Surgical Management of wounds, flaps, grafts, and scars

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1 Disclosures Surgical Management of wounds, flaps, grafts, and scars I have no financial disclosures Cherrie Heinrich, MD, FACS Department of Plastic Surgery Regions Hospital Assistant Professor University of Minnesota Background Options for wound closure Wounds can be created by a variety of ways: Trauma/injury Surgery Tumor or lesion removal Assess wound: Is wound clean? What is missing? Patient health Primary closure Skin grafts Local flaps Free Flaps Negative pressure wound therapy Reconstructive Ladder Methods Direct closure Skin Grafts Local and Regional Flaps Types Primary Secondary STSG FTSG Direct Closure Direct closure is simplest and often most effective means of achieving viable coverage May need to recruit more skin to achieve a tension free closure Distant Pedicle Flaps Free Flaps Fasciocutaneous, muscle, or bone 1

2 STSG FTSG Advantages May be meshed Large area Require less revascularization Temporary coverage Disadvantages Poor cosmesis Limited durability Contracts over time Donor site problems Pain Infection Advantages No wound contracture Increased sensibility Increased durability Better cosmesis Primary closure of donor site Disadvantages Longer to revascularize Cannot mesh Recipient site must have rich vasculature Primary closure & skin graft Wound Preparation for Grafts Vascularity Hemostasis Debride all necrotic tissue Optimize co-morbid conditions Donor Site Selection Skin graft (STSG) STSG inches thick (thickness #15 scalpel) Lateral buttock Ant. and Lat. Thigh Lower abdomen Avoid medial thigh and forearm FTSG Depends on area to be covered Large grafts-lower abdomen and groin Small- medial brachium and volar wrist crease Plantar skin from instep 2

3 Skin Harvest for FTSG Use template Cut out ellipse Defat after harvest Apply and compress with moist bolster Bolster x 5 days After bolster Skin Graft Care Nonstick gauze adaptic or xeroform 2 weeks Wash with soap & water in shower After 2 weeks start moisturizing with aquaphor or Vaseline no further dressing needed. Can start compression Semi-occlusive Avoid changing for first 7-10 days Start moisturizing at 2 weeks no dressing needed Normal shower by 2 weeks Aquaphor or vaseline Donor Site Care Indications for Flap Coverage Skin graft cannot be used Exposed cartilage, tendon (without paratenon), bone, open joints, metal implants Flap coverage is preferable Secondary reconstruction anticipated, flexor joint surfaces, exposed nerves and vessels, durablitiy required, multiple tissues required, dead space present Classification of Soft Tissue Flaps Local Based on dimensions Has a named blood vessel Advancement Rotation Distant Direct Tubed Free Pursestring(a form of local tissue advancement) 4/5/07 4/16/07 3

4 Cross finger flap Full thickness coverage Donor site morbidity 2 step process Delay 2-3 weeks Bilobed flap (local, random) Bilobed flap 8 year old Guatemalan child burned in kitchen fire at age 4. Index finger Middle finger Release of index finger flexion contracture and first web contracture with double dorsal finger flap First dorsal metacarpal artery flap All flaps and FTSGs viable at POD 4. 4

5 Reverse radial forearm flap Reverse radial forearm flap Harvesting the corn. Reverse radial forearm flap Free Flaps Transfer of composite tissue with vascular supply Comprised bone, fat, muscle, nerve and or skin Requires anastomosis of blood vessels Negative Pressure Therapy V.A.C. Therapy Scientific Basis Wound Healing Barrier Excess Bacterial Burden Inadequate Protection Excess Exudate Excess Edema Dry Wound Lack of Blood Flow Lack Granulation Tissue VAC Therapy Remove Infectious Material Provide Protected Wound Healing Environment Removes Fluid Removes Fluid Provides Moist Healing Environment Promotes Perfusion Decrease Barrier to Cell Ingrowth Blood Flow Granulation Tissue Formation Bacterial Clearance Cytokine Milieu 5

6 Evidence Based Trials P < 0.05 Wound management until definitive closure VAC W/M Joseph E., Hamori CA., Bergman S., et al. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. Wounds. 12(3): 2000, Closure with STSG when medically stable Temporizing dressing until ready for flap coverage Pin Site Care Questions Ok to wash with soap and water Leave open or cover with dry gauze under splint No ointment, no peroxide, no xeroform 6

7 Thank You 7

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