EWMA 2013 - Ep452 - Stage Closure Simple Approach for Challenging Wounds


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Chang T.J., M.D., Kim E.K., M.D., Ph.D.
Department of Plastic Surgery, Asan Medical Center, Seoul, Korea

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EWMA 2013 - Ep452 - Stage Closure Simple Approach for Challenging Wounds

  1. 1. Staged Closure: Simple Approach for Challenging Wounds Chang T.J., M.D., Kim E.K., M.D., Ph.D. Department of Plastic Surgery, Asan Medical Center, Seoul, Korea
  2. 2. Purpose Despite plastic surgeons try to follow a stairway of reconstructive ladder, there are moments that our armament cannot be utilized for some reasons. Poor locoregional condition (e.g. no available perforating vessel as either donor or recipient) as well as poor general condition (e.g. impracticable general anesthesia) might be a setback while closing a large difficult defect. Staged simple closure of the wound could be a solution in some circumstances when conventional techniques such as graft, local or free flap are not applicable for various reasons.
  3. 3. Methods Ten patients with soft tissue defect at chest, abdomen, buttock, and upper or lower extremity were treated with this method from January 2010 to October 2012. Two patients (one infant with open sternum and one adult with open abdomen) could not undergo general anesthesia. Four adult patients had poor local tissue with multiple incisional scars with severe fobrosis. One patient had a huge defect at buttock, with both legs amputated thus wanted to save maximum upper extremity function. This approach was also applied to three patients with subacute defect at their lower extremity (one compartment syndrome and two ALT flap donor site). Staged closure was performed with the help of serial debridement and negative pressure when appropriate. Local flap was elevated for final closure in three of these patients.
  4. 4. Results Fig. 1. A 1-month-old baby was referred for the open chest wound right above the sternum. Defect size was 5 cm X 3 cm. Staged closure was performed 6 times during 2 months of period.
  5. 5. Results Fig. 2. A 75-year-old female was referred for the full- thickness abdominal wall defect of 30 cm X 27 cm size. Initially, abdominal dual mesh was inserted for the fascial repair, and partial closure was done to decrease the skin defect size. Negative pressure wound therapy was applied post-operatively. Afterwards, 4 more times of staged closure was performed for 18 days under local anesthesia with the intention of narrowing the wound in three-end points. For the final closure, advancement flap was done.
  6. 6. Results Fig. 3. A 40-year-old male patient suffered from soft tissue defect on almost whole buttock (45 cm X 25 cm). The hugeness of his wound and his history of myxoma thromboembolism made other choices of reconstruction unfeasible. Therefore, staged closure was started. It took 2 months to close the wound with 23 times of the procedure. For the final closure, local advancement flap was performed.
  7. 7. Results Fig. 4. A 47-year-old male patient was referred for the closure of a fasciotomy wound (20 cm X 4 cm). Staged closure was started with negative pressure wound therapy. Afterwards, three times of staged closure was performed and the closure was completed on the 10th day from the beginning.
  8. 8. Conclusion Selecting coverage method for a specific wound, multiple factors should be considered such as location and property of the wound and surrounding tissue, post-operative function and posture, patient’s general condition, and even socioeconomic status. Staged closure of the wound utilizes the principle of creep and stress relaxation, standing in line with tissue expansion. When the patient or the wound is not appropriate for a certain conventional method to be applied, sometimes the most classical and primitive approach might give an answer for a very complicated situation.