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Surgical Management of

wounds, flaps, grafts, and

scarsCherrie Heinrich, MD, FACS

Department of Plastic SurgeryRegions Hospital

Assistant Professor University of Minnesota

Disclosures

� I have no financial disclosures

Background

� 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

Options for wound closure

� Primary closure

� Skin grafts

� Local flaps

� Axial

� Random

� Free Flaps

� Negative pressure wound therapy

Reconstructive Ladder

Methods TypesDirect closure

Skin Grafts

Local and Regional Flaps

Distant Pedicle Flaps

Free Flaps

Primary

Secondary

STSG

FTSG

Random

Axial

Random

Axial

Fasciocutaneous,

muscle, or bone

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

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STSG

� Advantages

� May be meshed

� Large area

� Require less

revascularization

� Temporary

coverage

� Disadvantages

� Poor cosmesis

� Limited durability

� Contracts over

time

� Donor site

problems

� Pain

� Infection

FTSG

� 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

� STSG� 0.015 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

Skin graft (STSG)

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Skin Harvest for FTSG

� Use template

� Cut out ellipse

� Defat after

harvest

� Apply and

compress with

moist bolster

Skin Graft Care

� Bolster x 5 days

� After bolster

� 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

Donor Site Care

� 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

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� Random

� Based on dimensions

� Axial� Has a named blood

vessel

� Local

� Advancement

� Rotation

� Distant

� Direct

� Tubed

� Free

Pursestring (a form of local tissue

advancement)

4/5/07 4/16/07

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RandomCross finger flap

� Full thickness

coverage

� Donor site morbidity

� 2 step process

� Delay 2-3 weeks

Bilobed flap (local, random)

� 8 year old Guatemalan child burned in

kitchen fire at age 4.

Release of index finger flexion

contracture and first web

contracture with double dorsal

finger flap

Index finger

Middle finger

Bilobed flap

All flaps and FTSGs viable

at POD 4.

First dorsal metacarpal artery flap

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Reverse radial forearm flap

Harvesting the corn….

Reverse radial forearm flap

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

Wound Healing Barrier VAC Therapy

Excess Bacterial Burden Remove Infectious Material

Inadequate Protection Provide Protected Wound

Healing Environment

Excess Exudate Removes Fluid

Excess Edema Removes Fluid

Dry Wound Provides Moist Healing

Environment

Lack of Blood Flow Promotes Perfusion

Lack Granulation Tissue Decrease Barrier to Cell

Ingrowth

� Blood Flow

� Granulation Tissue Formation

� Bacterial Clearance

� Cytokine Milieu

V.A.C. Therapy – Scientific Basis

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Evidence Based Trials

0

10

20

30

40

50

60

70

VAC W/M

P < 0.05

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, 60-67.

Wound management until

definitive closure

Closure with STSG when medically

stable

Temporizing dressing until ready

for flap coverage

Pin Site Care

� Ok to wash with soap

and water

� Leave open or cover

with dry gauze under

splint

� No ointment, no

peroxide, no xeroform

Questions

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Thank You