A multivariate analysis of factors affecting wound-healing time

Predictors of patient satisfaction with Mohs micrographic surgery at time of surgery and 3 months postsurgery: A prospective cohort study

BACKGROUND

Despite the importance of patient satisfaction in ensuring high-quality care, studies investigating patient satisfaction in Mohs micrographic surgery (MMS) are limited.

OBJECTIVE

We investigated the factors associated with patient satisfaction in MMS for nonmelanoma skin cancer and how patient satisfaction changes in the postoperative period.

METHODS

In this prospective cohort study including 100 patients, patient satisfaction surveys were administered at the time of surgery and at 3 months postsurgery. Sociodemographic characteristics, medical history, and surgical parameters were collected by chart review. Univariate linear and logistic regression models were created to examine these relationships.

RESULTS

Decreased satisfaction was observed in patients requiring 3 or more MMS stages both at the time of surgery (P = .047) and at 3 months post-surgery (P = .0244). Patients with morning procedures ending after 1:00 pm had decreased satisfaction at the time of surgery (P = .019). A decrease in patient satisfaction between the time of surgery and 3 months postsurgery was observed in patients with surgical sites on the extremities (P = .036), larger preoperative lesion sizes (P = .012), and larger defect sizes (P = .033).

LIMITATIONS

Single-institution data, self-selection bias, and recall bias.

CONCLUSION

Patient satisfaction with MMS is impacted by numerous factors and remains dynamic over time.

Bactericidal and Cytotoxic Effects of Chloramine-T on Wound Pathogens and Human Fibroblasts In Vitro

OBJECTIVES

To evaluate cytotoxicity and bactericidal effects of chloramine-T.

METHODS

In vitro study of various concentrations and exposure times to preparations containing human fibroblasts or 1.5 x 10 colony forming units per milliliter (CFU/mL) of 3 gram-positive bacteria-Staphylococcus aureus, methicillin-resistant S aureus, and vancomycin-resistant Enterococcus faecalis-and 2 gram-negative bacteria-Escherichia coli and Pseudomonas aeruginosa-with and without fetal bovine serum present.

MAIN OUTCOME MEASURES

Percentage reduction of bacterial growth and percentage of viable fibroblasts 48 hours after exposure.

RESULTS

All gram-positive growth was reduced by 95% to 100%, regardless of dose, with or without serum. E coli (gram-negative; with/without serum) was reduced 94% to 100% at antiseptic concentrations of 300 and 400 ppm. At 200 ppm, E coli growth was fully inhibited without serum present and by 50% with serum. P aeruginosa (gram-negative) was not significantly affected under any conditions. At 100 and 200 ppm, cell viability remained greater than 90% under all experimental conditions. A 300-ppm, 3-minute exposure to chloramine-T resulted in cell viability of up to 70%, with longer exposures producing lower viabilities. Serum did not affect cell viability in any condition.

CONCLUSIONS

In vitro, chloramine-T at 200 ppm for 5 to 20 minutes was effective against 3 virulent gram-positive bacteria without fibroblast damage. At 300 ppm and 3 and 5 minutes, 30% of fibroblasts were damaged and 95% to 100 % of E coli were inhibited, respectively.

Can povidone-iodine solution be used safely in a spinal surgery?

Intra-operative incidental contamination of surgical wounds is not rare. Povidone-iodine solution can be used to disinfect surgical wounds. Although povidone-iodine is a good broad-spectrum disinfecting agent, it has occasionally been reported to have a negative effect on wound healing and bone union. Therefore, its safety in a spinal surgery is unclear. A prospective, single-blinded, randomized study was accordingly conducted to evaluate the safety of povidone-iodine solution in spinal surgeries. Ascertained herein was the effect of wound irrigation with diluted povidone-iodine solution on wound healing, infection rate, fusion status and clinical outcome of spinal surgeries.

MATERIALS AND METHODS

From January 2002 to August 2003, 244 consecutive cases undergoing primary instrumented lumbosacral posterolateral fusion due to degenerative spinal disorder with segmental instability had been collected and randomly divided into two groups: the study group (120 cases, 212 fusion levels) and the control group (124 cases, 223 fusion levels). Excluded were those patients with a prior spinal surgery, spinal trauma, malignant tumor, infectious spondylitis, rheumatoid arthritis, ankylosing spondylitis, metabolic bone disease, skeletal immaturity or with an immunosuppressive treatment. In the former group, wounds were irrigated with 0.35% povidone-iodine solution followed by normal saline solution just before the bone-grafting and instrumentation procedure. However, only with normal saline solution in the latter. All the operations were done by the same surgeon with a standard technique. All the patients were treated in the same postoperative fashion as well. Later on, wound healing, infection rate, spinal bone fusion and clinical outcome were evaluated in both groups.

RESULTS

A significant improvement of back and leg pain scores, modified Japanese Orthopedic Association function scores (JOA) and ambulatory capacity have been observed in both groups. One hundred and seven patients in the study group and one hundred and nine in the control group achieved solid union. There was no infection in the study group but six deep infections in the control group. Wound dehiscence was noted in one group 1 and two group 2 patients. A subsequent statistical analysis revealed higher infection rate in the control group (P<0.05), but no significant difference in fusion rate, wound healing, improvement of pain score, function score and ambulatory capacity between the two groups.

CONCLUSION

Diluted povidone-iodine solution can be used safely in spinal surgeries, and it will not influence wound healing, bone union and clinical outcome.

THE PIG AS A MODEL FOR HUMAN WOUND HEALING

The medical literature describes numerous in vitro and in vivo wound-healing models. The selection of an animal model depends on a number of factors including availability, cost, ease of handling, investigator familiarity, and anatomical/functional similarity to humans. Small mammals are frequently used for wound healing studies, however, these mammals differ from humans in a number of anatomical and physiological ways. Anatomically and physiologically, pig skin is more similar to human skin. The many similarities between man and pig would lead one to believe that the pig should make an excellent animal model for human wound healing. The purpose of this paper is to review the existing literature for evidence of this supposition and determine how well the various models correlate to human wound healing. Studies of wound dressings, topical antimicrobials, and growth factors are examined. Over 180 articles were utilized for this comparative review. Our conclusion is that the porcine model is an excellent tool for the evaluation of therapeutic agents destined for use in human wounds.

Second intention healing after Mohs micrographic surgery

BACKGROUND

Although second intention healing has been used for many years in Mohs micrographic surgery, it has lost popularity. This is due to the long process and functional alteration of important anatomical units if certain wound healing factors are not carefully taken into consideration.

OBJECTIVE

To review indications, contraindications, complications, advantages, disadvantages, as well as basic concepts of the wound healing process, wound care and antibiotic prophylaxis in the management of open wounds after Mohs surgery.

METHODS

A short but comprehensive review of studies published in the literature dealing with second intention healing as a reconstruction alternative option in certain situations.

CONCLUSIONS

Second intention healing is a simple and cost-effective method for reconstruction after Mohs micrographic surgery in well-defined cases. It allows adequate tumoral control with good to excellent functional and cosmetic results.

Chronic wounds

Skin ulcers are the most common chronic wounds. Current management principles and theories of causation of the most common ulcers--pressure, diabetic, and venous--are described. Issues related to occlusive dressings, compression dressings, topical antimicrobials, debridement, growth factors, grafting, and bioengineered tissue therapy are discussed. Special emphasis is placed on regulatory concerns.

Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: review of ninety-one cases

BACKGROUND

Second-intention healing over exposed bone is considered by some to be subject to the complications of pain, infection, and nonhealing.

OBJECTIVE

Our purpose was to determine would healing by second intention over exposed scalp or facial bone after Mohs micrographic surgery for skin cancer.

METHODS

The chart records of all patients treated between 1981 and 1992 for skin cancer that resulted in exposed bone were identified.

RESULTS

There were 115 wounds in 91 patients that were managed by second-intention healing, or partial closure, or both. Three cases of soft tissue infection occurred adjacent to nasal and sinus areas. The overall complication rate was 5.4% (6 of 112 cases) and consisted of localized soft tissue infections (2.7%) and poor wound healing (2.7%). There were no cases of osteomyelitis. Second-intention wound healing was successful in 95% of the wounds.

CONCLUSION

The outpatient management of exposed bone after Mohs surgery is relatively safe. Relative risk factors for development of complications include (1) a history of previous x-radiation treatment for skin cancer, (2) manipulation of the operative site, and (3) an open defect located near the nose or exposed sinus cavity.

Prediction of wound tensile strength: an experimental study

Wound cell specimens were obtained using a Cellstic device after 24, 48 and 72 h healing time in guinea-pig skin wounds. Cell counts from these were compared with the tensile strength values of the same wounds 7, 14 or 21 days after operation. No single cell type was predictive of wound tensile strength, although absolute numbers of different cells and selected ratios of cell types on the second or third day after operation were more predictive. Absolute and proportional changes from day 1 to day 2 had the greatest predictive power with a mean error of 9.46 per cent (F = 13.6, P less than 0.0001). The same regression model was predictive in animals with lower wound tensile strengths given perioperative hydrocortisone (3 mg/100 g).

Comparison of cosmesis following healing by surgical closure and second intention

When deciding on whether to surgically close a wound or allow granulation and epithelialization to occur, it is necessary to evaluate each patient individually. The patient's needs and desires, along with cost effectiveness, immediate versus delayed gratification, and convalescent time must all be considered. Also, the skill of the surgeon and the resources available to both the surgeon and the patient must be taken into consideration.