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Radiation therapy performed within 1-3 days after
excision, ideally within 24 hours (recurrence rate
14%)
MANAGEMENT OF WOUNDS
INITIAL WOUND ASSESSMENT
Acute vs chronic (see Fig. 1-2)
Figure 1-2 The phases of wound
healing. (From Thorne CH, Gurtner GC,
Kevin Chung KC, et al., eds. Grabb and
Smith’s Plastic Surgery. 7th ed. Wolters
Kluwer; 2014. Figure 2.2.)
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Origin and duration of wound
Traumatic vs atraumatic
Zone of injury is larger in high- vs low-impact
traumas
Assessment for other associated injuries
Extent of contamination
Antibiotics are not needed for most wounds unless they
demonstrate signs of active infection (eg, cellulitis in
chronic venous stasis ulcers).
Bite wounds are always contaminated and have a high
likelihood of infection.
Assume that the contamination is polymicrobial,
and always treat with antibiotics that cover Grampositive and anaerobic organisms (eg,
ampicillin/sulbactam or amoxicillin/clavulanate,
ciprofloxacin + clindamycin if allergic to penicillin)
Consider bacteria specific to type of bite:
Human bites: Eikenella corrodens
Cat bites: Pasteurella multocida
Tetanus prophylaxis (Table 1-2)
TABLE 1-2 Tetanus Prophylaxis Guidelines
From CDC Guidelines, 1998.
Size of wound
Extent of exposed tissue: dermis, subcutaneous tissue,
fascia, muscle, bone
>85% chance of osteomyelitis in wounds with exposed
bone
Assessment of patient-specific local and systemic factors
Presence of ischemia-reperfusion injury
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Hypoxia of the wound bed
Bacterial load of the wound
Contaminated: Bacteria present without proliferation.
Colonized: Bacteria present and proliferating but
without causing host response.
Critically colonized: Bacteria present, proliferating, and
causing host response but not enough to overcome
host’s resistance.
Infected: Expanding bacterial counts that have
overcome the host’s ability to respond.
PHYSICAL EXAMINATION
General Assessment
Overall health of the patient
Quality of tissue surrounding the wound
Presence/absence of
Radiation-induced chronic skin changes
Edema
Color: dependent rubor vs erythema
Induration/focal fluid collections
Hemorrhage
Foreign bodies
Other wounds in the area
Condition of wound bed
Location: Evaluate the area for excess pressure or
dependent positioning.
Depth: Evaluate for damage to surrounding structures,
including blood vessels, nerves, bone, muscle, and
subcutaneous tissues.
Characteristics of wound bed
Amount of granulation tissue vs fibrinous exudate
Odor
Exposed structures
Foreign bodies
Sinus tract/tunnel formation
Drainage
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Neurosensory examination
Gross sensation based on dermatomes involved
Two-point discrimination: normal two point <5 mm
Vibration sensation
Vascular examination
The presence of both palpable peripheral pulses and
Doppler signals in vascular territories adjacent to the
wound
Temperature of extremity or digit
Skin changes consistent with venous stasis, peripheral
arterial disease, and/or lymphedema
Laboratory/Radiographic Testing
Complete blood count (CBC): evaluate for elevated WBC
count and anemia.
Albumin: evaluate for malnutrition if <3.5 g/dL.
Erythrocyte sedimentation rate and C-reactive protein:
may signal the presence or recurrence of osteomyelitis but
are nonspecific inflammatory markers that may be elevated
in any proinflammatory state, so should be interpreted in
the context of the entire clinical picture.
Hemoglobin A1C.
Creatinine
Renal failure may predispose patients to chronic
wounds and poor wound healing.
Calciphylaxis is an important underlying cause of
chronic wounds in patients with end-stage renal
disease.
Plain films: Assess for fractures, orthopedic plates/screws,
foreign bodies, and osteomyelitis.
Computed tomography (CT): Assess for abscesses,
chronic sinuses, extent of wound, and involved structures
Magnetic resonance imaging (MRI): To evaluate the
extent of osteomyelitis, especially if spine is involved.
Ankle-brachial indices
>1.2: calcified vessels (eg, diabetes)
0.9-1.2: normal
0.5-0.9: mixed arterial/venous disease
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<0.5: critical stenosis, symptomatic claudication
<0.2: ischemia and gangrene
Angiography: to evaluate the extent of vascular disease or
vascular injury
If there is evidence of significant peripheral vascular
disease, wounds should not be débrided until
revascularization procedures are complete to optimize
wound healing.
Exception: Wounds must be débrided regardless of
vascular status if there are signs of overt infection (eg,
“wet” suppurative gangrene).
Biopsy/cultures
Help target antibiotic regimens and durations; should
only be taken after appropriate débridement.
Evaluate for malignancy for atypical or chronic
nonhealing wounds.
Quantification of bacterial colonies helps in diagnosis
and in following progression of treatment.
DÉBRIDEMENT
Surgical, Enzymatic (Collagenase), Mechanical (Versajet,
Waterpik), and Autolytic
Reduces bioburden by removing inflammatory component
of wound, biofilms, fibrinous tissue, which contains cytotoxic
mediators that inhibit wound healing.
Promotes wound healing by converting a chronic wound
into an acute wound to promote keratinocyte migration.
Vital structures (eg, nerve, tendon, bone, and vessels)
should not be débrided whenever possible unless gross
infection or ischemia is present.
DRESSINGS
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Goals
Protect the wound from the external environment and
mechanical forces.
Absorb secretions/maintain a clean environment.
Promote granulation tissue formation and
reepithelialization: Moist environment leads to increased
granulation tissue formation and tissue reepithelialization as
compared with dry environment and can promote
débridement during dressing changes.
Optimize patient comfort.
Type of Dressings
Nonocclusive dressings (eg, Gauze)
Permeable to both gas particles and fluids
Typically utilized for “wet to dry” dressing
Allowing the gauze to dry prior to removal results
in mechanical débridement of the wound during
each dressing change.
Removal of the dry gauze also creates a mild
proinflammatory state, which can help with wound
healing.
Coarse gauze provides greater débridement
compared with fine gauze.
“Wet to wet” dressing: Used over exposed tendon,
bone, and neurovascular structures to minimize
desiccation.
Semiocclusive dressings (eg, Tegaderm)
Sheet dressings that are impermeable to fluids but
allow passage of gas molecules.
Typically used to cover skin graft donor sites and for
fingertip amputations to keep area moist and promote
healing.
Must be cautious in using on areas of thin/fragile skin.
Should not be used in contaminated wounds.
Occlusive dressings
Hydrogel (eg, AquaSorb and Hydrosorb).
Composed of complex polysaccharides, nonadhesive.
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Use in wounds with mild, superficially exudative
regions and in painful wounds.
Rehydrate wounds and maintain moisture independent
from the moisture that is inherently present in the
wound.
Can be used in infected wound beds.
Hydrocolloids (eg, Duoderm)
Comes in paste, powder, and sheet forms.
Fully adhesive, minimally absorptive.
Cannot use in infected wounds.
Induces autolytic débridement within wound.
Use in mild, superficially exudative wounds.
Foam (eg, Mepilex)
Usually composed of nonadhering polyurethane.
Highly absorptive, but nonhydrating.
Use in moderately to heavily exudative wounds.
Alginates (eg, Algiderm, Aquacel)
Derived from seaweed.
Comes in ribbon/rope forms.
Can absorb 20× the dry weight of the dressing.
Use in highly exudative wounds.
Antimicrobial dressings
Silver-coated or -impregnated dressings (eg, Silverlon)
Xeroform: 3% bismuth tribromophenate-impregnated
gauze
Negative pressure wound therapy
Consists of using a sponge, occlusive dressing, and
vacuum
Reduces edema
Removes excess interstitial fluid from the wound
bed, decreasing interstitial pressure and promoting
improved blood flow from wound bed capillaries
Vacuum imparts strain on cells within wound,
activating molecular changes including
upregulation of the VEGF pathway and
angiogenesis
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Does not auto-débride wounds but induces tissue
deformation
*Must not use over
Normal skin
Infected tissues
Tissues harboring malignant cells
Inadequately débrided wounds
Neurovascular structures
SURGICAL WOUNDS
Classification of Surgical Wounds
Clean (class I): nontraumatic; no entry into respiratory,
gastrointestinal (GI), genitourinary (GU) systems prior to
incision; no break in sterile technique (<2% risk of infection)
Clean-contaminated (class II): nontraumatic; minor
breaks in sterile technique; entry into GU, GI, and/or
respiratory tracts, but without significant spillage (<10% risk
of infection)
Contaminated (class III): traumatic, may include gross
entry and spillage from GI or GU systems, involves grossly
infected tissues/fluid (~20% risk of infection)
Dirty (class IV): traumatic, dirty wound, significant
devitalized tissue, fecal matter, foreign bodies, evidence of
perforated viscus, and inflammation (40% risk of infection)
General Considerations When Creating Incisions and for
Wound Closure
Type of skin and location on the body
Specific areas are prone to scar widening and
hypertrophy (eg, shoulder/sternal areas, high-tension,
lots of motion), whereas others tend to heal more
favorably (eg, eyelid and dorsum of the hand).
Hair-bearing skin: Scalp incisions are typically beveled
to allow for hair growth after incision has healed by
avoiding disruption of the hair follicles.
Extremity
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Longitudinal incisions are preferred to avoid
crossing joint surfaces to minimize tension and
lessen the chance of mobility-limiting scar
contracture.
Excisional and incisional biopsies should always
be oriented longitudinally in order to prevent later
morbidity and complexity if additional resection
and reconstruction is required (eg, sarcoma).
Hand incisions
Midaxial or volar zigzag (Bruner) incisions are
preferred to approach the digit volarly.
S-shaped, C-shaped, or curvilinear incisions are
preferred to approach the digit dorsally.
Direction and length of the incision
Langer lines of tension (relaxed skin tension lines):
Incisions that are able to be planned should be made
parallel to the relaxed skin tension lines.
Surgical technique
Minimize damage to skin edges with atraumatic
technique
Débridement of necrotic or foreign material
Tension-free closure
Wound edge eversion
Placement of suture that should not leave permanent
suture marks
Prompt removal of sutures
Face: 5-7 days
Hand/foot: 10-14 days
Trunk/breast: 7-10 days
Types of Closure
Primary closure: Tissues are reapproximated (using
sutures, staples, etc.) on initial presentation.
Edges must be under minimal tension.
Wound cannot be infected.
Secondary intention closure: Wound heals with time
through accumulation of granulation tissue, usually with
frequent dressing changes.
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Delayed primary closure: Wound initially heals through
secondary intention. Once wound bed is clean and under
minimal tension, wound edges can be reapproximated
using primary closure techniques.
Closure Materials (See Table 1-3)
TABLE 1-3 Commonly Used Suture Materials
Suture
Classified as absorbable vs nonabsorbable;
monofilament vs braided; synthetic vs natural
Absorbable
Lose at least 50% of strength in 4 weeks
Often used in children/unreliable patients to
avoid suture removal
Nonabsorbable: Permanent, body induces a cellmediated reaction around the suture, which
eventually encapsulates the suture.
Monofilament vs braided: Braided sutures have
greater knot security and flexibility but has slightly
increased risk of infection and greater friction
through tissue.
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