Skin Removal Aftercare Instructions

While healing, it's very important you eat enough (even if you don't want to), stay hydrated, and rest. Try and eat more protein than normal, and if possible, eggs, fish, and poultry. 30% of vegans are zinc deficient and this impairs healing; if you're vegan and haven't had your zinc levels tested, consider taking oral zinc supplementation.

Note: If you're seeing this page and I, the author, did not direct you here, then please heed this important context! This is our provisional aftercare procedure, and it (or some version of it) has worked fine a few times, but there is a TON we don't know! We have so many open questions right now. Don't take it as gospel, and DO experiment and write back to us (if you include A/B test pictures I will be so grateful 🥺).

You Should be Given

If you end up needing more bandages, please ask!

You Need to Have

Tell me if you don’t have these! I will provide them.

First 48 Hours

Leave your bandage on.

Around 48 Hours

  1. Wash hands thoroughly. Don clean gloves.
  2. Put down puppy pad under wound area to catch fluids.
  3. Remove bandage. If it sticks, use saline to loosen it.
  4. Assess wound for:
    1. Healing: pink tissue
    2. Signs of infection: redness, warmth to touch, fever, draining pus. If you think it might be infected, you will likely need a full course of systemic antibiotics. You need to go to urgent care. If drainage is lime green or yellow/green, this may be a sign of pseudomonas and you should get it checked out immediately.
  5. Soak a piece of gauze with saline, and gently dab or wipe the skin around the wound with it. Try to remove all drainage and any dried blood or other matter that may have built up on the skin.
  6. Use the saline spray to irrigate the wound. Spray from 1-6 inches away, and spray hard enough to wash away drainage and discharge. Use a clean piece of gauze to pat the wound dry.
  7. Apply a thin layer of hydrogel directly into the wound.
  8. If there is little to no exudate that the old bandage soaked up, cover with tegaderm. Otherwise, continue:
  9. Apply xeroform dressing.
  10. Add ABD pad. Tape it directly to the skin.
  11. If you can wrap the area in a self-adhesive bandage, do that to help hold the dressing/pad in place. Wrap it tight enough that the pad won't shift too much.

As needed (about once daily, for the first few days), change bandage following above instructions. Your main goal is to remove any dead tissue, while not significantly irritating the wound.

Around 72 Hours

Continue changing bandage as needed, using same technique, but use antibiotic ointment instead of hydrogel.

Around 2-4 Weeks

Scar tissue should have formed, it'll look a lot less like an open wound. Cease using antibiotic ointment, cease covering. Moisturize regularly, especially if it gets itchy.

Reasoning

If you're just here to read what to do, you can skip this part! Our goals for the healing process are to prevent infection, keep defined edges for the wound, and make the scar consistent and visible. We're generally not going for keloid scarring, as it's a bit harder to control, but I know people who have intentionally induced that to great success! Read this section critically!! It is here so that it can be argued with.

WHY HYDROGEL? We're using hydrogel for the inflammatory phase because it facilitates autolytic debridement, and we're using the kind with silver nanoparticles for their antimicrobial properties. We stop using this after the inflammatory phase, because silver nanoparticles are slightly cytotoxic to fibroblasts, and we want those operating at full capacity. We could do wet-to-dry dressings with manual debridement for the additional stress it puts on the wound, but I worry about the agitation being uneven and potentially blowing out the lines.

WHY COVERED? Keeping it covered while healing makes sense so that foreign particles don't lead to an infection.

WHY 48 HOURS? The Mont Reid Surgical Handbook (7ed, p.130) suggests protecting incisions for 48 hours, and using sterile technique if dressing must be changed before this time. We don't want to make subjects set up a sterile field. We guess this recommendation is because the most critical phase for preventing infection is during the early inflammatory phase, which lasts about 48 hours. A review of the cited sources for the handbook (HICPAC guidelines) may clarify this.

WHY CLEANING? Our goal in cleaning the wound is to remove necrotic tissue that could be a food source for infectious bacteria. We shouldn't be cleaning more than necessary to achieve that goal.

WHY ABD/TEGADERM? We use ABD pads because they soak up the exudate well, and should have less of an issue drying on the wound than gauze does. When we used just gauze, it was painful to remove and re-irritated the wound in ways we didn't want. The xeroform keeps it moist. We use tegaderm because it's fun to look at your scar as it's healing. (Also, I think having an occlusive dressing keeps the wound moist, which we want?)

WHY BACITRACIN? This is a clean (ideally; maybe leaning clean-contaminated) wound healing by secondary intention. I haven't found a lot of research about whether or not topical antibiotics are indicated for this case. AFAICT, the main risk of overusing topical antibiotics is poor antibiotic stewardship. Given this and the small scale we're working on, I'm leaning towards antibiotic use being okay. We're mainly using antibiotic ointment as an adjunct to the xeroform, to keep the wound moist. (Is it necessary if the xeroform has its own antibiotic properties?) I don't know if it's still needed. The current aftercare procedure relies more on defined events to create the scar tissue, rather than continual stress. We use solely bacitracin rather than a triple antibiotic, because some folks are allergic to neomycin or polymyxin.

WHY NOT CHG? We made the switch to CHG for wound cleansing after personal communication with someone who used to treat burn wounds professionally. Research about whether or not to use antiseptics for wound cleansing in general, and CHG specifically (and at what concentrations) is sparse. Some research says to use 0.05%, but this is not what was recommended to me. It's painful at the higher concentration. It seems to slow wound healing (but that's maybe okay in our case?), and it might be cytotoxic and not actually very antimicrobial in skin. The research is thin, and it feels like there's not necessarily a clear winning move, but it more and more seems to point towards CHG being nonoptimal. Given that, we've switched away from recommending CHG, and are following the Mount Sinai guide for open wound care, which suggests saline only.

There has been a lot of debate around concentration and whether CHG is necessary. I preferred it in the clinical space, and while it does appear to be somewhat painful, it was reportedly tolerable to most patients. The patients who reported higher pain levels from the CHG were larger surface area burns and had multiple people cleaning their burns at once.
I'm sure the research is accurate, in that 0.05% appears to be as effective - 4% is what I used there, and at home for my own wounds. 4% is also what we used to scrub in to procedures, so it is meant to be aggressive in ridding any residual bacteria/pathogen.
My general recommendation for CHG comes from not knowing what kind of home situation someone is doing wound dressings in. It's a wide cast net for circumstances where someone may have a pet, and may accidentally tap their phone with the same hand/finger they had to use to push their pet away during a wound dressiing change, even when gloved.
Personal communication from someone with professional experience treating burns

WHY NOT XYZ CREAM? We could add a numbing agent to the bandaging procedures. TBD. We could use silver sulfadiazine, but I forget what it does to scar formation. Need to research. We could clean with PVP-I, but AB soap should be less harsh.

WHY NO SCAB PEEL? We originally did a scab peel because this is what Enne started out doing, and it worked for it. We otherwise have no special attachment to this method of irritation, or speculation into why it works. Our bandaging procedure evolved until it was good enough to prevent scab formation. It seems to have good results. We're planning irritation trials to determine what methods may be appropriate to do instead. (Or maybe we go back to scab peels!)

WHY ZINC? There is not strong evidence to support oral zinc supplementation for wound healing in non-zinc-deficient individuals. However, it does seem to help in people who are deficient. ~30% of vegans are, so we suggest supplementing in this case. We haven't explored topical zinc application, yet.

WHY PROTEIN? Your body needs proteins for the healing process. Albumin, specifically, is one that we want more of. This information came from someone with professional experience in wound treatment.

Areas for Future Research

Stretching - good or bad? When to start?

CHG isn't optimal, so we've moved away from it. How's the stuff that's in the xeroform dressing? AB ointment?

Let's simplify the hydrogel stuff. We're giving out a tube that should only be used one time - weak. Can we get hydrogel with non-silver antibiotic effect? Is the hydrogel necessary at all? Or maybe we use one with no AB activity? Maybe we should do hydrocolloid bandages instead?

Possible Interventions 
chemical irritation
    hperox
    salicilic acid
    capsaicin
medihoney
topical corticosteroids
silicone sheets/gels in pattern (e.g. strips)
retinoids
topical zinc oxide
silver nanoparticle hydrogel
petroleum jelly/AB ointment
scraping during process
    maybe also deepening during healing?
tattoo over healing scars
    ink rubbing
    stick-n-poke
    layering diff inks?
mechanical irritation
    sterilized sand
    AB+granulated sugar
    peeling scabs
        frequency and time
    needling (texture)
Questions I Have