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Surgical Management of
wounds, flaps, grafts, and
scarsCherrie Heinrich, MD, FACS
Department of Plastic SurgeryRegions Hospital
Assistant Professor University of Minnesota
Disclosures
� I have no financial disclosures
Background
� Wounds can be created by a variety of ways:
� Trauma/injury
� Surgery
� Tumor or lesion removal
� Assess wound:
� Is wound clean?
� What is missing?
� Patient health
Options for wound closure
� Primary closure
� Skin grafts
� Local flaps
� Axial
� Random
� Free Flaps
� Negative pressure wound therapy
Reconstructive Ladder
Methods TypesDirect closure
Skin Grafts
Local and Regional Flaps
Distant Pedicle Flaps
Free Flaps
Primary
Secondary
STSG
FTSG
Random
Axial
Random
Axial
Fasciocutaneous,
muscle, or bone
Direct Closure
� Direct closure is simplest and often most
effective means of achieving viable coverage
� May need to “recruit” more skin to achieve a
tension free closure
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STSG
� Advantages
� May be meshed
� Large area
� Require less
revascularization
� Temporary
coverage
� Disadvantages
� Poor cosmesis
� Limited durability
� Contracts over
time
� Donor site
problems
� Pain
� Infection
FTSG
� Advantages� No wound
contracture
� Increased sensibility
� Increased durability
� Better cosmesis
� Primary closure of donor site
� Disadvantages
� Longer to
revascularize
� Cannot mesh
� Recipient site
must have rich
vasculature
Primary closure & skin graft Wound Preparation for Grafts
� Vascularity
� Hemostasis
� Debride all
necrotic tissue
� Optimize
co-morbid
conditions
Donor Site Selection
� STSG� 0.015 inches thick
(thickness #15 scalpel)
� Lateral buttock
� Ant. and Lat. Thigh
� Lower abdomen
� Avoid medial thigh and forearm
� FTSG� Depends on area
to be covered
� Large grafts-lower abdomen and groin
� Small- medial brachium and volar wrist crease
� Plantar skin from instep
Skin graft (STSG)
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Skin Harvest for FTSG
� Use template
� Cut out ellipse
� Defat after
harvest
� Apply and
compress with
moist bolster
Skin Graft Care
� Bolster x 5 days
� After bolster
� Nonstick gauze adaptic or xeroform 2 weeks
� Wash with soap & water in shower
� After 2 weeks start moisturizing with
aquaphor or Vaseline no further dressing
needed. Can start compression
Donor Site Care
� Semi-occlusive
� Avoid changing for
first 7-10 days
� Start moisturizing at 2
weeks no dressing
needed
� Normal shower by 2 weeks
� Aquaphor or vaseline
Indications for Flap Coverage
� Skin graft cannot be used
� Exposed cartilage, tendon (without paratenon), bone, open joints, metal implants
� Flap coverage is preferable
� Secondary reconstruction anticipated, flexor
joint surfaces, exposed nerves and vessels, durablitiy required, multiple tissues required, dead space present
Classification of Soft Tissue
Flaps� Random
� Based on dimensions
� Axial� Has a named blood
vessel
� Local
� Advancement
� Rotation
� Distant
� Direct
� Tubed
� Free
Pursestring (a form of local tissue
advancement)
4/5/07 4/16/07
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RandomCross finger flap
� Full thickness
coverage
� Donor site morbidity
� 2 step process
� Delay 2-3 weeks
Bilobed flap (local, random)
� 8 year old Guatemalan child burned in
kitchen fire at age 4.
Release of index finger flexion
contracture and first web
contracture with double dorsal
finger flap
Index finger
Middle finger
Bilobed flap
All flaps and FTSGs viable
at POD 4.
First dorsal metacarpal artery flap
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Reverse radial forearm flap
Harvesting the corn….
Reverse radial forearm flap
Reverse radial forearm flap Free Flaps
� Transfer of composite tissue with vascular
supply
� Comprised bone, fat, muscle, nerve and or
skin
� Requires anastomosis of blood vessels
Negative Pressure Therapy
Wound Healing Barrier VAC Therapy
Excess Bacterial Burden Remove Infectious Material
Inadequate Protection Provide Protected Wound
Healing Environment
Excess Exudate Removes Fluid
Excess Edema Removes Fluid
Dry Wound Provides Moist Healing
Environment
Lack of Blood Flow Promotes Perfusion
Lack Granulation Tissue Decrease Barrier to Cell
Ingrowth
� Blood Flow
� Granulation Tissue Formation
� Bacterial Clearance
� Cytokine Milieu
V.A.C. Therapy – Scientific Basis
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Evidence Based Trials
0
10
20
30
40
50
60
70
VAC W/M
P < 0.05
Joseph E., Hamori CA., Bergman S., et al. A prospective randomized trial of vacuum-assisted closure
versus standard therapy of chronic nonhealing wounds. Wounds. 12(3): 2000, 60-67.
Wound management until
definitive closure
Closure with STSG when medically
stable
Temporizing dressing until ready
for flap coverage
Pin Site Care
� Ok to wash with soap
and water
� Leave open or cover
with dry gauze under
splint
� No ointment, no
peroxide, no xeroform
Questions
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Thank You
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