Evidence-based aftercare for a skin surgery wound: petrolatum, bandages, bleeding, infection signs, activity limits, and how scars change over 12 months.
The instructions you receive after skin surgery are short. Your own surgeon's instructions come first, since they know the details of your operation. The reasoning behind the usual advice is laid out below.
Most people go home with a pressure bandage: a thick pad taped down firmly. Its purpose is to prevent bleeding under the skin. Leave it dry and in place for the time your surgeon specifies, commonly 24 to 48 hours.
Swelling and bruising are normal and peak around day 3 or 4. Surgery on the forehead or nose can produce puffy or black eyelids a few days later. An ice pack over the bandage for 20 minutes each hour while awake helps during the first 2 days. Acetaminophen controls pain for most people. Ask your surgeon before taking aspirin or ibuprofen for pain, since they can increase bleeding.
Once the first bandage comes off, the routine is simple and takes 5 minutes a day:
Skip hydrogen peroxide and rubbing alcohol after the first cleaning. They damage the new cells trying to cross the wound.
The old advice to let a wound dry out and form a scab was wrong. The American Academy of Dermatology states that petroleum jelly keeps the wound from drying out and forming a scab, and that wounds with scabs take longer to heal.
A randomized, double-blind trial settled this question decades ago (Smack and colleagues, JAMA, 1996). Researchers at Walter Reed Army Medical Center assigned 922 dermatologic surgery patients, with 1,249 wounds among them, to either white petrolatum or bacitracin ointment.
Infection was rare in both groups: 2.0% with petrolatum and 0.9% with bacitracin, a difference that was not statistically significant. Healing was the same on days 1, 7, and 28. No one using petrolatum developed an allergic skin reaction, while 4 bacitracin users did.
Contact dermatitis from bacitracin or neomycin produces a red, itchy, weeping rash around the wound that looks like an infection and often leads to needless antibiotics. Petrolatum costs less, works as well, and avoids the problem.
A little blood or pink fluid on the bandage during the first day is expected. For active bleeding, sit down, place clean dry gauze or a cloth over the wound, and press firmly for 20 minutes without lifting to check. Use a clock, since most people let go too soon.
If bleeding continues after 20 minutes, repeat once and call your surgeon's office or on-call line. A wound that swells rapidly into a tense, painful, purple lump may hold a pocket of blood called a hematoma, and it needs attention the same day.
A thin rim of pinkness along the stitch line is normal healing. Infection after skin surgery is uncommon, about 1 to 2 patients in 100 in the Walter Reed trial. When it happens it tends to appear between day 4 and day 8. Call if you notice:
Surface stitches usually come out in 5 to 10 days on the face and neck and in about 2 weeks on the trunk, arms, and legs. Dissolving stitches under the skin carry the load for weeks longer.
Limit vigorous activity, bending over, and heavy lifting for at least 7 days, and avoid stretching across the wound for longer than that. A healing wound is weak. At 2 weeks it has only a small fraction of normal skin strength, and even a mature scar reaches only about 80% of the strength of uninjured skin. Wounds on the back, shoulders, and over joints are the ones that spread into wide scars when stressed early.
Scars get worse before they get better. During the first 1 to 2 months the body lays down collagen quickly, and the scar becomes red, firm, raised, and sometimes lumpy. Remodeling then takes over and continues for up to 12 months. The scar flattens, softens, and fades from red to pink to pale. Judge the result at a year.
Sun darkens new scars and keeps them red longer. The American Academy of Dermatology recommends a broad-spectrum sunscreen of SPF 30 or higher on the healed wound, reapplied often, and clothing or a hat works even better.
Silicone gel or silicone sheets are the best-studied scar product sold without a prescription. They work by sealing in moisture, which calms the signals that drive excess collagen. Start once the wound has fully closed, and use them at least 12 hours a day for about 2 months. A Cochrane review judged many of the trials to be weak, so expect a modest benefit.
Ask about scar revision if, after several months, the scar is thick and itchy, pulls on an eyelid or lip, puckers, or still bothers you. Surgeons can inject steroid into raised scars, smooth uneven ones with dermabrasion or laser, and re-cut a scar that lies poorly. Surgical revision usually waits 6 to 12 months, since many scars improve enough by then that nothing more is needed.
