Closure of Complicated Wounds

Complicated wounds are those that cannot be closed primarily without complex surgical manipulation, and they often require adjunctive advanced wound care management. The exact approach to the closure of complicated wound depends on the causes for, location of, physical characteristics of, and healing potential of the wound. The closure of these wounds often falls under the purview of reconstructive surgeons or those appropriately trained in plastic surgical principles. Ideal outcomes in managing these wounds are achieved when the synergy between functional and aesthetic function is optimized.

While there are many etiologies for complicated wounds, most often they result as a consequence of significant traumatic injury or following extirpation of oncologic tumors. Given the plethora of ways in which complicated wounds may present, the field of reconstructive surgery is immensely broad, and the chosen treatment is highly individual to both patient and clinician. The focus of this article is the management of clean (ie, negative infectious and/or oncologic margin) wounds, particularly of the head and neck region. However, the fundamentals of many reconstructive techniques are discussed, which may be applied to the management of a multitude of complicated wounds.

The earliest documented surgical intervention to rebuild a complicated defect was from India in 700 BCE. Susruta used advancement of cheek tissues, Tagliacozzi used tubed skin flaps from the upper arm in the 1500s, and Lucas published his account of the Indian method of forehead rhinoplasty in Gentleman’s Quarterly in October 1794.

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 1597. 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. Sir Harold Gilles detailed the principles of flap and graft reconstruction of nasal defects in his 1957 treatise and initiated an interest in reconstructive surgery.

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.

In recent years, several adjuncts have become available to surgeons dealing with complicated wounds. These are not addressed in this article, but they include acellular dermal mattrices (of which there are allograft or xenograft sources, iee, human and nonhuman sources, respectively), bilaminar matrices such as Integra, and other dermal substitutes. The reader is directed to further reading on dermal substitutes, which are beyond the scope of this article.

In managing a complex defect, the surgeon must first assess the size and depth of the wound, as well as the presence or absence of exposed internal anatomy or surgical hardware (eg, orthopedic internal fixation or cranial plating) in the wound. A defect containing exposed bone, nerves, blood vessels, or hardware usually necessitates a more advanced closure than would a less complicated wound.

In reconstruction involving local tissue rearrangement or pedicled flaps, 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. In the face, 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.

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. Definitive reconstruction should be delayed with local wound care if possible until negative frozen or permanent margins have been obtained.

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 cosmetic issues are optimized secondarily. 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 leads to an undesirable result. Burget and Menick first published their subunit principles for reconstruction of nasal defects in 1985, ^[1] and they have continued to publish extensively. ^{[2, 3, 4]} Indeed, larger or longer scars on the face may be less noticeable than smaller scars, if those small scars are poorly oriented or located incorrectly. Additionally, the final scars are often designed to result in a curvilinear or zigzagged manner, as these appear less noticeable to the untrained eye. Planning is paramount in obtaining a cosmetic result in closure of complicated wounds on the face.