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© 2006 WebMD, Inc. All rights reserved.                                                         ACS Surgery: Principles an...
© 2006 WebMD, Inc. All rights reserved.                                                  ACS Surgery: Principles and Pract...
© 2006 WebMD, Inc. All rights reserved.                                                         ACS Surgery: Principles an...
© 2006 WebMD, Inc. All rights reserved.                                                      ACS Surgery: Principles and P...
© 2006 WebMD, Inc. All rights reserved.                                                        ACS Surgery: Principles and...
© 2006 WebMD, Inc. All rights reserved.                                                                          ACS Surge...
© 2006 WebMD, Inc. All rights reserved.                                                                                 AC...
© 2006 WebMD, Inc. All rights reserved.                                                      ACS Surgery: Principles and P...
© 2006 WebMD, Inc. All rights reserved.                                                        ACS Surgery: Principles and...
© 2006 WebMD, Inc. All rights reserved.                                                           ACS Surgery: Principles ...
© 2006 WebMD, Inc. All rights reserved.                                                      ACS Surgery: Principles and P...
© 2006 WebMD, Inc. All rights reserved.                                                          ACS Surgery: Principles a...
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Acs0303 Principles Of Wound Management And Soft Tissue Repair

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Acs0303 Principles Of Wound Management And Soft Tissue Repair

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 1 3 OPEN WOUND REQUIRING RECONSTRUCTION Joseph J. Disa, M.D., F.A.C.S., Eric G. Halvorson, M.D., and David A. Hidalgo, M.D., F.A.C.S. Approach to Surgical Reconstruction Acute Reconstruction Evaluation The initial step in the management of problem wounds is to de- EVALUATION AND INITIAL cide whether the wound is suitable for immediate soft tissue cover- TREATMENT OF OPEN age.Wounds that are surgically created during the course of an elec- WOUND tive procedure are almost always best treated with primary definitive Problem wounds are char- coverage.Traumatic wounds that present within 1 or 2 hours of in- acterized by one of the follow- jury and have a minimal crush component are also best treated with ing: large size that precludes a primary definitive coverage procedure after thorough operative de- direct primary closure, gross bridement (if the patient’s hemodynamic status permits). infection or uncertain bacteriologic status, or threatened loss of crit- Injuries with a significant crush component and exposure of crit- ical structures exposed as a result of insufficient soft tissue coverage. ical structures (e.g., nerves, vessels, tendons, or bone) are best treat- Surgically created wounds, which generally pose less of a problem ed more aggressively. In these cases, thorough debridement requires from a bacteriologic standpoint than traumatic wounds, are best considerable surgical experience because the tendency is to debride managed by an immediate coverage procedure when direct closure inadequately. The accuracy with which tissue viability can be as- is impossible. sessed varies from one type of tissue to another. For example, skin Traumatic wounds are more difficult to evaluate than surgical can be evaluated by its color, the nature of its capillary refill, the wounds for several reasons. First, the potential for infection is high quality of its dermal bleeding, or its bleeding response to pinprick. because of the environment in which the wound is created, the After I.V. fluorescein injection, skin viability can also be assessed mechanism of injury, and the time that elapses before operative qualitatively, with a Wood light, or quantitatively, with a dermofluo- intervention. Second, the mechanism of injury (e.g., crush, avul- rometer. Muscle is the most difficult tissue to evaluate. Color, capil- sion, or gunshot) may extend the zone of injury beyond what is lary bleeding, and contractile response to stimulation are not always immediately apparent [see Figure 1]. Serious postoperative infec- reliable indicators of muscle viability. In severe injuries, they can be tion may develop in these cases if definitive wound coverage is misleading. Inadequate debridement may lead to severe conse- provided in the absence of adequate debridement.Third, whereas quences resulting from infection.Therefore, serial debridement at accurate assessment of the chances for recovery of specific struc- 24- to 48-hour intervals is essential for accurately establishing the tures within the wound is vital for selecting the optimal method of limits of muscle injury. Efforts should be made during debridement acute treatment, such assessment is often difficult immediately af- to preserve tissues such as major nerves and blood vessels unless ter injury. they are severely contused. These structures are vital for function a b c Figure 1 (a) A so-called bumper injury of the leg is shown after initial debridement and bony stabiliza- tion (2 days after injury). (b) After the second debridement, the true extent of devitalization of bone and soft tissue is apparent (4 days after injury). (c) A latissimus dorsi free flap has been used to reconstruct the soft tissue defect (5 days after injury).
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 2 Acute reconstruction is indicated Evaluate and treat open wound. Use wet-to-dry dressings or negative-pressure wound therapy until infection is cleared and wound is healing. Select coverage procedure to achieve healed wound and avoid infection. Defer treatment of functional problems for secondary reconstruction. Wound does not contain exposed bone, cartilage, nerve, or tendon but cannot be closed directly Apply a skin graft. Wound is a small defect but Wound has a large surface Wound is clean but in an is in an area where graft area or is a small wound in area prone to contamination contracture is not desirable a noncritical area (e.g., face, hand, or flexion Apply meshed split-thickness crease) Apply split-thickness skin graft. skin graft. Reinstitute early dressing changes if infection Apply full-thickness skin graft; develops. donor sites include the ear, upper eyelid, neck, and groin. Secondary reconstruction of chronic defect is indicated Defect is a small localized There is a shortage of skin One or more of the following scar or a focal scar and subcutaneous tissue conditions is present: contracture only, but skin graft coverage • Composite defect is not desirable • Functional defect of muscle Revise with Z-plasty or other or bone local tissue rearrangement Use tissue expanders (except • Contour deformity procedure. on hand or foot). • Unstable soft tissue coverage of vital structure • Inadequate soft tissue coverage for bone or nerve grafting Repair with free or local flap.
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 3 Approach to Surgical Reconstruction Bone, cartilage, nerve, or tendon is exposed and cannot be covered by direct wound closure Perform flap coverage procedure. Local donor site meets needs and is not involved in Local flap is not possible or would not provide the primary process appropriate tissue Use local flap. Use free flap. • Small or clean wound: use local skin flap if possible. • If wound is clean and thin flap is desired, apply skin or • Large or contaminated wound: use regional myocutaneous flap. fascial free flap. • If wound is large or contaminated, apply muscle or myocutaneous free flap. Head or neck defect Abdominal defect Muscle flaps require coverage with a meshed split-thickness skin graft. • Small facial defect with no Use regional flap (e.g., tensor facial features involved: use fasciae latae, rectus femoris, or Z-plasty, Limberg flap, or rectus abdominis), or employ other advancement flap of component separation technique. Head or neck defect Knee or leg defect cheek or forehead. • Large defect of neck or lower • Large defect of scalp or • Major wound of the head: use regional myocutaneous upper face: cover with popliteal fossa: use free flap of trapezius, latissimus dorsi, Gluteal or perineal defect latissimus dorsi, scapular, flap if blood supply to or pectoralis major, or use or rectus abdominis gastrocnemius is anterolateral thigh flap. Use regional myocutaneous free flap, or use compromised. flap (e.g., gluteus maximus, anterolateral thigh flap. • Defect of the lower third gracilis, tensor fasciae latae, or • Floor of the mouth: replace of the leg: use latissimus biceps femoris). with forearm free flap. dorsi, rectus abdominis, Chest or back defect • Mandible: reconstruct with scapular, or gracilis various composite free free flap. In most cases, use regional flaps of bone and skin. myocutaneous flap (e.g., Thigh, knee, or leg defect • Oropharynx or cervical pectoralis major, rectus esophagus: use jejunum free flap or forearm flap, or Foot defect abdominis, latissimus dorsi, or • Thigh defect: use regional trapezius). muscle flap (e.g., tensor use anterolateral thigh flap. fasciae latae, rectus femoris, • Plantar: repair very large vastus lateralis, or vastus defect with muscle free medialis). Forearm defect flap covered with a Arm defect • Defect of knee or proximal leg: skin graft. use gastrocnemius muscle flap. • Dorsum: use fascial free Cover large forearm wound Cover large wounds above the • Proximal or midleg defect: use flap and overlying skin with free flap of rectus elbow with latissimus dorsi soleus muscle flap. graft, or use thin skin abdominis, scapular, or muscle transposed as a free flap. latissimus dorsi muscle. pedicled flap. Foot defect Hand defect • Plantar: close defect of Hand defect weight-bearing heel or midsole • Exposed tendons on the with medially based skin dorsum: cover with Free flaps are preferred, but rotation flap raised superficial temporalis fascia free flap. pedicled distant skin flaps from to plantar fascia or with • Defect of the web space: the chest or abdomen are also other myocutaneous or correct with lateral arm acceptable. Defects of the digits fasciocutaneous plantar flap. free flap. can be covered with cross- Cover limited defect of distal finger flaps or, for tip injuries, plantar surface with toe flap. with thenar flaps. • Posterior heel, Achilles tendon, malleoli: use either extensor digitorum brevis muscle as pedicled flap or lateral calcaneal artery flap.
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 4 and are of small mass compared with other tissues (e.g., skin, fat, dominant isolate, the wound should generally be treated openly and muscle) at risk for necrosis and subsequent infection. until cultures become negative. Wound debridement, therefore, should involve careful analysis of the injury from an anatomic point of view; debridement should not Systemic antibiotics The role of systemic antibiotics in consist of indiscriminate excision of blocks of tissue. Between de- wound management is not clearly defined. Broad-spectrum antibi- bridement procedures, the wound should be treated with sterile otics should be given in cases of severe trauma or established, un- dressings but in an open manner, with either dressing changes or controlled infection.They may also be useful for minor wounds that negative-pressure wound therapy (NPWT) if conditions permit. A cannot be closed within 3 hours of injury. definitive soft tissue coverage procedure should then be performed as soon after the initial injury as wound conditions permit. When Topical antibiotics Certain antibiotics provide broad-spec- thorough debridement and definitive coverage can be completed trum activity when applied topically. Neomycin, 10 mg/ml, or a within less than 1 week, the wound will generally heal uneventfully. combination of bacitracin, 50 U/ml, and polymyxin B, 0.05 mg/ml, Inadequate debridement frequently results in the loss of any addi- kills most common wound pathogens.These solutions can be used tional tissue invested to achieve acute soft tissue coverage. The when wet dressings are indicated. In the past few years, numerous wound becomes grossly infected, and important functional struc- antibacterial dressings have been developed, including an antibacte- tures within the wound are reexposed. rial NPWT sponge. Such dressings may prove useful in the treat- Infected surgical wounds, neglected wounds, or other complex ment of open, contaminated wounds; however, discussion of these wounds in which initial wound management fails should be debrid- products is outside the scope of this chapter. ed and then treated by open methods. Proper care of these wounds is achieved by a multifaceted approach aimed at converting estab- Topical antiseptics A variety of topical antiseptics have been lished gross infection to a much lower level of bacterial contamina- used empirically in wound care. In the concentrations usually rec- tion, which is then compatible with successful secondary wound ommended, however, these solutions are detrimental to wound closure. For example, advances in the use of NPWT [see Initial healing. Povidone-iodine (1%), hydrogen peroxide (3%), acetic acid Treatment, Negative-Pressure Wound Therapy, below] have simpli- (0.25%), and sodium hypochlorite (0.5%) all have been shown to fied the management of complex lower-extremity traumatic wounds, be lethal to fibroblasts, as well as to bacteria. More dilute concentra- reducing the use of free tissue transfer.1 tions of povidone-iodine (0.001%) and sodium hypochlorite (0.005%) are effective against bacteria while being safe for fibroblasts.7 A Initial Treatment number of these agents also inhibit normal white blood cell func- Debridement Devitalized tissue provides an ideal culture tion in the wound. medium for bacteria and isolates them from host defense mecha- nisms. Surgical debridement must be performed aggressively—and Wet dressings Open wounds can be treated with wet dress- on a serial basis if necessary—to remove all necrotic tissue. ings, generally consisting of gauze soaked in saline or an acceptable topical antiseptic. Wet-to-wet dressings prevent desiccation of ex- High-pressure irrigation A useful adjunct to debride- posed vital structures or freshly placed skin grafts.Wet-to-dry dress- ment is high-pressure irrigation, which has been shown experi- ings are useful for assisting in daily wound debridement. These mentally to reduce wound infection rates significantly.2,3 The dressings are allowed to dry on the wound; when they are removed, necessary pressure of 8 psi can be achieved by forceful irrigation adherent fibrinous debris is removed with the dressing.Wet dress- through a 35 ml syringe fitted with a 19-gauge needle. Low-pres- ings of either type should be changed at least twice a day. sure irrigation with a bulb-type syringe, for example, has not Small wounds can be expected to close by contraction and proved to be beneficial. An antibiotic-containing solution is com- secondary epithelialization after appropriate open management monly employed. with the techniques described. Large wounds will improve with aggressive open care but will then stabilize into a chronic state of Quantitative bacteriology The degree of bacterial wound wound colonization of varying degrees. A soft tissue coverage contamination can be accurately quantified. The standard tech- procedure may then be necessary to complete closure in these nique of quantitative bacteriology requires several days to com- cases. plete and is therefore of somewhat limited utility in the manage- ment of acute wounds. In addition to a count, it provides Negative-pressure wound therapy In the past 10 years, the identification and antibiotic sensitivities of the organism. As an al- vacuum-assisted closure device (VAC Abdominal Dressing System; ternative, quantitative bacteriology can be performed by using the Kinetic Concepts Inc., San Antonio,Texas) has gained widespread rapid slide technique, which provides valuable information about acceptance for the treatment of open wounds. Because this device the wound within 20 minutes.4,5 The level of bacterial contamina- does not accomplish debridement to any significant degree, it tion has been shown to be a significant predictor of outcome in should be applied only to a clean wound that has no necrotic debris. wound closure by either skin-graft or flap-coverage techniques. If any significant necrotic tissue remains after sharp debridement, According to the golden-period principle of wound closure, a wet-to-dry dressings may be employed until the wound is clean and minimum time interval is necessary for bacteria to proliferate to a granulating. Dressing changes are typically carried out every 2 or 3 certain threshold level. Contaminated wounds take a mean time days; this is a significant advantage, given that conventional dressing of about 5 hours to reach a bacterial count of 105/g of tissue. At- changes are generally done at least twice daily. Exudate is removed 5 tempts to close wounds that have counts higher than 10 /g of tis- and quantified by the suction device, and more robust wound gran- sue will fail 75% to 100% of the time, whereas attempts to close ulation and contraction can be observed. After treatment with a wounds with lower counts are successful more than 90% of the VAC device, wound closure can be accomplished secondarily with a time.6 β-Hemolytic streptococci are an exception in that much skin graft, local flaps, or free tissue transfer, depending on the clini- lower concentrations of these organisms consistently result in fail- cal situation.The disadvantages of NPWT include the need for spe- ure of wound closure. When a β-hemolytic streptococcus is the cialized equipment and training and the increased cost.
  5. 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 5 SELECTION OF COVERAGE PROCEDURE Successful healing of skin grafts requires immobilization of the recipient site to prevent shearing in the plane between the graft and The main goals of coverage the wound bed. Although complete immobilization is desirable, the procedures [see 3:7 Surface required dressings may preclude observation of a wound that is Reconstruction Procedures] in known to be significantly contaminated. In such cases, a meshed the management of both split-thickness graft is indicated, and the wound should be treated in acute and chronic wounds are an open fashion. A meshed graft can be placed directly over the (1) to achieve a healed wound muscle of a flap and secured over its irregular contour with staples and (2) to avoid infection. [see Figure 2]. Because the graft is meshed, serum can escape be- The treatment of functional problems is generally deferred for sec- tween the interstices and there is little risk of separation from the ondary reconstruction. underlying tissue. A meshed graft is also less vulnerable to disrup- The method of coverage depends on whether vital structures tion by shear forces. An additional advantage of a meshed graft is (e.g., vessels, tendons, nerves, and bone) are exposed in the wound. that it permits the wound to be treated with wet dressings if there is If no vital structures are exposed, skin-graft coverage is indicated. still risk for infection. A mesh expansion ratio of 1.5:1 is generally Skin grafts can also be used over tendon if the paratenon is intact, preferred, except when the surface area of the wound is very large over nerve if the epineurium is intact, and over bone if the perios- and the availability of donor sites is limited. teum is intact. Skin grafts are the most expendable type of soft tis- sue available for the coverage of open wounds. They allow the Flaps wound to heal completely and set the stage for secondary recon- Flaps consist of tissues that struction, during which more valuable tissue can be used to achieve have a self-contained vascular other goals at minimal risk.When vital structures are exposed in the system [see 3:7 Surface Recon- wound, a flap is preferred because it provides more substantial soft struction Procedures].They per- tissue coverage of the structure.The choice of flap depends on the mit a more substantial trans- location of the wound and on its overall size, depth, and topograph- fer of tissue bulk than do skin ic configuration (see below). grafts and may consist of skin and subcutaneous tissue, of Skin Grafts fascia, of muscle, of bone, or of a combination of several of these tis- Skin grafts may be either sue types. Local flaps consist of tissue that is mostly detached from partial thickness (i.e., split surrounding tissue but retains enough connection to preserve an ad- thickness) or full thickness [see equate blood supply to the entire flap. Local flaps are either trans- 3:7 Surface Reconstruction Pro- posed, rotated, or advanced into adjacent defects for purposes of re- cedures]. Split-thickness grafts construction. Island flaps are local flaps that are based only on their are preferred for wounds with skeletonized axial blood supply. Once created, an island flap is trans- a large surface area. Full- ferred through a subcutaneous tunnel into the defect. The skele- thickness grafts are suitable tonized pedicle remains in the subcutaneous space while the cutaneous only for small defects because their donor sites must be closed pri- portion of the flap fills the defect. Free flaps, in contrast, are totally marily; the most common donor sites for full-thickness grafts are detached; their blood supply is reconnected at the recipient site by the ears, upper eyelids, neck, and groin. Full-thickness grafts con- means of surgically performed microvascular anastomoses between tract less with time than split-thickness grafts and are therefore par- recipient-site blood vessels and the major vessels that supply the flap. ticularly suitable for wounds of the hands, extremity flexion creases, nose, eyelids, and other areas of the face. Local flaps versus free flaps The choice between a local flap and a free flap is determined by the amount and the type of tissue needed, as well as by the availability of flaps in the immediate area of the wound [see Figure 3].The availability of local flaps, in turn, is de- termined by the nature of the regional blood supply. The vascular anatomy of a particular area determines the availability of arterialized skin flaps, fasciocutaneous flaps, myocutaneous flaps, and other forms of composite flaps. Local flaps can be grouped regionally by the types of tissue that they provide [see Table 1]. A local flap is generally preferred over a free flap if the two pro- vide similar tissue, primarily because of the additional effort re- quired to transfer a free flap. A free-flap procedure commonly takes twice as long as a local-flap procedure. Free flaps are indicated in areas where local flaps are unavailable (e.g., the distal third of the leg) or when an extremely large flap is needed but cannot be obtained locally.When regional donor sites are affected by the primary process, free tissue transfer allows healthy, well-vascularized tissue to be brought into the compro- mised area. Moreover, if free tissue is transferred, the size of the Figure 2 A meshed (1.5:1 ratio) skin graft has been secured to the wound is not extended, because the donor site is not contiguous but irregular contour of a muscle free flap with staples. No additional instead is located at a distance from the wound. immobilization of the graft is needed.The interstices of the graft al- If expertise in microvascular surgery is available, free flaps are fre- low free drainage of serous exudate from the muscle. quently a first-line choice. Free flaps allow selection of the appropri-
  6. 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 6 most wounds can be met by so-called workhorse free flaps.These flaps typically have the advantages of large size, ease of dissection, and a vascular pedicle that is long and of large diameter.The disad- vantages, such as awkward patient positioning for flap harvest, are minor. Most workhorse flaps consist of muscle with an optional skin component; they are the flaps of choice for contaminated wounds [see Figure 4]. A second group of free flaps is useful for acute reconstruction of unusually large wounds.These flaps consist of combined vascular territories supplied by a single vascular pedi- cle. A third category consists of smaller free flaps that provide tissue that is superior in either amount or type to the local flaps that are otherwise available. An additional advantage of these flaps is that they tend not to be bulky.They are frequently used in areas such as the head, hands, distal third of the leg, and feet [see Figure 5]. Flap coverage procedures are illustrated in greater detail else- where [see 3:7 Surface Reconstruction Procedures]. Regional alternatives in flap selection Head, neck. LOCAL FLAPS MYOCUTANEOUS FLAPS FREE FLAPS Facial defects of small to moderate size are best treated Figure 3 Regional alternatives in flap selection are illustrated. with local skin flaps. A variety Defects in the central portion of the body are treated with myocuta- of flaps are available for re- neous flaps primarily; defects of the peripheral areas are treated construction of limited de- with either local flaps or free flaps. In some areas, several options fects of the eyelids, cheeks, exist, and the choice is influenced by the size of the defect and the nose, and mouth.8-10 Small specific tissue requirements. facial defects that do not directly involve the facial features can often be closed with any of several types of flaps that rearrange the exist- ate type of tissue in the most suitable size and configuration for the ing tissue in the area—for example, a Z-plasty or a Limberg flap. specific reconstructive problem. Compared with free flaps, local Tissues that are difficult to match (e.g., those of the eyelids or lips) flaps are inefficient ways of moving tissue because only a small por- can often be reconstructed with flaps that borrow tissue from their tion of a local flap actually reaches the defect itself. The choice of opposite, intact counterparts (e.g., the Abbe lip flap). donor site is greater with free flaps because the limitations imposed For coverage of some large defects in the head and neck region, by local availability are avoided. the trapezius, the latissimus dorsi, and the pectoralis major can be Free flaps used in acute reconstruction can be grouped into three used. Each muscle can be raised with an optional skin island.These major types [see Table 2]. The soft tissue coverage requirements of flaps are generally too bulky to be used on the face, and their reach Table 1—Selection of Local Flaps by Region and Tissue Type Site Skin Flaps Muscle and Myocutaneous Flaps Fascial and Fasciocutaneous Flaps Scalp; forehead; nasolabial; cervico- Head and neck Trapezius; latissimus dorsi; pectoralis major Superficial and deep temporal fascia facial; Mustardé; eyelid; lip Trapezius; pectoralis major; latissimus dorsi; rectus Chest and back Lateral thoracic; deltopectoral Scapular abdominis (superiorly based) Arm Medial arm (Tagliacozzi) Latissimus dorsi; pectoralis major Lateral arm; forearm Cross-finger; thenar; neurovascular Hand — Forearm island; fingertip advancement Abdomen and Rectus abdominis (inferiorly based); tensor fasciae latae; Groin Medial thigh perineum rectus femoris; gracilis Gluteus maximus; gracilis; tensor fasciae latae; biceps Gluteal area Sacral; thoracolumbar Gluteal thigh femoris Tensor fasciae latae; rectus femoris; vastus lateralis; vastus Anterior thigh; anteromedial thigh; Thigh — medialis; gracilis; biceps femoris; rectus abdominis posterior thigh; anterolateral thigh Knee and proximal — Gastrocnemius Saphenous artery; posterior calf leg Midleg — Soleus; tibialis anterior Anterior leg; lateral leg; posterior leg Distal leg — — — Dorsalis pedis; plantar rotation; lateral Flexor digitorum brevis; abductor hallucis; abductor digiti Foot — calcaneal artery; plantar V-Y minimi; extensor digitorum brevis
  7. 7. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 7 Table 2—Free Flap Selection for Soft Tissue Coverage* Requirement Specific Flap Advantages Disadvantages Latissimus dorsi Ideal pedicle†; ease of dissection Awkward patient positioning Reliable workhorse flaps Rectus abdominis Ideal pedicle; supine position; ease of dissection No major disadvantages Scapular Ideal pedicle; skin flap only Awkward patient positioning ‡ Combined latissimus dorsi and Independent component inset ; primary donor-site Awkward patient positioning scapular closure possible; ideal pedicle Flaps of very large surface area Extended tensor fasciae latae and Supine position; large skin flap component Donor-site healing§; pedicle configuration|| partial quadriceps Gracilis Small muscle Small vessels Lateral arm Thin, sensate; convenient for hand trauma Small vessels; donor-site scar Minor hand morbidity; poor donor-site Forearm Thin skin flap; ideal pedicle appearance Small flaps Thinnest flap; ideal coverage for exposed tendons¶; Temporalis fascia Variable donor-site scar alopecia can transfer hair-bearing scalp Thin; moderate surface area available for harvest; Variable anatomy; possible requirement Anterolateral thigh minimal donor-site morbidity for perforator dissection *Includes only the more commonly used free flaps for purposes of comparison. § Donor-site closure requires a skin graft, which may result in delayed healing. † Characterized by large-diameter vessels and long pedicle length. || Pedicle enters middle of undersurface of flap. ‡ Each part can be arranged and sewn into the wound separately. ¶ Permits tendon gliding underneath if used on dorsum of the hand or of the foot. is limited when used as pedicled flaps: none of them can cover ma- a b jor portions of the scalp or comfortably reach the upper face. Latissimus dorsi, scapular, and rectus abdominis free flaps are useful for very large defects of the scalp or upper face. Smaller de- fects of the scalp are best treated with local scalp flaps. Other free flaps of a specialized nature are superior for recon- struction of the floor of the mouth and mandible, even though local myocutaneous flaps will reach this area. For example, the forearm free flap based on the radial artery is quite thin and pliable and therefore provides an ideal replacement for the floor of the mouth. Composite free flaps that contain both bone and skin (e.g., those taken from the scapula, the ilium, the radius, and the fibula) pro- vide tissue of the appropriate type and proper configuration for de- fects of the lower face in which the mandible must be reconstructed along with the intraoral lining, the external skin, or both. Chest, back. Most clean de- fects of the chest and back are amenable to treatment with c d local myocutaneous flaps be- cause of the wide arc of rota- tion of muscles located in these areas.11 In the presence of contamination, open wound management is indi- cated. Traditionally, this has Figure 4 (a) Shown is a facial tumor that has recurred after previ- ous orbital exenteration. (b) The defect has been resected. Local flaps and regional myocutaneous flaps are not available for this de- fect. (c) A rectus abdominis myocutaneous free flap is designed. This flap can be designed in other sizes and configurations depend- ing on specific needs.The vascular pedicle is long and of large diam- eter, and the flap is easily accessible in the supine patient. (d) After surgery, soft tissue coverage with a reasonable restoration of facial contour has been achieved.
  8. 8. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 8 a b c d Figure 5 (a) A soft tissue sarcoma has recurred in the scar of a previous excision. (b) Reexcision of the defect has exposed bone and tendons. No regional flaps are available for satisfactory coverage of this defect. (c) The forearm is a source of small, thin free flaps. (d) Flap transfer is complete.The radial artery and ve- nae comitantes have been anastomosed to their dorsalis pedis counterparts. been accomplished with wet-to-dry dressing changes, which are es- can be achieved with a single flap (e.g., a gracilis muscle flap), this pecially effective for superficial debridement. Currently, these procedure is not generally recommended; rather, a skin flap (e.g., a wounds are increasingly being managed with NPWT after all scapular free flap) is preferred as a first stage of reconstruction to necrotic tissue is debrided. A common example is the wound result- achieve wound healing. ing from the treatment of poststernotomy mediastinitis. After sepsis is eliminated and the wound is granulating, definitive flap closure Hand. Both free flaps and can be performed.12,13 Midline sternal wounds can be covered with pedicled skin flaps are useful either pectoralis major or rectus abdominis flaps; lateral chest de- for soft tissue coverage of fects with latissimus dorsi or pectoralis major flaps; and midline hand wounds. A temporalis back defects with latissimus dorsi or trapezius flaps.To cover mid- fascia free flap is particularly line defects, the pectoralis major, the latissimus dorsi, and the thin and is ideal for coverage trapezius can be divided from their primary vascular supply and of exposed tendons on the folded over as local flaps based on their medial intercostal sec- dorsum of the hand. A lateral ondary blood supply. arm free flap is ideal for re- construction of a large defect of the first web space; it has sensory Arm, forearm. Large potential because it contains a large sensory nerve. Both of these wounds above the elbow can free flaps are small. Pedicled distant skin flaps from the chest or ab- be covered with a latissimus domen are available as an alternative form of coverage of sizable dorsi myocutaneous flap hand defects. However, pedicled skin flaps have major disadvan- transposed as a pedicled flap, tages: wound care is difficult, edema persists because elevation and provided that the vascular movement of the hand are seldom possible while it is attached to pedicle of the muscle has not the trunk, and a second procedure is needed to divide these flaps. been affected by the injury. Digital injuries with exposed tendons can be closed with a variety Forearm wounds that require of cross-finger flaps of skin and subcutaneous tissue raised from ei- flap closure are best treated with free flaps. A rectus abdominis, ther the volar or extensor aspect of an adjacent digit. Because these scapular, anterolateral thigh, or latissimus dorsi muscle flap can be flaps do not contain a great deal of subcutaneous tissue, they are used for large defects of the arm or forearm. Although soft tissue preferred for coverage of digits proximally, where a thick subcuta- coverage with simultaneous functional forearm muscle replacement neous pad is not essential. A thenar flap is useful for fingertip in-
  9. 9. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 9 juries in which the soft tissue pad of the fingertip is lost and bone is tation skin flaps. The gluteus maximus, for example, can be exposed.This flap provides an ideal pulp replacement, as well as bet- used as a rotation flap, a V-Y advancement flap, or a turnover ter sensory recovery than skin grafts. Fingertip injuries can also be flap in the treatment of pressure sores. As a turnover flap, it can closed with several types of V-Yadvancement flaps that can be raised be proximally or distally based, or it can be split along its longi- from either the volar surface or the lateral surfaces of the end of the tudinal axis so that only a portion of it is used. Also useful for finger. covering defects in the gluteal area and the perineum is the my- ofasciocutaneous gluteal-thigh flap, which is a combination of a Abdomen. Clean defects of gluteus muscle flap and a fasciocutaneous flap from the posteri- the abdominal wall that re- or thigh that is supplied by an extension of the inferior gluteal quire flap closure are best artery. Because of its size and location, the gracilis muscle is treated with local muscle well suited for coverage of defects of the perineum. The gracilis flaps such as the tensor fasci- and the biceps femoris are generally secondary choices for the ae latae and the rectus treatment of pressure sores over the ischium. The tensor fasciae femoris from the thigh. The latae is frequently used for treating open wounds over the rectus abdominis also can oc- greater trochanter. The entire quadriceps can be used to close casionally be transposed to defects resulting from hemipelvectomy. cover an abdominal defect. Each of these flaps is harvested along with skin, although a large tensor fasciae latae flap will probably Thigh. Flaps are rarely required for soft tissue coverage in the necessitate skin-graft closure of the donor site.The tensor fasciae thigh area, because critical vital structures are located deep within latae flap has the advantage of including the thickened deep fascia the thigh and are rarely exposed by injury or by surgical proce- (iliotibial band) of the thigh, which can provide additional strength dures. A number of regional muscle flaps are available for coverage for abdominal wall closure. Midline defects resulting from previ- in this region, however, including the tensor fasciae latae, the rec- ous operation or trauma can often be closed by means of the com- tus femoris, the vastus lateralis, and the vastus medialis.The gra- ponent separation method.The external oblique fascia is divided cilis and posterior thigh muscles are rarely used in this area. An an- lateral to the lateral edge of the rectus sheath, and the bloodless terior defect that involves exposure of the femoral vessels can be plane between the external and internal oblique muscles is devel- covered with either an ipsilateral or a contralateral rectus abdo- oped.This maneuver mobilizes the recti toward the midline, usu- minis myocutaneous flap.The rectus femoris may also be divided ally allowing primary closure. distally and turned over to provide coverage of exposed femoral As a consequence of the growing realization of the benefits of the vessels or grafts. A number of smaller local skin flaps that are sup- open abdomen, increasing numbers of patients treated for abdomi- plied with blood from the deep fascia can be raised over portions nal trauma, sepsis, and compartment syndrome are presenting for of the thigh. The anterolateral thigh flap is the most commonly management and closure. With contaminated wounds, the use of employed thigh flap; however, it is typically used for free tissue permanent meshes for reconstruction is contraindicated, and defin- transfer to distant areas. itive flap closure is best delayed. In these difficult situations, the wound must be treated in an open manner, with close attention paid Knee, proximal leg, midleg. to the unique vulnerability of the intestines to fistula formation. The two heads of the gas- Many treatment options are currently available for the open ab- trocnemius can be used ei- domen [see 7:6 Operative Exposure of Abdominal Injuries and Closure ther together or indepen- of the Abdomen]. Important considerations for any treatment modal- dently to cover defects of the ity include whether the method controls abdominal contents, knee and the proximal third whether it avoids promoting fistula formation, whether it achieves of the leg. The soleus is use- skin and fascial closure, whether it removes and quantifies exudate, ful for coverage of defects of whether it controls infection, and whether it promotes wound heal- the proximal and middle ing.The VAC device performs well with respect to all of these con- thirds of the leg. Local flaps should not be used for major leg siderations, perhaps because of reverse tissue expansion and full- wounds if the extent of the injury suggests involvement of the thickness wound contraction.14,15 Once all acute problems have muscle donor site. Instead, a free flap should be used to bring been addressed and recovery is well under way, an absorbable mesh healthy tissue into the area.Therefore, free flaps are a first choice, is commonly applied, followed by dressing changes or NPWT. To for example, for coverage of major wounds of the popliteal fossa, protect the underlying bowel, a layer of nonstick gauze should be ap- knee, and proximal leg that involve the sural artery blood supply plied before dressings or NPWT sponges. Once granulation is to the gastrocnemius; they are also highly useful for coverage of achieved, a skin graft can be placed. Chronic hernia formation is the defects in the distal third of the leg.Traumatic wounds of the dis- rule; the hernia can generally be treated as a stable chronic ventral tal lower extremity can also be managed with NPWT. Increased hernia, provided that the wound is closed and free of infection. use of this modality has been associated with the performance of fewer free tissue transfers and more delayed local flap procedures Gluteal area, perineum. for definitive closure.1 Local muscle flaps with or Skin flaps fed by the fascial blood supply can also be raised without skin are indicated over the leg.16 A number of fasciocutaneous flaps have been de- for defects in the gluteal scribed in this area, but they tend to be smaller than muscle area or the perineum. Such flaps and generally less reliable. These flaps are longitudinally flaps are preferable to large, oriented over the course of the anterior tibial artery or the per- random-pattern advancement oneal artery. The maximum length at which such fasciocuta- skin flaps from the posterior neous flaps are safe and their specific applications have not been thigh and thoracolumbar ro- well established.
  10. 10. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 10 SHORTAGE OF SKIN AND Foot. The foot is as complex SUBCUTANEOUS TISSUE as the hand and the face in that A shortage of skin and sub- it is composed of separate re- cutaneous tissue may result gions, each of which has a from excision of a large scar unique set of alternatives for or a large congenital defect reconstruction. These regions (e.g., a nevus). Mastectomy include the plantar surface; commonly leaves a shortage the dorsum; and the posteri- of skin that prevents creation or (non–weight-bearing) heel, of a breast mound. In these cases, extra tissue can be created locally Achilles tendon, and malleoli. with the use of tissue expanders.These devices are inflatable plastic Superficial defects that lie completely within the non–weight-bear- reservoirs of various shapes and volumes that are implanted under ing portion of the midsole do not need flap coverage. Defects of the the skin.The skin over the expander is stretched during a period of weight-bearing heel and midsole area that are less than 6 cm in diam- several weeks as the expander is gradually filled by percutaneously eter can be closed with a medially based skin rotation flap that is raised injecting saline into an incorporated or remote fill port. The ex- superficial to the plantar fascia.17 This flap maintains plantar sensa- pander is then removed as a second procedure, and the expanded tion. Limited defects of the distal plantar surface can be treated with area of skin is advanced to cover the defect.The process of tissue ex- local toe flaps that also maintain sensation.Very large plantar defects pansion results in thinning of all layers of tissue overlying the ex- are best resurfaced with a muscle free flap (e.g., latissimus dorsi or rec- pander—except for the epidermis, which actually thickens. tus abdominis) covered with a skin graft. Although this type of flap A number of important principles govern the use of tissue ex- lacks sensation, it appears to provide the most durable form of cover- panders. The expanders must be placed so as to allow expansion age because it resists shear forces well.18 only in normal skin adjacent to the defect, not in the defect itself.To Defects of the dorsum that require flap coverage are best covered ensure adequate expansion, a sufficiently large expander or multiple either with a fascial free flap (e.g., temporalis fascia) and an overly- expanders must be used. Complications associated with the use of ing skin graft or with a skin free flap that is thin (e.g., from the fore- tissue expanders include infection, extrusion, deflation, flipped ports arm or the anterolateral thigh).The extensor digitorum brevis can (remote type), and hematoma formation.19 be raised from the dorsum as a pedicled flap fed by the dorsalis Tissue expanders are used in secondary reconstruction only; they pedis artery.This flap, which measures approximately 5 × 6 cm, has play no role in acute wound management. They are not indicated an arc of rotation that makes it useful for the coverage of defects of for contour defects (see below), because the tissue they provide is the malleolus or the Achilles tendon area. A narrow transposition two-dimensional and lacking in bulk. Nor is expanded tissue ade- skin flap fed by the lateral calcaneal artery is useful for coverage of quate for coverage of chronically exposed structures (e.g., bone). defects approximately 3 cm in diameter that lie over the Achilles ten- Tissue expanders do not provide adequate replacement tissue to es- don or the non–weight-bearing posterior heel. A distally based re- tablish a suitable bed for nerve or bone grafting.Therefore, they are verse sural artery flap transfers skin, subcutaneous fat, and fascia not a substitute for flaps in general. from the proximal posterior calf and can also be used for defects of The scalp is an ideal location for the use of tissue expanders be- the ankle; however, this flap is prone to venous congestion. cause no equivalent substitute for this type of hair-bearing tissue exists. Expanders work effectively when implanted over the hard Secondary Reconstruction calvarium and are useful in cases of burn alopecia and large nevi Selection of the proper involving the scalp. Expanders are also useful for breast recon- method for secondary recon- struction, for carefully selected large lesions of the face, and for struction requires analysis of certain scars of the limbs.They are generally not indicated for use the type and extent of tissue in the hands or feet. Although some local flap donor sites (e.g., the deficiency that is present and forehead) can be expanded before flap transfer, there is a loss of consideration of the functional tissue pliability that appears to limit the usefulness of this particu- goals that are involved. Super- lar application. ficial defects may require re- COMPLEX DEFECTS placement or supplementation of only skin and subcutaneous tissue, whereas more complex defects may require replacement of several Certain reconstructive types of tissue. Specialized tissue, such as vascularized nerve (i.e., a problems require substantial nerve free flap) or intestine, may be necessary to provide a functional amounts of tissue of one or reconstruction in some cases (see below). more types or of a very spe- cialized type. Either local or SMALL LOCALIZED SCAR free flaps are used to meet When reconstruction is indicated for a small localized scar, soft tis- these tissue requirements. sue coverage is generally sufficient and poses no threat of breakdown Composite Defect leading to exposure of important structures. Instead, the reconstruc- tive problem is generally functional in nature. An example is a tight A composite defect may result from resection of an intraoral car- scar band across a flexion crease, which is commonly seen after a burn cinoma with loss of the mandible and either the lining of the mouth injury. A local procedure that rearranges the existing tissue can relieve or external skin. Another example is a crush injury of the leg with the tension by making more tissue available in one direction, though loss of soft tissue and a segment of weight-bearing bone.These de- the amount of tissue in the area is not actually increased. fects require that a composite flap be brought to the area to meet The Z-plasty is an example of such tissue rearrangement [see 3:7 more than one type of tissue deficiency. Local flaps generally do not Surface Reconstruction Procedures]. Multiple Z-plasties or other proce- provide the necessary types of tissue or permit the freedom of design dures, such as W-plasty, may be useful for some localized scars. possible with free flaps.The wide variety of free flap donor sites that
  11. 11. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 11 exists allows selection of tissue in the appropriate quantity and con- Procedures]. A free flap from the abdomen or the gluteal area is an- figuration for a particular defect [see Figure 6]. other alternative. The best reconstructive solution for a particular person is determined by variables such as body habitus and the size Functional Defect and configuration of the contralateral breast. Functional defects require repair with specialized flaps. Free flaps A contour defect of the lower extremity is best reconstructed with are frequently used because the specific tissue requirements usually a large myocutaneous free flap that provides tissue of sufficient cannot be satisfied by a local flap. A functional defect may result, for quantity and flexibility to allow sculpting into the appropriate shape. example, in the cervical esophagus from tumor resection or in the An excellent example is the latissimus dorsi free flap, which provides forearm from Volkmann’s contracture. A segment of small intestine a large volume of thin, pliable muscle, which can be wrapped can repair the esophageal defect; transfer of a vascularized and in- around orthopedic hardware. nervated muscle (e.g., the gracilis) can replace forearm muscle.20 Unstable Soft Tissue Coverage Contour Defect Marginal soft tissue coverage (e.g., skin grafts) may break Contour defects, such as those that result from mastectomy or down after repeated minor trauma. Bones may become exposed from trauma to the lower extremity, can be reconstructed with either and are then at risk for osteomyelitis.This situation can be avoid- local or free flaps. A mastectomy defect, because of its location on ed by elective replacement of the tissue at risk with a more sub- the chest, is suitable for reconstruction with one of several myo- stantial soft tissue covering. As in acute reconstruction, local flaps cutaneous flaps from either the back or the abdomen [see 3:5 Breast are the first choice for lesions of the trunk or the proximal ex- a b c d e Figure 6 (a) A chronic draining sinus of the ulna with poor overlying soft tissue coverage is shown. Simul- taneous replacement of both bone and overlying soft tissue with a composite tissue flap is needed. (b) A radiograph shows nonunion of the ulna with orthopedic hardware. (c) A fibular free flap provides bone and skin in the appropriate amount and configuration for replacement of the affected tissues in a single stage. (d) The segment of ulna and overlying skin has been replaced. (e) A radiograph shows the vascularized fibula in place.
  12. 12. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 12 tremities, whereas free flaps are often more appropriate for le- fore grafting a bone or nerve gap. A skin or muscle flap is most sions of the distal extremities. commonly used in such cases. This problem is most common in Soft tissue coverage is sometimes inadequate even in a healed areas such as the distal extremities, where native soft tissue cover- wound. For example, certain procedures (e.g., nerve or bone graft- age is not overly abundant and is easily lost as a consequence of ing) require an ideal soft tissue bed to promote adequate graft trauma or tumor resection. Free flaps are usually chosen to provide revascularization. In some cases, it may initially be necessary to re- a healthy, well-vascularized soft tissue bed before further function- place the existing soft tissue coverage as a first-stage procedure be- al reconstruction is undertaken. Discussion Wound Healing pattern of the recipient site. Sebaceous glands, on the other hand, se- The wound healing process consists of several identifiable phas- crete independently of graft reinnervation by the recipient bed.Thin es [see 1:7 Acute Wound Care].The first phase is an inflammatory re- split-thickness skin grafts tend to be quite dry because they contain sponse that includes both vascular and cellular components. The inadequate numbers of functioning sebaceous glands, which are second stage is fibroplasia, during which collagen deposition by fi- more abundant in thicker grafts. For this reason, such grafts may re- broblasts increases the tensile strength of the wound.The matura- quire application of a moisturizer for an indefinite period. tion phase of wound healing begins at about 3 weeks, when the rate of collagen degradation begins to balance the rate of collagen pro- Revascularization duction.The previously random arrangement of collagen fibers be- A phase of serum imbibition lasts for the first 2 days after place- comes more organized, and the ratio of type I to type III collagen ment of a skin graft. During this period, the graft is nourished by returns to normal.The wound gradually progresses from a raised, passive absorption of nutrients from serum in the recipient bed, not indurated, red scar to a mature form that is flat, soft, lighter in color, by direct vascular perfusion. Absorption of fluid causes the graft to and of increased tensile strength.The maturation phase continues increase in weight by as much as 40%.Vessels within the graft grad- for more than a year.The final strength of a scar is typically about ually dilate and fill with static columns of blood. A fibrin network in 80% of the normal strength of the skin. the wound bed causes graft adherence during this early phase. Contraction of open granulating wounds is caused by myofi- The next phase in revascularization is a period of inosculation, broblasts, which are modified fibroblasts that have smooth muscle during which anastomoses are formed between vessels in the graft characteristics.The number of myofibroblasts within the wound is and those in the wound bed. It is not clear, however, whether con- proportional to the rate at which the wound contracts.21,22 These nections are established between existing vessels in the recipient cells are scattered throughout the wound and pull the edges of the bed and graft or whether new vessels grow into the graft from the wound toward the center. Skin grafts inhibit wound contraction, recipient bed. Both processes may occur, and both may be impor- apparently by accelerating the life cycle of the myofibroblast. tant in graft revascularization. In any case, circulation is sluggish during postoperative days 3 and 4 but gradually increases during postoperative days 5 and 6 to become essentially normal by day 7.23 Postoperative Management Issues Lymphatic drainage from the graft is established at approximate- ly the same rate as the circulation of blood. Lymphatic flow is pre- SKIN GRAFTS sent by postoperative day 5 or 6, and the graft starts losing the extra fluid weight it has gained. The graft begins to resume its normal Contraction and Reinnervation weight by postoperative day 9. Split-thickness skin grafts include the epidermis and only a por- tion of the dermis, whereas full-thickness skin grafts include the en- Factors Affecting Graft Survival tire dermis. Skin grafts contract to a degree that is related to their Hematoma formation beneath a skin graft is the most common thickness. After their harvest from donor sites, full-thickness grafts cause of graft failure. Blood accumulation interferes with graft ad- contract to a surface area as small as 40% of their original surface herence, as well as with both imbibition and inosculation. Early area, whereas split-thickness grafts contract only about half as evacuation of blood from beneath a skin graft can result in graft sur- much.This reduction in area, referred to as primary contraction, is vival. Shear forces that result from inadequate immobilization cause a passive phenomenon caused by elastin within the dermis of the graft failure by preventing or disrupting developing communica- graft. Secondary contraction occurs as a graft heals at the recipient tions between vessels of the graft and the recipient bed. Infection of site. Full-thickness grafts undergo minimal secondary contraction, the recipient bed makes the bed unsuitable for grafting, and such whereas split-thickness grafts contract to a degree that is inversely infection is another major cause of graft failure. Proteolytic enzymes proportional to their dermal content. In other words, thick split- produced by microorganisms destroy the fibrin bond between the thickness grafts contract less than thin split-thickness grafts. graft and the recipient bed. Bacteria such as β-hemolytic strepto- Skin grafts gradually regain sensation through reinnervation from cocci and Pseudomonas are particularly virulent because they pro- the wound bed.Thick grafts and healthy wound beds contribute to duce high levels of plasmin and other proteolytic enzymes.The type greater sensory recovery; however, even after healing is complete, the of organism present may actually be a more important factor in degree of sensation in the graft does not equal that of normal skin. graft failure than the number of organisms present.24 Graft thickness also affects recovery of certain other functions of nor- mal skin, such as secretion from sweat glands and sebaceous glands, Healing of Donor Sites and of hair growth.These processes will be active only in full-thick- Donor sites for split-thickness grafts heal by reepithelialization. Ep- ness and thick split-thickness grafts. Secretion from sweat glands de- ithelial cells from remaining portions of skin appendages (e.g., hair pends on sympathetic reinnervation of the graft and follows the sweat follicles, sebaceous glands, and sweat glands) migrate across the ex-
  13. 13. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 3 Open Wound Requiring Reconstruction — 13 posed dermis to establish a new epidermis. Donor sites for thin grafts duration of ischemia has been associated experimentally with ob- heal more rapidly and leave less of a scar than those for thick grafts, struction to blood flow in the microcirculation.27,28 This obstruction which take longer to heal and can be associated with significant scar- results from cellular edema, increased interstitial fluid pressure, and ring. The epidermis of a healed donor site is fully differentiated with- sludging of blood and thrombus formation. This phenomenon is in 3 to 4 weeks; however, the dermis shows little evidence of regener- initially reversible but becomes irreversible as the duration of is- ation. An occlusive dressing such as OpSite (Smith & Nephew, Hull, chemia increases. After 12 hours of ischemia under experimental United Kingdom) promotes more rapid healing of the donor site conditions, obstruction to blood flow has been demonstrated to be than coverage with fine mesh gauze and is potentially less painful.25 complete, preventing successful reperfusion of the flap. How long uninterrupted ischemia can safely continue in a clinical setting is not FLAPS precisely known, and evidence suggests that different types of tissue have different levels of tolerance for ischemia. For example, flaps Resistance to Infection that are primarily bone are more durable than muscle or bowel In experimental settings, skin flaps, myocutaneous flaps, and fas- flaps. Evidence gained by clinical experience indicates that most free ciocutaneous flaps have been shown to vary in their resistance to flaps can safely tolerate up to 4 hours of ischemia. bacterial infection.26 Random-pattern skin flaps are not as resistant as myocutaneous flaps.The cutaneous portions of myocutaneous and Tissue Expansion of fasciocutaneous flaps have similar levels of resistance, but the Histologic changes noted in expanded skin include thinning of muscle component of myocutaneous flaps is more resistant than the the dermis but not of the epidermis,29 suggesting a permanent net fascial component of fasciocutaneous flaps in situations where the gain in epidermal tissue only.The mitotic rate in the epidermis has flap lies over a focus of infection within the wound. Muscle therefore been shown to increase with expansion, but the mechanism for this appears to be the type of flap that is most resistant to infection. Such increase is unclear.30 resistance is of clinical significance in cases of exposed bone with The circulation of expanded skin also changes. The increase in chronic osteomyelitis, for example.This condition can be successful- vascularity observed in expanded tissue is partially explained by the ly treated by debridement and immediate coverage with a muscle flap. fact that tissue expansion is a form of delay procedure. Experimen- tal studies suggest, however, that an increased potential for flap sur- Free Flaps and Concept of No-Reflow vivability is directly attributable to the expansion process and not Free tissue transfer is unique in that the flap is completely is- merely to its delay component.31-33 The fibrous capsule that forms chemic for a given period. How long ischemia can be tolerated with- around the prosthesis during expansion appears to contribute to out resultant flap failure (despite technically satisfactory microvas- the increased vascularity of these flaps, and the increased pressure cular anastomoses) is an important clinical question. An increasing around the expander may stimulate angiogenesis. References 1. Parrett BM, Matros E, Pribaz JJ, et al: Lower ex- tive pressure wound therapy. Wounds 16(12 suppl Operative Plastic Surgery. Evans GRD, Ed. Mc- tremity trauma: trends in the management of soft- B):1, 2004 Graw-Hill, New York, 2000, p 59 tissue reconstruction of open tibia-fibula fractures. 13. Domkowski PW, Smith ML, Gonyon DL Jr, et al: 24. Teh BT: Why do skin grafts fail? Plast Reconstr Plast Reconstr Surg 117:1315, 2006 Evaluation of vacuum-assisted closure in the treat- Surg 63:323, 1979 2. Edlich RF, Jones KC Jr, Buchanan L, et al: A dis- ment of post-sternotomy mediastinitis. J Thorac 25. Smith DJ Jr,Thomson PD, Bolton LL: Microbiolo- posable emergency wound treatment kit. J Emerg Cardiovasc Surg 126:386, 2003 gy and healing of the occluded skin-graft donor site. Med 10:463, 1992 14. Kaplan M, Banwell P, Orgill DP, et al: Guidelines Plast Reconstr Surg 91:1094, 1993 3. Stevenson TR, Thacker JG, Rodeheaver GT, et al: for the management of the open abdomen: recom- 26. Gosain A, Chang N, Mathes S, et al: A study of the Cleansing the traumatic wound by high pressure sy- mendations from a multidisciplinary expert adviso- relationship between blood flow and bacterial inoc- ringe irrigation. JACEP 5:17, 1976 ry panel.Wounds 17(10 suppl):1, 2005 ulation in musculocutaneous and fasciocutaneous 4. Hollander JE, Singer AJ, Valentine SM, et al: Risk 15. Miller PR,Thompson JT, Faler B, et al: Late fascial flaps. Plast Reconstr Surg 86:1152, 1990 factors for infection in patients with traumatic lacer- closure in lieu of ventral hernia: the next step in 27. Kerrigan CL, Stotland MA: Ischemia reperfusion ations. Acad Emerg Med 8:716, 2001 open abdomen management. J Trauma 53:843, injury: a review. Microsurgery 14:165, 1993 5. Edlich RF, Rodeheaver GT,Thacker JG:Technical 2002 28. Kirschner RE, Fyfe BS, Hoffman LA, et al: Is- factors in the prevention of wound infection. Surgi- 16. Taylor GI, Giantoutsos MP, Morris SF: The neu- cal Infectious Diseases. Simmons R, Howard R, rovascular territories of the skin and muscles: chemia-reperfusion injury in myocutaneous flaps: Eds. Appleton-Century-Croft, East Norwalk, Con- anatomic study and clinical implications. Plast Re- role of leukocytes and leukotrienes. Plast Reconstr necticut, 1981 constr Surg 94:1, 1994 Surg 99:1485, 1997 6. Robson MC, Heggers JP: Delayed wound closures 17. Hidalgo DA, Shaw WW: Reconstruction of foot in- 29. Johnson TM, Lowe L, Brown MD, et al: Histology based on bacterial counts. J Surg Oncol 2:379, 1970 juries. 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Rudolph R: Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg 63:473, 1979 Acknowledgment 12. Orgill DP, Austen WG, Butler CE, et al: Guidelines for treatment of complex chest wounds with nega- 23. Angel MF, Giesswein P, Hawner P: Skin grafting. Figure 3 Carol Donner.

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