Background
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.
History of the Procedure
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.
Presentation
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.
Relevant Anatomy
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.
Contraindications
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.
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Preoperative planning for a banner flap to repair a facial defect (same patient as in Image 2).
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Postoperative photo showing the completed banner flap repair (same patient as in Image 1).
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A nasal defect after excision of squamous cell carcinoma and prior to repair with an interpolated flap (same patient as in Images 4-6).
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The preoperative plan for the interpolated flap is designed to leave the donor scar in the natural wrinkle line of the nasolabial fold (same patient as in Images 3 and 5-6). The interpolated flap is most similar to a banner flap, and, in this case, it is folded over to reconstruct the nasal ala.
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Intraoperative appearance of the interpolated flap, folded upon itself to provide greater thickness and coverage of skin and mucosal surfaces (same patient as in Images 3-4 and 6).
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Final appearance of the interpolated flap repair, illustrating the advantage of placing the donor scar along a natural wrinkle line (same patient as in Images 3-5).
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A large lesion of the right cheek amenable to repair with a rotation flap (same patient as in Images 8-9).
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An intraoperative illustration of the rotation (cervicofacial) flap transposed into the defect site (same patient as in Images 7 and 9).
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Postoperative appearance of the completed rotation flap repair of the right cheek defect (same patient as in Images 7-8).
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A leiomyosarcoma of the scalp to be excised and closed via opposing rotation flaps (same patient as in Images 11-13).
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A scalp defect following excision of a leiomyosarcoma. Preoperative marking for repair with opposed rotation flaps is seen in blue. The anterior portion of the scar is oriented parallel to the patient's original hairline (as indicated by the dashed line) (same patient as in Images 10 and 12-13).
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Postoperative appearance of the opposed rotation flaps scalp repair (same patient as in Images 10-11 and 13).
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Final appearance of the rotation flap scalp repair (same patient as in Images 10-12).
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A lesion due to amyloidosis amenable to a V-Y closure (same patient as in Images 15-16).
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Postoperative appearance of the V-Y advancement flap (same patient as in Images 14 and 16).
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Final appearance of the V-Y advancement flap closure (same patient as in Images 14-15).
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Patient with an ischemic wound of left lower extremity status post ileopopliteal bypass revascularization (same patient as in Images 18-20).
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Left lower extremity wound immediately following eschar debridement (same patient as in Images 17, 19-20).
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Defect prepared for reconstruction following serial debridement with interval dressing changes and vacuum-assisted closure therapy (same patient as in Images 17-18, 20).
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Left lower extremity wound fully healed at 2 years following meshed split-thickness skin grafting (same patient as in Images 17-19).
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Lateral plantar foot ulceration, just proximal and in line with the fourth webspace, prior to excision and reconstruction (same patient as in Images 22-23).
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Intraoperative markings for the proposed pedicled flap, based on the medial plantar digital artery of the first plantar metatarsal artery (FPMA). Note the vertical marking signifying the pedicle (FPMA) course and length, as well as the proposed segment of tissue in the first webspace to be used for reconstruction (same patient as in Images 21, 23).
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Postoperative clinic visit showing transposition/rotation and inset of medial plantar digital artery island flap into defect. The extent of proximal pedicle dissection can be seen by the longitudinal scar in line with the first webspace (same patient as in Images 21-22).
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Significant posterior ankle defect with exposed Achilles tendon, precluding skin grafting (same patient as in Images 25-26).
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Templated design of a 4 x 12 cm free radial forearm flap based on the radial artery (same patient as in Images 24, 26).
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Recipient site following free radial forearm flap anastomosis to the posterior tibial vessels, flap inset, and closure demonstrating excellent coverage, contour, and plantarflexion function (same patient as in Images 24-25).
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Patient with significant scalp alopecia extending from ear to ear (same patient as in Images 28-30).
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Design and inset of a posteriorly based tissue expander for staged reconstruction (same patient as in Images 27, 29-30).
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Patient following serial expansion, removal of expander, and scalp flap advancement of hair-bearing tissues (same patient as in Images 27-28, 30).
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Postoperative result showing near-anatomic reconstruction of hair-bearing scalp tissues (same patient as in Images 27-29).