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Fig. 39.2 A 68-year-old man with a 5× 3 cm necrotic pressure ulcer in the chin due to mechanical ventilation in the prone position for ARDS COVID-19 related (a). Initial surgical debridement of the necrotic eschar was performed followed by wound care using daily heliother­apy, hyaluronic acid/collagenasis ointment, and parafn
gauze. Secondary-intention wound healing was achieved in around 2 months leaving an anesthetic scarring area (b). Secondary autologous fat grafting was performed 8months later improving the chin contour and projection (c)
39 Reconstructive Options inWound Care: FromSimplest toMost Complex
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39.8 Conclusions
This chapter is to provide an overview of the vari­ous reconstructive options available for the treat­ment of chronic pressure ulcers in common and atypical anatomical locations. At present, no con­sensus has been established regarding the most appropriate reconstructive procedure for chronic pressure ulcers in particular locations. Several factors can guide for the suitable reconstructive option including the ulcer defect and grade, risk factors, general condition of the patient, quality of the surrounding tissues, morbidity of the donor site, surgeon preference and microsurgical expe­rience, and the patient’s expectations. The patient education and compliance in the preoperative and postoperative period are of paramount impor­tance especially regarding the rehabilitation pro­tocol and pressure preventive regimes.Financial Disclosure StatementThe authors have nothing to disclose. No funding was received for this article.
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Surgical Indications inAll
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Diagnostic andCare Pathways (DTCP) Settings
EmanueleCammarata, FrancescaToia, AntoninoSpeciale, MartinaMaltese, TizianoPergolizzi, andAdrianaCordova
40
40.1 Introduction
Conventionally, skin ulcers are dened as tissue lesions that show poor or no tendency to sponta­neous healing [1].
Ulcers are frequently encountered in the gen­eral population, with an estimated prevalence of about 0.3% at the age of 60 and up to 5% at the age of 90, and occur in patients in all healthcare settings, thus representing one of the most wide­spread and challenging pathologies in wound care [2].
They have a strong impact on patient’s func­tional ability and psychosocial well-being [3]. For this reason, appropriate and timely treatment is mandatory in order to reduce the morbidity burden associated with the disease and improve the patient’s quality of life. However, there is still a lack of implementation of evidence-based guidelines for ulcer treatment in daily clinical practice, which leads to poor outcomes.
Therefore, in order to provide promptness and continuity of treatments, to ensure high levels of care, and nally to improve the overall manage­ment of the pathology, each patient with an ulcer should be included in a diagnostic and therapeu-
E. Cammarata · F. Toia (*) · A. Speciale · M. Maltese · T. Pergolizzi · A. Cordova University of Palermo, Palermo, Italy e-mail: emanuele.cammarata@unipa.it;
francesca.toia@unipa.it; antonino.speciale01@unipa.it; martina.maltese@unipa.it; tiziano.pergolizzi@unipa.it
tic care pathway (DTCP), a predetermined suc­cession of diagnostic and therapeutic activities that encompasses several types of specialists and based on the latest scientic evidence [4].
Considering the complexity and the multiple etiologies of skin ulcers, treatment should be multidisciplinary (dermatologists, general sur­geons, vascular surgeons, plastic surgeons, infec­tiologists, and other clinicians) and tailored to the individual, with the aim of targeting the specic condition.
The implementation of a DTCP and the cre­ation of dedicated disease-specic paths, rein­forcing collaboration between the territorial services and the hospitals, are the keys to:
– Reduce costs through outpatient and home
management of uncomplicated cases.
– Improve outcomes through the selection of
complex cases that need referral to a rst- or
second-level center for surgical treatment [5].
40.2 Etiological Classication
andGeneral Assessment
Skin ulcers have a complex and multifactorial pathogenesis. They are classied based on etiol­ogy into different categories, each with its own typical location, depth, and appearance: venous ulcers, arterial and mixed ulcers, diabetic ulcers, pressure ulcers, traumatic ulcers, inammatory
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
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and vascular ulcers, and neoplastic ulcers. Ulcers related to venous insufciency are the most common type, accounting for about/almost 70% of cases. Arterial and mixed etiology ulcers rep­resent 10% and 15% of cases, respectively, with the remaining 5% of ulcers resulting from other less common causes [6]. In order of frequency, the most affected body sites are the medial infe­rior third of the leg, and the medial and the ante­rior part of the ankle and the foot [3].
To appropriately treat a skin ulcer, an under­standing of the pathophysiology of the wound is critical, as each type deserves a specic treatment.
Initially, all chronic wounds should be evalu­ated as stated by the TIME principle, which rep­resents the backbone of treatment: tissue type characterization (epithelializing, granulating, sloughy, and necrotic) detection of infection (contamination, colonization, and local or sys­temic infection), moisture balance (wet vs. dry, how much exudate is there?), and wound edges assessment (plain, rolled, cliff, and erythema­tous) [7].
Assessment should start with a thorough clini­cal physical examination, which can often guide an adequate initial workup. The wound location, size (surface area in cm2), depth, the presence of drainage and tissue type, as well as peripheral pulses should be documented.
Some common diagnostic tests might also be performed in order to orient the future treatment: a vascular assessment including ankle-brachial pressure index (ABPI), doppler ultrasound, and/ or angiography to detect venous reux and/or peripheral arterial disease, a microbiological swab to rule out infection, a tissue biopsy in case of atypical nonhealing wounds with doubt regard­ing malignancy or rheumatic disease, a rheumatic panel, a blood glucose test including glycated hemoglobin (HbA1c), a urinalysis to assess gly­cemic control, and a plain X-ray as an initial screening of underlying osteomyelitis, followed by eventual CT/MRI scan [4, 8].
After these general measures are done, the ulcer must be correctly diagnosed and classied by suspected etiology, so that appropriate care can be provided (Table40.1).
Table 40.1 Etiological classication of skin ulcers
Ulcer type Typical appearance and location Venous • Shallow ulcer
• No eschar
• Located in the gaiter region (often over the medial aspect of the leg)
Pressure • Supercial or deep
• Located over bony prominences (sacrum and heels) or other areas subjected to unrelieved pressure
Arterial • A deep ulcer that appears “punched-out,” with well-demarcated borders
• Pale, non-granulating base
• +/− Eschar
• +/− Exposure of deep structures
• Located over toes and heels
Diabetic • Supercial to deep
• Extensive callus formation
• +/− Associated deformity
• Located in the hand and foot (stocking and glove distribution) Traumatic • Located in an area of previous trauma or burns Neoplastic • Rolled edges
• Located in the context of an area of chronic inammation or scarring (chronic wounds, burn
injuries, venous ulcers, osteomyelitis, and radiation dermatitis)
Vasculitic • Often symmetrical
• Irregular edges
• Associated satellite lesions
• Located in the inner side of the lower limbs
• Often very painful
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40.3 Common Principles ofTreatments
In the management of skin ulcers, the treatment of the underlying pathology is always manda­tory, but a regular approach, that is common for every type of ulcer, can be outlined/schema­tized as follows/consists of four important steps.
40.3.1 Debridement
Debridement is the removal of dead cells and bacterial biolms and is the rst-line treatment for skin ulcers, representing a key factor in wound healing. Several different types of debridement are available: autolytic, enzymatic, biologic, and surgical, using either sharp technique or high-
a
pressure water jet dissection (hydrosurgical debridement) [9, 10] (Fig.40.1).
40.3.2 Infection Control
Treatment of associated infection (if present) is another key element in ulcer management. Infection is generally controlled with topical agents, including dressings with silver, polyhexa­methylene biguanide, and cadexomer iodine. Antimicrobial washes may also be benecial if the presence of a biolm is suspected. If signs of systemic infection or cellulitis are present, sys­temic antibiotics may also be indicated. Moreover, hyperbaric oxygen therapy (HBOT) can be useful as an additional anti-infective agent [11, 12]. Final reconstruction is usually deferred after negative results of antimicrobial swabs.
b
c
Fig. 40.1 Surgical debridement of a venous ulcer on the lateral malleolar region. (a) Preoperative picture. (b) Intraoperative marking of the entire surface of the ulcer with blue methylene dye. (c) Mechanical sharp debride-
d
ment with a Volkmann spoon. (d) “Radical” debridement of the ulcer through complete removal of the methylene blue dye from the wound bed
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40.3.3 Wound Bed Preparation (WBP)
Preliminary wound bed preparation is crucial for a successful reconstruction. It can be performed with advanced medications and/or negative pres­sure wound therapy (NPWT) [13–16].
40.3.4 Wound Closure
Wound closure is the nal step of ulcer manage­ment. Healing can be achieved by secondary intention, through re-epithelialization from the margins of the wound or the skin appendages, or by rst intention or reconstruction in one or more surgical stages, using dermal substitutes, grafts, and different types of local and free aps. Nevertheless, each ulcer subtype deserves a spe­cic treatment based on its etiology, and some reconstructive procedures could be not indicated in certain ulcer subtypes.
For example, skin grafts are a valid option in case of venous ulcers but are not appropriate in case of deep pressure ulcers, which need to be reconstructed with well-vascularized tissue, in order to provide thickness and ll dead spaces. In this case, locoregional or free aps are the tech­nique of choice, and, as a general rule, cutaneous or fasciocutaneous aps are preferred at rst while muscular aps are considered as a second lifeboat option in case of reconstructive failure [17].
However, a thorough description of ulcer­type- specic reconstructive techniques is not the subject of this paragraph and will be further pro­vided below.
40.4 Indications forHospital
Surgical Referral intheDTCP
After a rst assessment in primary care settings, patients with uncomplicated ulcers are usually managed by the general practitioner and success­fully treated at home by community nurses.
In selected difcult cases, when healing is not obtained with basic methods, the management of
skin ulcers should be addressed in a timely way at a specialized rst- or second-level center for a more extensive and structured treatment by a coordinated multidisciplinary team [3].
Particularly, the following conditions require referral to a specialized center/unit for surgical treatment:
– Non-healing ulcers: ulcers not following
expected healing progression within 6weeks
(no or poor improvement in ulcer measure-
ment), dened as less than 40% reduction in
surface area, with a standard pathway of care
consisting in best management of wound
through conventional dressings.
– Ulcers greater than 6 months old at rst
diagnosis.
– Large ulcers (greater axis>10cm or surface
>100cm2).
– More than three episodes of local wound bed
infection.
– Rapid deterioration of the ulcer. – Osteotendinous exposure. – Gangrene after revascularization. – Suspected malignant ulcer in which a skin
biopsy is mandatory to rule out cancer.
– Recurrent ulcers, regardless of the previous
criteria [5, 18–20].
40.5 Specic Recommendations
Based onUlcer Subtype
40.5.1 Venous Ulcers
Venous ulcers of the lower limbs (VLU), identi­ed as stasis ulcers, stasis dermatitis, or varicose ulcers, are the most severe and devastating form of chronic venous disease (CVD) and account for about 80% of lower extremity ulcerations. VLU affects approximately 1% of the general population in most countries, and the incidence rate increases with age and female gender [21]. They are classically located over the medial aspect of the leg but may also extend circumfer­entially in severe cases. In the clinical view, venous ulcers occur due to “pure” venous causes, or due to “mixed” causes, as in cases in
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which arterial ischemia, lymphedema, autoim­mune disease, local trauma, infection, and other processes coexist with venous hypertension. The mixed ulcers often have a different rate of heal­ing and demand additional treatment beyond the
cially in the case of deep ulcers, because they can provide a better morphological result through the augmentation of dermal thickness [23].
A correct grafting procedure should follow some important principles:
appropriate venous measures for healing to occur [22].
– Graft adherence to the wound bed with no
tenting effect through the preparation of a
40.5.1.1 Operative Management
At rst, a surgical debridement should be always performed to remove supercial necrotic tissue, and excessive bacterial and cellular burden of dead and senescent cells.
In the case of non-infected venous ulcers, it is
not necessary to prepare the wound bed using
smooth wound bed surface.
– Sterility and infection control with Argentum-
based antimicrobial wound dressings.
– Adequate compression with foams. – Strong xation of the graft and immobility
through the use of counterposed stitches.
– Non-adherence of the dressing at removal. negative pressure devices, and the reconstruction can be performed in a single surgical step.
A skin graft is the more common reconstruc­tive surgery for shallow venous ulcers. However, dermal substitutes are a feasible option too, espe-
Finally, the treatment of the associated venous perforator incompetence by ligation could be useful for complete recovery and normalization of the venous pressure [24] (Fig.40.2).
ab c
Fig. 40.2 Case of chronic venous leg ulcer in a 70-year­old man with venous insufciency, peripheral arteriopa­thy, and lymphatic drainage dysfunction. (a)
Post-debridement ulcer. (b) Postoperative picture 1week after reconstruction with a skin graft. (c) Final result 1 month after surgery
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