    Wong EM, Rainer TH, Ng YC, Chan MS, Lopez V. Cost-effectiveness of Dermabond versus sutures for lacerated wound closure: a randomised controlled trial. Hong Kong Med J. 2011 Dec;17(Suppl 6):4-8. PMID: 22147351
6)    Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002 Sep;19(5):405-7. doi: 10.1136/emj.19.5.405. PMID: 12204985
7)    Tandon S, Smale M, Pacilli M, Nataraja RM. Tissue adhesive and adhesive tape for pediatric wound closure: A systematic review and meta-analysis. J Pediatr Surg. 2021 May;56(5):1020-1029. doi: 10.1016/j.jpedsurg.2020.07.037. Epub 2020 Aug 5. PMID: 32888718
8)    American College of Surgeons. Breast cancer: after your operation.
9)    National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. Published April 11, 2019.
10) World Health Organization. Global guidelines for the prevention of surgical site infection, second edition. Published Jan. 3, 2018.
11) Neues C, Haas E. Beeinflussung der postoperativen Wundheilung durch Duschen [Modification of postoperative wound healing by showering]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2000; 71(2):234–236. https://doi.org/10.1007/s001040050040
12) Riederer SR, Inderbitzi R. Gefährdet das Duschen die postoperative Wundheilung? [Does a shower put postoperative wound healing at risk?]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 1997; 68(7):715–717. https://doi.org/10.1007/s001040050259
13) Heal C, Buettner P, Raasch B, et al. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ. 2006 May 6;332(7549):1053-6. doi: 10.1136/bmj.38800.628704.AE. Epub 2006 Apr 24. PMID: 1663602
14) Hsieh PY, Chen KY, Chen HY, et al. Postoperative showering for clean and clean-contaminated wounds: a prospective, randomized controlled trial. Ann Surg. 2016; 263(5):931–936. https://doi.org/10.1097/SLA.0000000000001359
15) Dayton P, Feilmeier M, Sedberry S. Does postoperative showering or bathing of a surgical site increase the incidence of infection? A systematic review of the literature. J Foot Ankle Surg. 2013; 52(5):612–614. https://doi.org/10.1053/j.jfas.2013.02.016
16) Voineskos SH, Ayeni OA, McKnight L, et al. Systematic review of skin graft donor-site dressings. Plast Reconstr Surg. 2009;124:298–306.
17) Masella PC, Balent EM, Carlson TL, Lee KW, Pierce LM. Evaluation of six split-thickness skin graft donor-site dressing materials in a swine model. Plast Reconstr Surg Glob Open. 2014 Jan 6;1(9):e84. doi: 10.1097/GOX.0000000000000031. PMID: 25289278; PMCID: PMC4174104.
18) Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016 Dec 20;12(12):CD003091. doi: 10.1002/14651858.CD003091.pub4. PMID: 27996083
19) Toon CD, Lusuku C, Ramamoorthy R, Davidson BR, Gurusamy KS. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev. 2015 Sep 3;2015(9):CD010259. doi: 10.1002/14651858.CD010259.pub3. PMID: 26331392
20) Toon CD, Sinha S, Davidson BR, Gurusamy KS. Early versus delayed post-operative bathing or showering to prevent wound complications. Cochrane Database Syst Rev. 2013 Oct 12;(10):CD010075. doi: 10.1002/14651858.CD010075.pub2. Update in: Cochrane Database Syst Rev. 2015;(7):CD010075. PMID: 24122544
 
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