History of surgery for wounds

Wounds, mostly resulting from trauma, have existed since the beginning of man. The Edwin Smith Papyrus, which was written more than 5,000 years ago, is the oldest known surgical treatise. It contains 142 different references to the management of sores and wounds. Surgical management of wounds is nearly as old. Hippocrates said, “He who wishes to be a surgeon should go to war.” His words highlight the relationship of surgical advances and war-related injury. Modern reconstructive surgery had its beginnings with traumatic injury, at a time when the nose was cut off as a form of punishment. In Italy during the sixteenth century, noses were reconstructed using the skin of the inner upper aspect. This flap is known as the Tagliacozzi flap. Modern plastic surgery came into its own during World War II when the sulfa antibiotic allowed many wounded soldiers to survive their injuries, and consequently they required reconstructive surgery. Today, surgery remains an important aspect of wound care, and advances in surgical options continue to be made.

Surgical decision making

Selection of wound closure method

Selecting a method of closure depends on a holistic assessment that considers the needs and goals of the patient. A common set of decision-making steps (e.g., the reconstructive ladder) serves as a guide for plastic and reconstructive surgery (Figure 33-1). The simplest method that accomplishes the patient’s goals usually is the first choice. In addition to the complexity of the surgery, consideration is given to the morbidity that would be created for the donor site. For example, if a person lost a thumb, transplantation of the great toe to replace the thumb would be considered; however, the thumb would not be used to replace a great toe.

FIGURE 33-1 Reconstructive ladder.

When considering donor site morbidity for pressure ulcer surgery, it is important to keep in mind that tissues usually can be moved or donated only once. Therefore, the choice of which tissue to use is important. Surgeons try to select donor areas that will not interfere with future potential flap donor sites, especially in patients with paraplegia or quadriplegia because this patient population often requires more than one operation during their lifetime. Large wounds of the entire perineum in patients with paralysis may require removal of the leg and filleting of the tissues to form an adequately sized flap of muscle and skin that will sufficiently close the wound. This situation is a dramatic example of donor site morbidity.

Surgical wound closure can be achieved using a number of techniques, such as linear closure, secondary healing, skin grafts, skin substitutes, and tissue flaps. Many factors are considered when determining the optimum wound closure technique. When little tissue is missing, the skin is sufficiently pliable and the wound is considered to be clean, a linear closure (i.e., approximating the wound edges and securing with suture) is a reasonable choice.

Secondary healing (i.e., letting a wound heal by scar tissue formation) is the simplest method of healing and a logical selection for a clean Stage II pressure ulcer. The ongoing risk of infection in the deeper open wound, however, may prompt a decision for surgical closure to speed healing. Similarly, some partial-thickness wounds (e.g., burn on the hand) create significant morbidity due to the contractile scars that form during healing. In these situations, skin grafting would be warranted to close the wound.

Skin grafts (i.e., sections of intact epidermis and upper layer of the dermis) can be removed from the patient’s donor site and transferred to cover shallow, vascularized wounds. Split-thickness skin grafts can be placed as entire pieces of skin or meshed to promote drainage of wound exudate and contouring to the skin surface. Skin grafts also can be full thickness, but only where vascularity in the donor site is sufficient to heal full-thickness grafts.

Skin grafts provide superficial coverage but do not replace deeper tissue layers, such as subcutaneous tissue and muscle; thus they are unable to provide the padding needed to protect bony prominences from recurrent breakdown. Therefore, skin grafts are rarely, if ever, used in the surgical management of pressure ulcers, except to close donor sites from flaps containing multiple layers of tissue. Skin grafts are commonly used to manage burn wounds and are described in greater detail in Chapter 32. Skin grafts have also been used in the management of venous ulcers (Robson et al, 2006).

Skin substitutes can be used to close a wound. The skin substitute can be epidermis only, dermis only, or both. Epidermal skin substitutes are composed of keratinocytes, take 2 to 3 weeks to “grow,” and are generally used when the patient does not have sufficient healthy skin graft donor sites available. Dermal substitutes are composed of fibroblasts embedded in a “matrix” material that provides a scaffolding for cellular and capillaries migration. Epidermal replacements and extracellular matrix scaffolds are discussed in Chapter 19.