1) Staged closure is a simple approach for closing large, difficult wounds when conventional techniques like grafts or flaps are not possible due to poor local or general patient conditions. 2) The method involves serial debridement and negative pressure therapy followed by staged closure procedures to gradually narrow the wound over time using the principles of creep and stress relaxation. 3) The document describes 4 cases where staged closure was used successfully to close wounds on the chest, abdomen, buttock, and extremities when other reconstructive options were not feasible or practical.

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. 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. 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. 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. 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. 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. 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. 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.