Two Innovative Approaches for Wound Care/Closure
In previous blogs, I have advocated the use of Montgomery straps to relieve tension on wounds. Montgomery straps are readily available online and can be purchased through Amazon or individual medical supply companies (Google search Montgomery straps). Each strap is approximately 11 in long with a 6-in wide adhesive strip. The silk tape adhesive is porous, “kind” to the skin, and can be worn in the shower (afterward, it dries quickly). Each piece has a clear plastic strip ~2.5 in wide that runs the full strap length with holes that resemble the holes on loose-leaf paper (see Figure 1). To apply Montgomery straps, you place one strap on each side of the wound with the clear plastic edges facing each other; these edges must be ~1.5 in apart in order to lace and tighten them. The straps should not be laced too tightly, because this can cause the skin under the adhesive to blister, preempting reuse of the straps over the same spot. When you tighten the laces, watch for slight skin wrinkling at the inside-top of the strap, even only on one side (usually the bottom strap). When you see these small wrinkles, stop tightening; you are only trying to provide slack (reduce the pull of gravity on the wound), not approximate the edges of the wound — the clinician must make a sensitive clinical judgment regarding the tension on the adhesive straps. In the past, I have tried to teach the patient to loosen the straps, apply gentian violet, and change the gauze dressing, but the tension on the straps was always either too tight (causing itching and blistering that meant discontinuing use of the Montgomery straps) or too loose and not effective. As such, the clinician is the best person to implement use of Montgomery straps.
Case 1. Recently, one of the surgeons at our local hospital sent me a post-herniorrhaphy patient whose surgical wound never completely healed. Although the patient was not generally overweight in appearance, he had a protuberant abdomen. His 4 cm x 5 cm wound was granular and situated slightly to the right of midline and lower than his umbilicus. The problem was easily identified: the weight of the lower half of his abdomen was pulling down on the wound’s lower edge. I knew I needed to give the upper and lower wound edges some slack. I cut one piece of the Montgomery strap in half and put half above the wound and half below, placed approximately 1.5 in apart. I used gift wrap ribbon to lace up the holes on each side and pull the edges toward each other (the thin gift ribbon is strong and disposable if it gets soiled).
The direct wound care treatment application in this case was gentian violet 1% solution; this product will last through several showers. With a thin, 100% cotton gauze cover dressing, the whole apparatus (wound dressing and straps) could stay on for a week until the next office visit (note: the antimicrobial effects of gentian violet continue for as long as the blue-violet color is present).
For this patient, removing the downward pull on the wound reduced wound size to 1.5 cm x 2 cm after 1 week. By week 3 of treatment, the wound was completely healed.
Case 2. I received a call from a previous patient who he had been in the hospital for a serious respiratory ailment. The treatment in the hospital involved using a bilevel positive airway pressure (BiPAP) respirator mask that had caused a pressure ulcer on the bridge of his nose. When I assessed the wound, I noted the nasal bone was protruding from this wound and the right and left sides of the wound had retracted away from the bone, down the sides of the nose. The wound measured 2 cm long (almost all bone) x 1.5 cm wide. The skin edges were healthy and granulating, but there was no evidence of any wound closure.
Our first challenge was to relieve the pressure caused by the face mask the patient needed to sleep at night. The family, patient, and I all worked together and by strategic use of extra BiPAP straps that would go over the top of the head (lifting the weight of the mask off the nose) and adhesive cast padding under the forehead piece of the mask that pushed the top of the mask slightly forward, the pressure was ameliorated.
This wound also needed some slack. The forces pulling the edges apart may be missed by some wound clinicians. In this case, gravity was pulling down on the facial soft tissues (the same gravity that causes facial drooping with age and why we call the plastic surgery a “face lift”). My plan was to use the same principles involved in using Montgomery straps but with a smaller set of “straps” that would be just as effective in pulling the edges together and enable maintenance of a good seal with the BiPAP face mask. We decided to use flexible 1-in cloth Band-Aid brand bandages (Johnson & Johnson, New Brunswick, NJ). These have an excellent grip on the skin despite getting damp (in this case, from the humidifier at night).
I used a skin prep barrier wipe on the skin where the bandage would be placed (give it a minute to dry). To prepare the bandage, I cut it in half lengthwise (the width was too wide to use) to create two 0.5-in wide “straps.” To avoid use of bulky dressings that might interfere with the breathing mask, I used gentian violet 1% solution on the wound; to provide moisture absorption in addition to the small dressing patch on the bandage, I used Adapt Stoma Powder (Hollister Inc, Libertyville, IL) over the gentian violet. I placed the cut portions of the bandage on each side of the nose, mimicking a “steri-strip” technique taught to me by a great wound care physician, Dr. Sofwat Mosad. I crisscrossed the bandages (see Figure 2), gently lifting the skin on both sides of the nose. Together, the bandage and powder provided sufficient drainage protection, and the porous cloth material of the bandage allowed moisture to evaporate. Healing occurred within 3 weeks.
Tension was relieved… and so were the patients!