Reducing Risks for Poor Surgical Wound Healing

Abstract

This review summarizes common risk factors for poor surgical healing on the face and neck and a generalized approach to treating a delayed healing wound. During the preoperative evaluation patients should be screened for prior irradiation, cigarette or e-cigarette use, chronic steroid use, alcoholism, diabetes, malnutrition, and other chronic medical conditions and medications. Despite the surgeon's best efforts to prevent poor surgical healing, some wounds may display signs of persistent inflammation. The facial plastic surgeon should be astute in recognizing delayed healing and identifying intrinsic and extrinsic risk factors so that timely intervention can be performed.

Keywords: Chronic wounds; Cigarette smoking; Delayed healing; Irradiation; Malnutrition; Vaping; Wound healing.

Fig. 1.

Depiction of overlapping phases of repair in wound healing. Any disruption in the natural cascade of healing will ultimately delay healing and potentially lead to poor surgical healing, chronic wounds, and scarring. ECM, extracellular matrix; EPCs, endothelial progenitor cells. (From Baltzis D, Eleftheriadou I, Veves A. Pathogenesis and Treatment of Impaired Wound Healing in Diabetes Mellitus: New Insights. Adv Ther. 2014;31(8):817-836. https://doi.org/10.1007/s12325-014-0140-x with permission.)

Fig. 2.

(A) An 82-year-old man with a history of scalp postoperative radiation treatment 10 years previously and multiple excisions of squamous cell cancers on the scalp. He had a persistent 2 year history of an open nonhealing scalp wound down to calvarial bone. Multiple biopsies showed no evidence of neoplastic recurrence and CT scan showed no evidence of osteomyelitis. Over 2 years he saw multiple physician providers and despite multiple different aggressive daily dressings and antibiotic trials, no clinical healing or granulation tissue occurred. (B) He required “jump starting” this chronic wound to get it back to the acute wound healing state by burring down the outer calvarium to the diploic layer to stimulate granulation tissue growth along with moisture retentive dressings. Other possible options for treating this wound would be a vacuum-assisted closure (VAC) device or a synthetic dermal substitute, (ex. Integra, Integra Life Sciences, Plainsboro, NJ)to stimulate granulation tissue on the bone. (C) After adequate granulation tissue formation, a split thickness skin graft successfully covered most of the open wound so that he no longer required aggressive daily dressing changes. The chronic wound was transformed into an acute healing wound.