Hi, my name is Todd R. Wilcox, MD and I want to introduce myself as the incoming editor of jailmedicine.com.  I have followed Dr. Keller’s work and this website since it was first published and I’ve been a big fan of the level of practicality and informative insights he has brought to the practice of medicine in correctional facilities.  I hope to be able to continue that trend and to broaden the input with some additional specialists who see incarcerated patients and manage their unique healthcare needs.  I have worked in correctional healthcare as a physician for 26 years and I am the medical director of the Salt Lake County Jail System in Salt Lake City, UT.  I completed my undergraduate work at Duke University and then attended medical school at Vanderbilt University School of Medicine.  I also have a Masters of Business Administration from the University of Utah. I am board certified in Urgent Care Medicine and my clinical interests include wound care, pain management, orthopedic injuries, and HIV medicine.  I am a frequent lecturer at NCCHC, ACA, AJA, and the National Sheriff’s Association and I look forward to engaging with colleagues who are similarly interested in the challenges of delivering healthcare to our incarcerated patients.  

Skin Abscess Treatment with the Seton Technique

In correctional health settings, we encounter a lot of skin abscesses on various parts of the body. The traditional technique of doing an incision and drainage (I&D) of an abscess has many limitations which has prompted the development of a new technique called a seton placement. This technique originally started with the colorectal surgeons who were treating pilonidal cysts and peri-rectal abscesses and it has been adopted for skin abscesses by the emergency medicine physicians.

A traditional I&D is generally accomplished using lidocaine infiltrated into the skin and into the abscess cavity and then a number 11 or 15 blade is used to open up the entire abscess and squeeze all of the pus out which then creates a cavity that needs to be packed. While this technique is effective and is the traditional treatment for skin abscesses, there are many limitations for using this technique in a correctional setting.

• it is difficult to anesthetize an abscess due to the acidic nature of the pus that deactivates the local anesthetic
• I&D technique is generally very painful for the patient
• I&D tends to be very messy with a lot of pus and blood produced that is often under pressure and squirts all over
• the wound backings that are necessary to get this wound to heal by secondary intention are painful for the patient
• the wound packings take a lot of time for the nursing staff
• the cosmetic result is unfavorable
• the total treatment time to get a wound to heal by secondary intention is often two weeks or more

The new technique of seton placement was designed to address many of these shortcomings. The technique is described below:

Necessary equipment

• Local anesthetic.  I generally use 1% lidocaine with epinephrine.
• 5cc syringe with 18 g and 25-27 g needles
• Chux pad
• 4×4’s
• #11 scalpel
• Silicone vessel loops (we stock 2 sizes)
• Noyes alligator forceps
• Island gauze dressing

The Technique

1. This technique does not require sterile technique or prepration.  It is a clean technique, not a sterile one. 
2. The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
3. You can use a pen to draw on X at your marked spot.
4. In identifying the two spots for the incisions it is important to locate one of them at the most dependent area of the abscess so that drainage of the entire abscess will occur.
5. A wheal of local anesthetic is raised at those two spots
6. A number 11 blade is then used with the cutting edge facing away from the body to make two small stab incisions at the identified spots and they need to extend into the abscess cavity completely.  This should result in a return of pus and blood as the scalpel is taken out.  It is much easier to shield and divert the pus in this technique compared to a traditional I&D
7. Once the two incisions are made, a Noyes passer is used to connect the two incisions and the passer goes in one incision, through the middle of the abscess cavity, and then out the other incision.  A Noyes passer is much easier to use and to pass than a hemostat, but you can use a hemostat if needed.  Your incision holes will need to be bigger to accommodate the width of the hemostat. 
8. The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
9. The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
10. The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
11. An island dressing is applied over the top of this and the patient is free to go.
12. The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
13. The patient is instructed to grasp the knot and move the silastic loop back and forth once a day to break up any crusting or adhesions to keep the holes open.
14. The general order for removal is done on day five and a nurse goes and clips the silastic loop with a scissor and removes it just like a suture.
15. By day five the abscess is generally completely resolved and the overlying skin has adhered back down to the deeper tissue and the treatment for the abscess is resolved at that time.

This technique affords many advantages over the traditional technique:

• Because you are anesthetizing the very edge of the abscess you are actually anesthetizing normal skin which is much easier to achieve good anesthesia with a local anesthetic than attempting to anesthetize the top of an abscess.
• Properly done, this technique is almost painless for the patient.
• From a provider standpoint, this technique is far faster than doing a traditional I&D. In my experience I can do a seton loop placement in about one third the time it would take me to do a traditional I&D.
• With this technique, the initial rush of pus and blood can be controlled and it is much less messy for everyone and the risk of an exposure is much less. 
• Because the skin over the top of the abscess cavity remains intact and vascularized, there is no need for this wound to heal by secondary intent. This results in a much faster healing of the abscess.
• The post technique nursing care is virtually nothing. All you have to do is provide a Band-Aid or an island dressing to put over the top of the seton for five days and the patient can apply that themselves after they shower. Your nurses will thank you profusely for not making them pack a big abscess cavity.
• Because the skin overlying the abscess is not cut, the cosmetic result from this technique is substantially superior to a traditional I&D.

The preceding description is a basic description of how this technique is done. Once you gain experience there are some advanced hints and tricks that are possible to use with this technique.

1. I generally do not use a pen to place an X on the skin except in unusual circumstances where the placement of the anesthesia will obscure the edge border. This typically happens on the thicker skin of the face. Generally my technique uses lidocaine with epinephrine and I utilize the placement of the lidocaine with epinephrine to make my mark for me because the vasoconstrictive effects of the epinephrine will make it very obvious where to make your incision.
2. Most abscesses require the placement of one seton through the abscess. There are occasionally abscesses that have loculations or are large enough that additional setons need to be placed.
3. I have use this technique with very large abscesses in breast tissue a well as over the deltoid and in those the vessel loops are not large enough to accomplish the drainage. In larger areas I have used sterile tourniquets to place through the abscess cavity as my seton and that has worked beautifully.
4. For simple abscesses, I have not found antibiotics to be necessary above and beyond the drainage technique for complete resolution of the abscess.  Clearly this is a matter of professional judgment as well as anatomy, and there are certain abscess presentations where supplemental antibiotics would be advisable.  There is some evidence in the emergency medicine literature supporting adjunctive use of anbiotics for some clinical presentations.   

The American College of correctional physicians has a video of this technique on their website.

What technique do you use to I&D abscesses? Please comment!