Wound closure and the reconstructive ladder in plastic surgery

Abstract

Wound closure requires deep understanding of wound physiology, anatomy, and the healing phase of the wound. The basic principles of wound closure, diabetes control, normal nutrition status, infection control, mechanical stress avoidance, and nursing care are all important elements in achieving healing of acute and chronic wounds. This goal is achievable only through the interdisciplinary approach to wound healing. A number of wound closure techniques are available to the plastic surgeon. This armamentarium includes a variety of techniques, from simple primary wound closure to more-sophisticated and -costly flap reconstructive techniques. This article summarizes the components of the reconstructive ladder for wound closure that are available to the reconstructive surgeon.

Keywords: Flaps; Primary closure; Secondary intention; Skin grafts; Tissue expansion; Wound closure; Wound healing.

Figure 1

Healing Secondary Intention. A, Necrotic wound after attempted primary closure. B, Healing wound by secondary intention. C, Healed wound by secondary intention after 2 months.

Figure 2

Primary Closure. A, Preoperative marking for basal cell carcinoma excision. B, Postoperative view after excision and primary closure of resulting wound.

Figure 3

Full-Thickness Skin Graft. A, Preoperative view of left infraorbital defect after basal cell carcinoma excision. B, 6 month Postoperative view after full thickness skin graft harvested from left supraclavicular area.

Figure 4

Split-Thickness Skin Graft. A, Preoperative view of left shoulder fibrohistiocytoma. B, Postoperative view at 1 week, after excision and split thickness skin graft harvested from left thigh. C, Postoperative view at 1 month. D, Postoperative view at 1 year.

Figure 5

Local Flaps. A, Preoperative view of stage IV sacral pressure wound. B, Postoperative view of right gluteal fasciocutaneous rotational flap closure.

Figure 6

Local Flaps. A, Preoperative view nasal tip basal cell carcinoma. B, Intraoperative view after basal cell carcinoma excision and dorsal nasal flap design. C, Final result after wound reconstruction with an advancement dorsal nasal flap.

Figure 7

Distant/Regional Flaps. A, Right nasal side wall Mohs defect after squamous cell carcinoma excision. B, First stage reconstruction using right nasal labial fold pedicle flap. C, Final result after second stage reconstruction including division and inset of flap.

Figure 8

Tissue Expander. A, Preoperative view after left breast mastectomy. B, Postoperative view of left breast reconstruction with tissue expander. C, Final result after left breast tissue expander exchange with saline implants, left nipple reconstruction and right breast mastopexy to achieve symmetry.

Figure 9

Free Flap. A, Preoperative view of high-impact accident with comminuted tibial and fibular bone fracture and significant soft tissue loss (Gustillo IIIB; courtesy of Jessie Taylor, MD, University of Cincinnati, Plastic Surgery). B, Postoperative view of anterolateral thigh free tissue transfer to cover defect (courtesy of Jessie Taylor, MD, University of Cincinnati, Plastic Surgery).