Wound management

Wounds can be managed either nonoperatively or operatively depending on the individual clinical situation.

Nonoperative Wound Management

Adequate dressings may convert an initially nonhealing wound into a healing wound. A well-hydrated wound will epithelialize more rapidly than a dry wound, which explains why wet dressings promote wound healing.

Occlusive dressings are associated with increased angiogenesis, improved dermal repair, and accelerated wound epithelialization, due to thermal insulation, alterations in pH, PO2, and PCO2, and the maintenance of growth factors in the wound environment.14 Skin maceration is the major downside of occlusive dressings, which is why many modern occlusive dressings are semipermeable. A newly developed and recently popularized type of occlusive dressing is the vacuum-assisted wound closure (VAC). The VAC system combines an occlusive dressing with suction thus creating a wound vacuum (Fig. 7-7). The system is placed on a clean wound bed to promote granulation tissue growth, fluid removal, and wound contraction, as well as to provide a moist healing environment, to enhance blood flow and to protect the wound from outside contaminants.15,16 The subatmos-pheric pressure is set to 125 mmHg below ambient pressure and changed every other day. This is an appropriate, manageable, and efficacious therapy for both inpatients and outpatients.

Operative Wound Management

There are certain fundamentals of wound closure which apply to any operative management of a skin wound:

• The incision lines should be placed in the natural skin folds, especially in the face so that the final scar lies in relaxed skin tension lines.

• Tissues should be handled gently, including using appropriate surgical instruments and suture material of the proper thickness.

• Hemostasis should be ensured and iatrogenic contamination avoided.

Figure 7-7 Vacuum-assisted wound closure; the VAC system combines an occlusive dressing with suction creating the ideal environment to promote wound healing while providing temporary wound closure.

• Tension at the wound edges should be avoided.

• Suture material should be kept in place as long as necessary but should be removed as early as possible.

The reconstructive ladder represents a generally accepted principle in the operative management of wounds. A wound itself can either be simple or complex. Therefore, its management can encompass various types of reconstructive strategies from simple wound closure to closure using a local flap to wound reconstruction with a pedicled flap and finally to microvascular free tissue transfer. The principles of simple wound closure are discussed earlier. A local flap can include skin, muscle, fascia, or a combination of such tissues randomly rotated or advanced into the nearby defect or wound (Fig. 7-8A and 8B). Z-plasties, and VY-plasties are examples of local, random pattern flaps without a defined blood supply. A pedicled flap is a regional transfer of skin, muscle, fascia, or a combination of the tissues based on a defined axial blood supply with a pedicle containing a named artery and its venae

Figure 7-8 Myocutaneous (muscle/skin) flap rotated into a nearby defect (wound), in this case a sacral decubitus ulcer after debridement.
Figure 7-8 (Continued)

comitantes (associated veins). Microvascular free tissue transfer represents the transplantation of an axial pattern flap to a distant location, for example, the transfer of the latissimus dorsi muscle and its cutaneous paddle from the back to cover a large forearm wound (Fig. 7-9A and 9B). Such transfer is performed by temporarily interrupting the blood supply of the muscle and subsequently restoring blood flow via anastomosis to vessels at the new location.

Split thickness skin grafts (STSG) and full thickness skin grafts (FTSG) represent a simple form of free tissue transfer. However, the initial nutritional and oxygen supply of a graft is maintained by diffusion from the host bed.

Figure 7-9 Microvascular free tissue transfer; transplantation of an axial pattern flap to a distant location by temporary interrupting the blood supply; in this case a myocutaneous latissimus dorsi flap to a forearm wound (same patient as in Fig. 7-1).
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