Convex ostomy skin barriers (also known as wafers, baseplates or flanges) are so-called because of the way the flange adheres to the peristomal skin area. n this system, the flange protrudes towards the skin, giving it a ‘convex’ appearance. These products are not meant for every patient but for those with certain stoma types. They are used under a doctor or a stoma nurse’s direction. Routine use without prescription can lead to long-term stoma or peristomal area complications.
“One of the guiding principles of ostomy care is to establish and maintain a secure and predictable seal. Products that incorporate convexity are often considered an important tool for achieving this goal. Convexity is defined as A curvature on the skin side of the barrier or accessory. Convex products are frequently cited as the preferred means to manage flat or retracted stomas and to compensate for irregular peristomal planes such as creases or folds. Although a variety of convex products are available with different depths and shapes, there is little supporting evidence to guide their selection and use.
The origins of convex product development are not known. Limitations in early ostomy product availability and the need to cope with poorly constructed stomas or irregular body contours were historically addressed by creative use of pastes, belts, rings, and medical adhesives. During the 1980s and early 1990s, multiple ostomy product manufacturers designed and released firm convex skin barriers designed for both 1- and 2-piece pouching systems. More recently, manufacturers have introduced additional accessories with convex features such as barrier rings and soft convex skin barriers.
Although the terms ‘convex’ and ‘convexity’ are consistently used to describe the curvature on the adhesive side of the skin barrier or accessory, other descriptors remain undefined. There are no industry standards for the depth, profile, tension, firmness, softness, and flexibility of products with a convex feature.”1
Patients should consult their ostomy nurse if they can benefit from using convex ostomy products, and have a physical stoma and abdominal examination. The nurse will check the physical appearance of the stoma, including scars, peristomal skin problems, and the influence of abdominal folds and contours, if any. After examination, the health professional will be able to advise the patient accordingly.
How Convex Ostomy Skin Barriers work
The protruding peristomal convex curvature forces the stoma out. The curvature also creates a secure adhesive that conforms to the peristomal skin. This mechanism offers superior results to manage complicated stoma, in comparison to the standard flat barriers.
Convex Ostomy wafers can be part of:
- One-piece ostomy systems: the ostomy pouch and the flange cannot split.
- Two-piece ostomy systems: the flange and the pouch are separable. You can change the pouches without removing the skin barrier.
Classification of convex barriers according to type
A combination of different types of convex flanges and ostomy systemd are available to the health care giver and the patient.
- Fixed convex flange. Flanges are molded and strengthened. Their design is ideal for various stoma issues. They can bedeep or moderate convexity depending on the degree of the protrusion.
- Non-fixed convex flanges. Made with plastic rings, these arefixed to standard flat flanges. The attachment creates a convex appearance, which is usually not as deep as in fixed convex flanges. However, non-fixed convex flanges are soft and more malleable, easily adapting to the body’s contours.
Indications for ostomy convex products
Convex products are useful in cases where a flat flange would not prevent stomal discharge and leakage. Six common situations include:
- Flat or introverted stomas
- Post loop-ostomy surgery. This type of stoma is almost always retracted
- Wrinkled peristomal skin
- Irregular surgical scars
- A Telescoping stoma. These stomas protrude when the patient is upright but retract when reclining.
- Flabby uneven abdomen
Importance of the use of ostomy convex products
“Ostomy surgery results in a dramatic alteration in elimination processes and body image – changes that impact both the patient and family. Peristomal skin complications further magnify this alteration, negatively affecting patient adjustment. For the healthcare system, peristomal skin complications usually mean resource utilization – increased patient care needs and the struggle to attain an optimal functional status or comfortable state of well-being are expensive. When addressing prevention and treatment, an outcomes measurement plan that tracks and documents 1) clinical effectiveness of the intervention; 2) impact on functional status and well-being, 3) satisfaction with care provided, and 4) cost should be considered. Measuring outcomes documents intervention effectiveness and demonstrates the value of services.
As in most situations, treatment is more expensive than prevention. Additional patient visits, equipment expenses, embarrassment about leakage and odor problems, plus lost work days and altered social activities, are costs that could be avoided or significantly decreased with routine surveillance.
The skin plays an important role in ostomy care, providing the surface on which the pouching system is adhered. Intact, dry epidermis and a well-fitted pouching system enable a sustained, predictable wear time. When skin integrity is compromised or when drains or an open incision infringe on adhesives, potential for pouch leakage exists. The cyclical pattern of pouch leakage/skin erosion/pouch leakage must be broken to enable epidermal resurfacing and restoration of an intact seal. Peristomal skin protection is the cornerstone of ostomy management; treatment of the skin relies on methods to create dry surfaces, fill irregular contours, and treat infections, while an adhesive seal is maintained.”2
Complications associated with using Convex Ostomy Skin Barriers
“The main mechanism of convex ostomy products is persistent pressure on the area around the stoma. This pressure can cause problems in the peristomal skin, including:
- Peristomal skin disturbances. “Thousands of patients suffer from some type of peristomal skin disturbance at some point while living with an ostomy whether temporary or permanent. There are mechanical, chemical, microbial culprits to these skin complications. These dermatological conditions can range from an abrasion or skin stripping to the more complex, pyoderma gangrenosum.”3
- Skin irritation, redness, and pain. “Contact dermatitis occurs in stoma patients as a response of the skin to contact with external agents. The etiology may be either an irritant or an allergic reaction. Irritant contact dermatitis -the most common type- is caused by mechanical injury to the skin from pouch removal, contact of the skin with stoma effluent, or irritation from solvents, cements or other products acting alone or in combination. Treatment of irritant contact dermatitis should include removal of the irritant chemicals, pouch refitting, and often patient education. Peristomal skin medications are usually not necessary, since the problem should resolve when the underlying cause has been removed. If the skin is erythematous and moist, applying the Stanley procedure will help to absorb moisture and provide an intact surface for adhesion of the appliance. This involves the application of three layers of a skin-barrier powder / and alcohol-free skin prep onto any denuded peristomal skin. Each layer is allowed to completely dry between applications.
Allergic contact dermatitis is an allergic reaction to a specific stomal product. Because allergic contact dermatitis is relatively rare, it is important to search for an irritant cause first. If the condition is considered to be allergic, then patch testing should be performed to identify the causative agent and to confirm that the reaction is allergic. It is important not to attribute what might be a simple irritant contact dermatitis to an allergic reaction, since this restricts the patient’s ability to use thee adhesive material that has been implicated in the allergic reaction, even though the material may otherwise have been useful for the patient.”4
- Skin lacerations, stoma injury and bleeding.
“Stoma trauma or lacerations is an injury or cut on the stoma mucosa. This can occur when the appliance opening is too small or is improperly placed over the stoma, with shaving, or as a result of direct in jury to the stoma. A laceration appears as a yellow to white linear discoloration in the mucosa where the injury occurred. Bleeding may occur at the site and there may be blood in the pouch. No pain is evident as there are no nerve endings in the mucosal layer of the bowel. Management of a stoma laceration is to identify and correct the cause. The appliance should be altered to fit the stoma appropriately. If the stoma mucosa is bleeding significantly at the time of appliance change, direct pressure should be applied to the site until bleeding is controlled.”5
- Infection and gangrene formation. “Gangrene is a term that describes dead or dying body tissue(s) that occur because the local blood supply to the tissue is either lost or is inadequate to keep the tissue alive. Gangrene has been recognized as a localized area of tissue death since ancient times. The Greeks used the term gangraina to describe putrefaction (death) of tissue. Although many laypeople associate the term gangrene with a bacterial infection, the medical use of the term includes any cause that compromises the blood supply that results in tissue death. Consequently, a person can be diagnosed with gangrene but does not have to be ‘infected.’ There are two major types of gangrene, referred to as dry and wet. Many cases of dry gangrene are not infected. All cases of wet gangrene are considered to be infected, almost always by bacteria.”6
- Peristomal hernia. “Peristomal hernia is an incisional hernia that develops at the site of a colostomy or ileostomy, and is among the more common complications of intestinal stomas. The hernia sac usually lies within the attenuated layers of the abdominal wall, but in some instances may tract subcutaneously adjacent to the stoma. Like many stomal complications, formation of a hernia often results from one or more technical errors, which underscores the importance of proper preoperative planning and close attention to detail in the operating room. Other factors that may contribute to the development of peristomal hernias include obesity, advanced age, malignancy, malnutrition, steroid use, and increased abdominal pressure from ascites, chronic pulmonary disease, or obstructive uropathy.”7
The most effective way to avoid complications associated with the use of convex ostomy skin barriers is prevention. “Preventative measures are often just as important as the wound care treatments themselves, and the best way to ensure that complications are avoided is to partner with qualified and experienced health care providers for preoperative as well as postoperative care. Specially trained ostomy nurses may assist patients by not only treating complications of the stoma, but just as importantly by helping the patients take good care of their stoma, and maintain a good fit of the products they use.
With proper prevention and care, the quality of life of patients with stomas can be high. Anxiety, financial considerations, and disability can be assuaged with proper care and teamwork between medical staff, patient, and family.”8
To improve the efficiency of convex ostomy skin barriers, accessories such as ostomy belts can be used. These belts assist holding the convex flange more securely to the peristomal skin area. As with standard flanges, convex types are manufactured as pre-cut or cut-to-fit and their use should be determined after consulting with your healthcare provider. Ensure that you and your ostomy nurse discuss how to take proper care of your stoma and decide on the most appropriate skin barriers for you.
(1) Alvey, B., & Beck, D. E. (2008). Peristomal dermatology. Clinics in colon and rectal surgery, 21(01), 041-044. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780183/
(2) Hoeflok, J., Salvadalena, G., Pridham, S., Droste, W., McNichol, L., & Gray, M. (2017). Use of convexity in ostomy care: Results of an International Consensus Meeting. Journal of Wound, Ostomy, and Continence Nursing, 44(1), 55. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266410/
(3) Rolstad, B. S., & Erwin-Toth, P. L. (2004). Peristomal skin complications: prevention and management. Ostomy Wound Management, 50(9), 68-77. Available online at https://pdfs.semanticscholar.org/4802/365d52c8ccf12af38d648cd84426fbce40dc.pdf
(4) Gordon, P. H., & Nivatvongs, S. (2007). Principles and practice of surgery for the colon, rectum, and anus. CRC Press. Available online at https://books.google.co.ve/books?id=GEXMBQAAQBAJ&pg=PA1070&lpg=PA1070&dq=Skin+lacerations+due+to+skin+barrier+stoma&source=bl&ots=bDwsgubSbo&sig=ACfU3U0fAlHuUojey3T0sAU1u0usZmYc6Q&hl=es-419&sa=X&ved=2ahUKEwiw2bSokpHiAhVLvlkKHS4iD004ChDoATAEegQIBhAB#v=onepage&q=Skin%20lacerations%20due%20to%20skin%20barrier%20stoma&f=false
(5) Fischer, J. E., Bland, K. I., & Callery, M. P. (Eds.). (2006). Mastery of surgery. Lippincott Williams & Wilkins. Available online at https://books.google.co.ve/books?id=PgUFJg_-f4YC&pg=PA1459&lpg=PA1459&dq=Skin+lacerations+due+to+skin+barrier+stoma&source=bl&ots=f0Xk6OyKK8&sig=ACfU3U1efSLvgJin0fe4USqogDMb5doTfg&hl=es-419&sa=X&ved=2ahUKEwiw2bSokpHiAhVLvlkKHS4iD004ChDoATABegQICRAB#v=onepage&q=Skin%20lacerations%20due%20to%20skin%20barrier%20stoma&f=false
(6) Zulfekar, A., Shirin, S. (2012). Gangrene. Technical Report. Available online at https://www.researchgate.net/publication/279201119_GANGRENE
(7) Pearl, R. K., & Sone, J. H. (2002). Management of peristomal hernia: techniques of repair. Nyhus and Condon‘s Hernia, 5th edn. Lippincott Williams & Wilkins, Philadelphia, 415-422. Available online at https://books.google.co.ve/books?id=kfASqVs2r5QC&pg=PA415&lpg=PA415&dq=Peristomal+hernia&source=bl&ots=cMc_ioksHG&sig=ACfU3U30gX3TZaSUnHCKmcDKVcDmpEAHYA&hl=es-419&sa=X&ved=2ahUKEwiwjfPYjJHiAhUEpFkKHVJyA-Y4FBDoATADegQICRAB#v=onepage&q=Peristomal%20hernia&f=false
(8) Doctor, K., & Colibaseanu, D. T. (2017). Peristomal skin complications: causes, effects, and treatments. Chronic Wound Care Manage Res, 4, 1-6. Available online at https://www.researchgate.net/publication/311752387_Peristomal_skin_complications_causes_effects_and_treatments