You are in: eMedicine Specialties > Dermatology > SURGICAL Closure of Complicated WoundsArticle Last Updated: Jan 23, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Erik A Hoy, MD, Department of Plastic Surgery, Plastic Surgery Resident, Brown University, Rhode Island Hospital Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Mark S Granick, MD, Professor and Chairman, Department of Surgery, Division of Plastic Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Santiago A Centurion, MD, Staff Physician, Department of Dermatology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey Editors: Désirée Ratner, MD, Director of Dermatologic Surgery, George Henry Fox Assistant Clinical Professor, Department of Dermatology, Columbia Presbyterian Medical Center, New York Presbyterian Hospital; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: transposition flaps, banner flaps, bilobed flaps, advancement flaps, rotation flaps, rhomboid flaps, island flaps, Z-plasty, W-plasty, V-Y plasty, flap repair INTRODUCTIONSection 2 of 10
  Complicated wounds are those that cannot be closed primarily without complex surgical manipulation. The approach to the closure of the complicated wound depends largely on the nature of the wound. When managing these wounds the goals are optimal aesthetic outcome and preservation of function. Complicated wounds may occur as a result of trauma or following the excision of tumors of the skin. The focus here is the management of the clean wound following skin tumor resection, particularly of the head and neck region. However, the principles presented may be applied to the management of all complicated wounds. History of the ProcedureThe earliest documented surgical intervention to rebuild a complicated defect was from India in 700 BCE. Susruta published a description of a forehead flap for nasal reconstruction. This information was not available to Western medicine until the late 1700s, when a British surgeon noted it and wrote a brief description in Gentleman's Quarterly. Independently, the Italians developed delayed flaps, tube flaps, and flap transfers by utilizing the upper inner arm skin to reconstruct a nose. This technique was published by Tagliacozzi in the 1500s. In modern medicine, the use of local flaps to repair facial defects began to evolve around the mid 1800s. A variety of flaps were used, but the blood supply and the dynamics of the surgery were not well understood. Harold Gilles popularized tube flaps and flap delays and initiated an interest in reconstructive surgery in the 1920s. Local skin flaps such as those described in this article were primarily developed in the 1950s in Europe and the United States by the second generation of plastic surgeons. Ian MacGregor, however, recognized the importance of an axial blood supply in flap surgery in the 1970s. Subsequent refinements have led to muscle flaps and free flaps. RELEVANT ANATOMYSection 3 of 10
In managing the excisional defect, the surgeon must first assess the size and the depth of the wound as well as the presence or the absence of exposed internal anatomy in the wound. A defect containing exposed bone, nerves, or blood vessels usually necessitates a more advanced closure than would a less complicated wound. The quality of the surrounding skin is also of great importance. Skin quality may vary from young, tight, and elastic, to aged, dry, and lax. The wrinkled skin of an older patient produces less obvious scarring and offers the opportunity to conceal scars within skin tension lines. Skin that is more heavily pigmented or oily generally yields a less favorable scar. The presence of actinic damage, skin diseases, and premalignant satellite lesions should also be considered. Finally, location is of major concern. Defects adjacent to unique anatomical structures present a more involved reconstruction. Defects approaching the eyelids, the nasal openings, the oral commissure, and the external auditory meatus must be reconstructed so as to avoid distorting the anatomy unique to those areas. Any alteration of these surrounding landmarks can potentially compromise functional and aesthetic results. Facial defects merit special consideration because they represent particularly visible and potentially functionally detrimental reconstructions relative to wounds elsewhere. However, the principles presented here may be applied to the management of all complicated wounds. CONTRAINDICATIONSSection 4 of 10
When repairing facial tumor defects the most important consideration is the management of the tumor. Incompletely excised tumor should not be covered over by a flap. Skin adjacent to a tumor resection margin should not be turned over to line the nasal cavity or any other site where it will be difficult to examine. In patients who have a history of multiple or recurrent skin cancers, a strategy must be developed to allow for serial repairs. No bridges should be burned along the way. When planning a reconstruction, function must be protected first, and, then, the cosmetic issues are considered. A good-looking static repair that compromises dynamic function is unacceptable. When considering the cosmetic issues, try to avoid crossing anatomical boundaries with a flap. The obliteration of folds and creases that occur naturally will lead to an undesirable result. TREATMENTSection 5 of 10
Surgical therapyTumor resection The paramount consideration in tumor excision should be the complete removal of the tumor. Although the surgeon should have a number of reconstructive options in mind, the planned reconstruction should not dictate the extent of tumor excision. The surgeon must remain open to alternative reconstructive techniques, despite the intended reconstruction. If the defect obtained in excising the tumor cannot be reasonably reconstructed at the time of the operation, the wound should be dressed, and the reconstruction reconsidered, delayed, or the patient referred to another surgeon specializing in these repairs. This option is clearly preferable to a suboptimal reconstruction. Skin tumor excision can be performed in a number of ways. These techniques include surgical excision, micrographic excision, and electrodesiccation and curettage. Tumors can also be ablated by thermal energy or radiation. Micrographic surgery, originated by Dr. Frederick Mohs in the 1930s at the University of Wisconsin, consists of serial excision and micrographic analysis of a tumor until the margins appear histologically clear. Although micrographic excision of tumors is tissue sparing, patients with extensive tumors are preferentially treated by this technique, leaving some challenging tumor defects to repair. Undermining Undermining is performed to mobilize the tissue in areas surrounding the defect and to facilitate the draping of skin over the wound. The use of undermining allows the surgeon to move portions of the wound and not others to avoid the distortion of nearby anatomy, such as the nasolabial fold or the oral commissure. However, because tight closures make for unsightly scars, alternatives should be considered prior to undermining the edges of a gaping or complicated wound. Dog ears When using elliptical skin excisions, the long axis should be 4 times greater in length than the smaller axis. When an ellipse is made too short, or one side of the ellipse is of unequal length, the skin may bunch at one end of the closure. This is known as a dog ear. Excising dog ears when they occur is simple. This excision is accomplished by extending the elliptical excision or by cutting the corner of the excision into a Burow's triangle. Alternatively, placing a small right angle or 45° bend in the affected end of the wound closure can provide a satisfactory result. Finally, a V-shaped excision of the lateral ellipse can be used, resulting in an M-plasty closure. Wounds of unequal length In any wound, whether it is of equal or unequal length, closure is begun at the ends of the defect to avoid unnecessary dog ears. Any redundancies can be dealt with in the middle of the wound during closure. Irregularities or pleats in the mid portion of the wound generally resolve over time. Intraoperative detailsThe final outcome in any closure depends mainly on appropriate assessment of the defect and the selection of an appropriate closure technique. Primary closure involving direct approximation of the wound edges is a first option. An intermediate closure consists of approximation and closure of deeper tissue levels prior to final skin closure. Complex closure entails approximation and adjustment of the wound edges by means of undermining, the excision of any dog ears, or trimming of wound edges prior to closure. Finally, the options of skin grafting, allografting, and flap repair must be considered. When a wound cannot be closed primarily, the options are as follows: allowing the wound to heal secondarily, the placement of a skin graft of appropriate thickness (discussed elsewhere), or local tissue transposition. Healing by secondary intention consists of 2 phenomena. The major method of reduction in size of the defect is wound contracture, accompanied by reepithelization to a lesser extent. Often, this wound contracture is responsible for the distortion of nearby mobile anatomical features, such as the oral commissure or the epicanthi. The contraction of scar tissue alters the orientation of the surrounding normal anatomy, which may result in an unacceptable cosmetic outcome and more importantly, poor function. Healing by secondary intention is a viable option in fixed areas away from important anatomy, as in the case of the middle of the forehead, the cheek, or the neck. In areas adjacent to important, easily deformable, anatomical structures, transposition flaps are often a better wound closure approach. A brief explanation of these different flaps is included below. Flap coverage Local flaps offer several advantages. Flaps provide skin where it is needed to fill a defect. The skin provided is a close match in both color and texture, the donor site can be closed directly, and scar contracture is minimal. However, these flaps require experience and planning. The choice of the flap to use depends on the location and the size of the defect and the quality of the surrounding skin and where adjacent excess tissue is located. Anticipating the appearance of the donor site scar is necessary, and when possible, plan to leave the scar in a natural crease line (eg, the nasolabial fold). Transposition flaps Local transposition flaps involve the movement of adjacent skin from an area of excess to the area of deficiency. Rhomboid flaps, Z-plasties, and W-plasties are variations on this basic theme. They involve the transposition of a random skin and subcutaneous tissue flap into an adjoining defect. These flaps are designed so that the donor scar is well camouflaged. They must be meticulously designed according to the specific requirements of the reconstruction. However, transposition flaps are quick and easy for the experienced surgeon and are versatile solutions to many coverage problems. Banner flaps are transposition flaps designed as a pendant of skin tangential to the edge of a round defect. The flap is elevated, and the donor site closed. The flap edges are then trimmed to better fit the defect, and the recipient site is closed. The bilobed flap is a variant of the banner flap, in which 2 adjacent segments are raised, one smaller than the other. The 2 flaps are oriented perpendicularly to one another. The smaller flap (usually one half the diameter of the larger flap) is used to fill the larger donor site, and the small donor site is closed primarily. The original defect is then closed by means of the larger of the 2 lobes. The final result is the 180° rotation of excess tissue to fill the skin deficit. Bilobed flaps are most commonly used in the closure of nasal defects, and they are a means to transfer excess adjacent skin into the area of deficiency. Rhomboid flaps Rhomboid flaps are rhomboid-shaped skin flaps transposed into like-shaped defects leaving an angulated donor site, which can then be closed primarily. A corner of the rhombus is extended at a length equal to one of the short diagonals. This new limb is joined by another at a 60° angle. Because all rhomboids possess 4 corners that can be extended, any rhomboid defect is amenable to any of 4 possible rhomboid flaps. The end result is a scar of geometric appearance, which is best when hidden in the natural crease lines of the skin. Rather than the customary angles of 60° and 120° in the rhomboid flap, variations of the rhomboid flap using 30° and 150° angles are possible. This allows coverage of rhomboid defects with unequal sides. Because this approach involves more meticulous planning, first converting the defect into a rhombus of 60° and 120° angles is sometimes simpler. When a larger wound needs to be closed, the circular defect can be converted into a hexagon and closed with 3 rhomboid flaps. This procedure is even more complicated to plan, and it leaves a stellate-shaped scar. The scar is difficult to merge into natural crease lines and is consequently noticeable as a geometric scar. Use this technique with caution. Z-plasty The Z-plasty is a double transposition flap, and it is often an appropriate option in scar revision or in the release of scar contractions. These flaps are well suited for the correction of skin webs and disrupting circumferential scars or constricting bands. Furthermore, the Z-plasty elongates the operated tissues. The Z-plasty entails the exchange of 2 adjacent triangular flaps. The incision consists of a central limb and 2 limbs oriented to resemble a Z. All limbs are the same length to facilitate closure. The length of the central limb dictates the absolute gain in length after Z-plasty, while the angles chosen determine the percent of length increase. The typical Z-plasty has 60° angles, resulting in a gain in length of 70% relative to the central limb. The angles may range from 30-90°, providing gains in length of 25% and 120%, respectively. However, these gains are theoretical, and smaller gains are seen in practice because of restrictive skin factors. In addition, because the Z-plasty relies on healthy adjacent skin, it is a poor choice for the correction of burn wound contractures. However, the gain in length granted by the Z-plasty is well suited to other scar contractures, and the changed axis of the final scar often provides a more aesthetic result in facial scar revision. When laying out the Z-plasty, the final position of the central limb is plotted first. This final position is perpendicular to the original central limb incision, and it should be oriented parallel to the skin lines. Consecutive Z-plasties result in further transposition of skin and obliteration of straight-line scars. Multiple Z-plasties produce transverse shortening and lateral tension on the wound. W-plasty The W-plasty is similar to a Z-plasty in its ability to break up a linear scar, though, here, multiple smaller triangular flaps are interposed among one another. The base of each triangle is aligned with the vertex of the one opposite it. However, unlike the Z-plasty, the W-plasty does not confer any gain in length to the contracted scar line. The W-plasty increases rather than decreases lateral tension, and skin must be sacrificed in its construction. Therefore, the procedure should only be undertaken in areas of scar with excess adjacent skin. As the ends of the scar are approached, the triangles should decrease in size, and the limbs of the triangles should decrease as well. Rotation flaps Rotation flaps are semicircular flaps raised in a subdermal plane and rotated from the donor bed around a pivot point adjacent to the defect. The defect site is visualized as a triangle with its base as the shortest side. After the flap is rotated into the defect, the donor site is closed primarily, yielding an arcuate scar. Considerable tension may be present in this flap, which needs to be recognized. The line of maximal tension is directly opposite the pivot point and adjacent to the defect. Excessive tension along this line may result in ischemia and subsequent necrosis of the flap. Rotation flaps require a great degree of planning, and little gain is realized relative to the size of the flap. In some cases, the donor site cannot be primarily closed and may require a skin graft. However, depending on the location of the defect to be repaired, rotation flaps may be preferable to transposition or advancement flaps. Advancement flaps Advancement flaps involve raising skin in a subdermal plane and moving its leading edge into the defect. The movement of the flap is longitudinal rather than rotational. Again, these flaps may be a multitude of sizes as per the size of the defect. Burow's triangles are often excised at the base of the flap to provide for greater length of transposition to cover larger defects. These flaps have limited coverage potential and limited utility. V-Y plasty In performing a V-Y plasty, the skin flap is not elevated, and it remains attached to the underlying subcutaneous tissues. A V-shaped flap is designed adjacent to the defect. The surrounding skin is elevated, and the V-shaped tissue is advanced into the wound. The flap lends itself to disguising the scar in natural crease lines. Alternative ways to elevate a V-Y flap include central undermining and lateral pedicles or partially undermining the central attachment. The donor site is closed primarily, yielding a Y-shaped closure. This technique is well suited to elongating the nasal columella and correcting the whistle deformity of the lip, but it is applicable to many defects elsewhere on the skin. Island flaps Island flaps, as their name implies, involve the transposition of an island of skin that is raised on its blood supply. The skin island is moved into the defect, and the donor site is closed primarily. Often, this involves tunneling the flap under adjacent skin on its vascular pedicle. In areas, such as the eyebrow, the island flap provides a supply of like tissue without allowing for the distortion of the normal anatomy. The nasolabial island flap is frequently used as a flap based on a single pedicle to reconstruct defects of the nasolabial fold or portions of the nose. More recently, a bipedicled flap has been proposed to provide nasolabial skin for repair of cheek defects. Regardless of location, a circular island flap may pincushion, and this should be recognized, planned for, and avoided. Follow-upFollow-up care is an important aspect in the treatment of any surgical wound. The timing of suture removal is critical in preventing suture cross marks and epithelial cysts. Patients need to be advised as to the proper management of new scars and monitored to be certain that the healing process is progressing normally. As in any condition, follow-up and continuity of care is a vital aspect of good medical practice. Importantly, also realize and explain to the patient that 3-6 months will elapse before the flap is mature and has its optimal appearance. COMPLICATIONSSection 6 of 10
Early complications of flap reconstruction The possible complications following flap reconstruction range in severity and require distinct approaches depending on the complication type. Fortunately, most of the complications are preventable as well as amenable to treatment. The more common early complications following skin flap reconstruction surgery are the development of infection, hematoma, seroma, or wound dehiscence. Infection is uncommon in clean surgery, and perioperative antibiotics are used as indicated. When a wound becomes cellulitic, then antistaphylococcal and streptococcal medicines are administered. Abscessed wounds require incision and drainage. Culture and sensitivity should be undertaken, and the appropriate antibiotic should be administered. Good hemostasis is paramount in the prevention of hematomas and seromas. Hematomas should be drained or aspirated whenever possible to prevent induration and irregularity of the operative field. Seromas often resolve without treatment, but they may be aspirated as needed. Wound dehiscences can occur as the result of poor surgical technique, poor patient compliance, or poor patient healing ability. Patients with renal failure, those undergoing chemotherapy for cancer, those who are malnourished, or those who have been irradiated heal poorly. A judicious method of dealing with minor dehiscence is to allow the patient to heal spontaneously and to attempt repair at 6 months after the scar has matured and normal healthy tissue surrounds the original defect. The complication of flap necrosis is a more serious one and is usually due to a design flaw or an error in execution of the reconstruction. These errors include the use of too small a flap for a given defect, damage to the flap's blood supply, extending the flap beyond its blood supply, or closing the defect in such a way that it is subject to too much tension. Flap necrosis usually can be avoided by more precise flap design and avoidance of undue tension upon closure of the wound. Treatment of distal necrosis is conservative and may include allowing certain areas to heal by secondary intention and/or subsequent surgical revision of the area. However, in areas where the flap was placed to prevent a deforming scar contracture, such as the eyelid, a new reconstruction should be performed as soon as the wound condition permits. Late complications of flap reconstruction These complications are avoided for the most part by experience and careful planning of the flap reconstruction. Unfavorable scarring is a complication that occurs when scars are placed outside of the direction of the skin tension lines. Scars that lie in the wrong direction can be revised with a Z-plasty or a W-plasty. Pin-cushioning (trap door deformity) of the flap is another complication that arises from a curvilinear scar. Correction of the pin-cushion deformity should not be performed until the scar matures. Options for correction include excision of the old scar, defatting of the flap, and closure with Z-plasties or a W-plasty. Hypertrophic scars are uncommon on the face. However, keloids can be a big problem. Any patient with a personal or family history of keloids or a personal history of hypertrophic scars must be warned about the risk of developing a keloid or a hypertrophic scar. Once a keloid forms, many treatment options are available, most of which are only partially effective in minimizing the scar. Pressure, topical silicone, steroid injections, and massage are the standard treatments, although reexcision in conjunction with intralesional steroids and postoperative radiation may also be considered for unresponsive lesions. OUTCOME AND PROGNOSISSection 7 of 10
If local flaps are insufficient to cover a wound properly, distant tissue may be imported by using techniques, such as skin grafting, pedicled flaps, axial flaps, fasciocutaneous flaps, myocutaneous flaps, or free flaps. If the removal of sutures that are too tight or a correction of a hematoma delays the repair, this is a small price to pay for the avoidance of flap necrosis and a better end result. The primary goal in tumor surgery is to adequately treat the tumor. Only then can a definitive reconstruction be undertaken. The reconstruction must preserve function and provide the best possible cosmetic result. FUTURE AND CONTROVERSIESSection 8 of 10
The future may hold many promising options for repair of facial defects. Advances in tissue expansion techniques, prefabricated skin flaps, advanced wound therapies, skin substitutes, angiogenesis, in vitro tissue culture, and applications of stem cell therapies may facilitate closure of complicated facial wounds. However, local skin flaps and the techniques described in this article should continue to play a major role. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Closure of Complicated Wounds excerpt Article Last Updated: Jan 23, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
