PRINCIPLES OF WOUND CLOSURE

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

1. Introduction
2. Principles of wound closure
3. Types of wounds in perspective of wound closure
4. Principles in Wound Closure & Reconstruction Planning
5. Options for Wound Closure and Reconstruction
6. How Does Flap Differ from Graft?
7. Tissue Expansion�����

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Content

Wound Care Training Module - National Wound Care Committee

Content

Wound Care Training Module - National Wound Care Committee

INTRODUCTION

The goal:

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• To create an optimal wound healing environment by producing a well vascularised, stable wound bed that is conducive to normal and timely healing.

Wound Care Training Module - National Wound Care Committee

The ultimate aims:

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• Safety i.e. immediate success of wound closure and ensure preservation of life or limb.
• Restoration of form with optimal aesthetic outcome.
• Preservation of function.

Wound Care Training Module - National Wound Care Committee

PRINCIPLES OF �WOUND CLOSURE

1. Perform general and local wound assessment.
2. Perform wound or defect analysis by assessing:
1. Location – whether near or exposing the vital organs or structures
2. Size – small or large
3. Physical components involvement – type of soft tissues like muscle, tendon and nerve or bone

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Wound Care Training Module - National Wound Care Committee

3. Multidisciplinary approach to treat the underlying causes or problems of unstable wound hence managing the patient in the holistic manner.
4. Wound closure by replacing tissue defect “like with like” tissue (appropriate tissue match) whenever possible.
5. Choose appropriate technique of wound closure ensuring safety, preservation of function and aesthetically pleasing.

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Wound Care Training Module - National Wound Care Committee

TYPES OF WOUNDS IN PERSPECTIVE OF �WOUND CLOSURE

1. Simple wounds
2. Complex wounds
3. Unstable wounds

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Wound Care Training Module - National Wound Care Committee

1. Simple wounds

• Wounds that are readily managed by local wound care with subsequent healing by secondary intension, primary closure, split thickness skin graft (SSG), or local tissue/ flap rearrangement.

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Wound Care Training Module - National Wound Care Committee

2.Complex wounds

• Wounds that have excessive depth or size, in an unfavorable location, limb or life threatening conditions that usually require a distant pedicled tissue flap transposition or by microsurgery tissue flap transplantation (free flap) for closure.

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Wound Care Training Module - National Wound Care Committee

3.Unstable wounds

• Wound recurrence after a simple or complex wound closure technique or due to other related causes of wounds.

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Wound Care Training Module - National Wound Care Committee

PRINCIPLES IN WOUND CLOSURE & RECONSTRUCTION PLANNING

Wound Care Training Module - National Wound Care Committee

OPTIONS FOR WOUND CLOSURE AND RECONSTRUCTION

Reconstructive Ladder

• The reconstructive ladder provides a systematic approach to wound closure emphasizing selection of simple to complex techniques based on local wound requirements and complexity.

Wound Care Training Module - National Wound Care Committee

• Whenever it is indicated, closure of wound must not only safe and preserve form but also restore function.
• Nevertheless, selection of the wound closure techniques still needs to consider individual patient factors and also factors involving surgeons’ judgments, experience and familiarity with the techniques and availability of services for advanced wound closure technique i.e. negative pressure wound therapy, dermal matrices or skin substitute like collagen, tissue expansion and flap microsurgery.

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Simple wound

Wound contraction

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Post trauma simple wound

Primary closure after bone fixation

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Post trauma large simple wound

Negative pressure wound Therapy

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Large simple wound post degloving injury after wound bed preparation showing healthy granulation tissue

Split thickness skin graft (SSG) closure of the wound

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Unstable wound post renal transplant surgery exposing viable and functioning transplanted kidney

After debridement and wound bed preparation the wound is ready for closure

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Locoregional flap (pedicled flap) closure using anterolateral thigh fasciocutaneous flap

After inserting the flap to cover the kidney, the donor site wound in the thigh is closed primarily

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Unstable wound post compound fracture right tibia/ fibula complicated with osteomyelitis

Wound after debridement and removal of osteomyelitic bone leaving a complex wound exposing a significant bone gap is ready for closure

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Wound closure with free tissue/ flap transfer

Fibula osteofasciocutaneous flap harvested from left lower limb

Wound Care Training Module - National Wound Care Committee

Example of type of wound and �its closure

Bone gap and soft tissue defect reconstructed with free osteofasciocutaneous flap

One year after surgery

Wound Care Training Module - National Wound Care Committee

HOW DOES FLAP DIFFER �FROM GRAFT?

FLAP

• Tissue that is mobilized on the basis of its vascular anatomy.
• e.g. cutaneous, fasciocutaneous, osteofasciocutaneous, myocutaneous, muscle flap, etc.)

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GRAFT

• Transfer of tissue without its own blood supply (skin, bone, nerve or vein).
• Survival of graft depends entirely on the blood supply from the recipient site.

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Wound Care Training Module - National Wound Care Committee

TYPE OF FLAP

1. Pedicle flap / locoregional flap

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• Free flap

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Wound Care Training Module - National Wound Care Committee

1. Pedicled flap/ locoregional flap

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Tissue transferred while still attached to its original blood supply.

Wound Care Training Module - National Wound Care Committee

Example: Pressure wound closed with local flap

Wound Care Training Module - National Wound Care Committee

2. Free flap

Tissue transferred with physically detached from its native blood supply and then reattached to vessels at the recipient site by microsurgical anastomosis.

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Flapreconstructive surgery is technically demanding and has a very steep learning curve.

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Wound Care Training Module - National Wound Care Committee

Example: Complex wound after cancer extirpation exposing vital structures is closed with free fasciocutaneous flap�

Wound Care Training Module - National Wound Care Committee

TYPE OF GRAFT

1. Split thickness skin graft (SSG)

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• Full thickness skin graft (FTG)

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Wound Care Training Module - National Wound Care Committee

1. Split thickness skin graft (SSG)

Contains varying thickness of dermis

Wound Care Training Module - National Wound Care Committee

• Example: Burn wound closure with SSG

Wound Care Training Module - National Wound Care Committee

2.Full thickness skin graft (FTG)

Contains the entire dermis

Wound Care Training Module - National Wound Care Committee

INDICATION

FLAP

• Flap is generally to cover a significant contour defect that may be exposing vital structures e.g. internal organ, bone, neurovascular bundle, implant, etc

GRAFT

• SSG is generally to cover large area of wound with healthy granulation tissue (without exposing vital structures) e.g. burn injury wounds, degloving injury wounds.

Wound Care Training Module - National Wound Care Committee

TISSUE EXPANSION

• Utilizing this modality for the primary closure of the particular wound may be limited due to the fact that the size, location, or zone of injury may preclude the use of adjacent tissue for expansion.

Wound Care Training Module - National Wound Care Committee

• However, tissue expansion does have a role at a secondary procedure.
• A wound may be treated with SSG initially to close the wound.
• The surrounding skin is then expanded at a secondary procedure for durable skin coverage, with correction of the resulting scar or contour deformity.

Wound Care Training Module - National Wound Care Committee

Subcutaneous pocket is created to insert the tissue expander.

Post traumatic large soft tissue loss over the right gluteal region was skin grafted resulting in contour deformity and scar.

Wound Care Training Module - National Wound Care Committee

Skin grafted scar excised and expanded normal skin approximated hence closed primarily.

Periodical expansion till the desired volume achieved.

Wound Care Training Module - National Wound Care Committee

TAKE HOME MESSAGES

• Healthy and stable wound is a prerequisite before wound closure.
• Options for wound closure must always ensure:
• safe and successful surgery,
• restoration of form and aesthetically acceptable,
• preservation of function.
• Reconstructive ladder is a guide to wound closure.

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Wound Care Training Module - National Wound Care Committee

REFERENCES

• Hansen, S. L., Mathes, S. J. Problem wounds and Principles of closure. Plastic Surgery 2^nd ed. Saunders Elsevier, Philadelphia 2006.
• Mathes, S. J., Nahai, F., Reconstuctive Surgery: Principles, Anatomy, and Technique. New York, Churchill Livingstone, 1997.
• Jeffrey E. Janis, Robert K. Kwon, Christopher E. Attinger. The New Reconstructive Ladder: Modifications to the Traditional Model. PRS January Supplement 2011. 205s – 212s.

Wound Care Training Module - National Wound Care Committee

THANK YOU

Wound Care Training Module - National Wound Care Committee