What is the best course of action for a patient with wound dehiscence (wound separation) after lipoma excision, presenting with excess skin and a flapped wound?

Management of Wound Dehiscence After Lipoma Excision

Immediately irrigate the wound with copious sterile saline or clean tap water, reapproximate the skin edges without suturing, apply a non-adherent dressing, and closely monitor for infection over the next 24-48 hours. 1, 2

Immediate Wound Management

Do not resuture the wound at this time. 1 The 2005 Clinical Infectious Diseases guidelines explicitly state that infected wounds should not be closed, and even clean wounds presenting with dehiscence after suture removal should be managed conservatively initially. 1

Initial Wound Care Steps:

• Cleanse the wound thoroughly with sterile normal saline or clean tap water (no need for iodine or antibiotic solutions) to remove any debris or contamination. 1, 2

• Gently reposition the excess skin flap to cover the wound bed, allowing it to act as a natural biological dressing—this is the same principle used in skin tear management. 2

• Remove only superficial debris; deeper debridement is unnecessary and may impair healing by enlarging the wound. 1, 2

• Apply a greasy emollient over the wound area to maintain moisture and prevent dressing adherence. 2

• Cover with a non-adherent primary dressing followed by an absorbent secondary foam dressing to collect any drainage. 2

Critical Assessment for Infection

The timing of this dehiscence (10 days post-procedure) places it outside the typical window for serious early infections, but vigilance is still required. 3

Signs That Would Require Antibiotics:

• Fever above 38.5°C (101.3°F) or heart rate above 110 bpm 3
• Expanding erythema greater than 5 cm around the wound 3
• Purulent discharge with foul odor (not just clear/yellowish serous fluid, which is normal) 3
• Severe pain disproportionate to the wound appearance 1

Do not start empiric antibiotics without these clear signs of infection. 3 Serous drainage and minimal clear fluid are expected and normal in wound healing. 3

Wound Closure Strategy

Plan for delayed primary closure or healing by secondary intention rather than immediate resuturing. 1 The 2005 IDSA guidelines recommend approximation of wound margins with Steri-Strips and subsequent closure by either delayed primary or secondary intent for wounds presenting after initial closure failure. 1

Specific Approach:

• Use Steri-Strips to approximate the skin edges without tension, allowing the excess skin to naturally conform. 1

• Reassess in 24-48 hours for signs of infection or healing progress. 3

• If the wound remains clean and shows early granulation (typically 3-5 days), consider delayed primary closure with sutures. 1

• If any signs of infection develop, leave the wound open and manage with dressing changes every 5-7 days until healed by secondary intention. 2

Follow-Up Protocol

• Examine the patient within 24 hours either by phone or office visit to assess for infection signs. 1

• Change dressings every 5-7 days if no complications arise, or more frequently if significant drainage occurs. 2

• Monitor for wound dehiscence complications including seroma formation (occurs in 18.3% of soft tissue excisions) or surgical site infection (18.3% incidence). 4

Common Pitfalls to Avoid

• Do not assume all drainage represents infection—clear to yellowish serous fluid without foul odor is normal and expected. 3

• Do not attempt immediate resuturing of a wound that has already failed once, as this increases infection risk and further tissue trauma. 1

• Do not use aggressive cleansing that could further damage the fragile healing tissue. 2

• Avoid topical antiseptics or antimicrobial dressings for routine wound healing unless clear infection is present. 2