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J. P. Hong and A. Datli
aggressive surgical debridement, removing all
brotic and ischemic bone and soft tissue surrounding the wound that impedes antibiotic
delivery followed by denitive reconstruction
with the objective of restoring ambulatory function [35]. In the last three decades, major surgical
advancements to provide vascularized coverage
to the infected bone have brought recurrence
rates in chronic osteomyelitis down from 30% to
10–15% [65, 66]. Reconstruction can be complex
applying combined aps to obliterate the dead
space, reconstruct the bone defect, and resurface
the skin defect. With a multidisciplinary approach
using proper antibiotics and a surgical approach,
the recurrence rate after reconstruction was 8.3%,
the primary remission rate was 91.6%, the secondary remission rate was 98.3%, and the amputation rate was 1% in our series [33]. Signicant
predictors of recurrence were peripheral vascular
disease and major vessel compromise, which had
5.1 times higher odds of recurrence [33].
Unstable scars frequently go through wax and
wane progress of healing for ulcers. It may also
cause severe contracture as the scars mature during healing. It hinders the daily activities of the
patient as epithelialization can easily breakdown
despite minimal stimuli. This occurs due to the
lack of padding and durability of normal cutaneous structure. In cases of severe contracture, there
is an absolute lack of normal skin after release.
When there is an extensive defect after the
removal of the unstable scar, microsurgical
reconstruction is required. The principle of
aggressive debridement followed by denitive
surgery is applied, and this problem can be overcome. The same can be said for radiation-induced
scars. The outcome may be similar to any nondiabetic microsurgical reconstruction.
41.5 Conclusion
Along with a multidisciplinary approach and
good principle of wound care, the repair and restoration strategies using aps and microsurgery
have widened the possibilities for limb salvage
from complex acute and chronic wounds.
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Advanced Reconstruction
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inWound Care
Hung-ChiChen andBurakKaya
42
42.1 Background
The healing of wounds has been one of the most
important issues of health care since ancient
times. A wound is a disruption of tissue integrity.
The management of wound healing aims to
reconstruct the structural and physiological integrity of the damaged tissues, as well as functional
recovery. The wound healing process consists of
three phases: the rst stage is inammation, the
second stage is proliferation, and the third stage
is maturation and remodeling. However, some
authors consider hemostasis, which is considered
in the inammation stage, as the rst stage and
divide the wound healing process into four stages.
Each interrelated stage, which starts with the
injury and ends with scar maturation, has a vital
role in wound healing. Deviation from the normal
healing process in each stage results in delay or
deterioration in wound healing, resulting in
chronic wounds [1–3]. In rare conditions, the
wounds will become chronic and nonhealing.
The most common causes of chronic wounds are
ischemic arterial ulcers, venous stasis ulcers, dia-
H.-C. Chen (*)
Department of Plastic Surgery, China Medical
University Hospital, Taichung, Taiwan
e-mail: 019722@tool.caaumed.org.tw
B. Kaya
Department of Plastic Reconstructive and Aesthetic
Surgery, Ankara University Faculty of Medicine,
Ankara, Turkey
betic foot ulcers, pressure ulcers, and postirradiation ischemic wounds [4, 5]. There are
similarities among these nonhealing wounds in
pathophysiology that prevent wound healing;
however, the mechanism interfering with healing
may be slightly different [6].
Many factors relating to the wound or the
patient’s general condition can cause chronic
ulcers. The most important factor is wound infection and the patient’s conditions leading to tissue
hypoxia [5, 7]. If the pathophysiological mechanisms that lead to nonhealing wounds are known,
and the measures to eliminate them can be
applied, most chronic wounds can heal by modern wound care [4].. However, even though the
negative factors that cause nonhealing wounds
are eliminated, and the wound begins to heal, in
some cases, the ulcer is so complicated that it
cannot be closed with local wound care. Under
such circumstances, it is necessary to close these
ulcers using the reconstruction principles of plastic surgery [8].
Plastic surgery offers many options for wound
closure. These options are primary closure, skin
grafts, local tissue arrangements, regional aps,
and free aps [9]. Some of these options are simple, while others require a long learning curve,
are technically demanding, and require experience. This section explains and discusses
advanced reconstructive methods, including
regional aps and free aps that can be used to
treat nonhealing ulcers.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_42
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H.-C. Chen and B. Kaya
From a historical point of view, different
approaches have been used for choosing the
reconstructive method to close the wounds.
Mathes and Nahai proposed the reconstructive
ladder in 1982 [10]. The steps of the conventional reconstructive ladder were direct closure,
skin graft, local ap, and distant ap, proposing
a path from the simplest procedures to the more
complex ones for the closure of tissue defects.
With the development of microsurgical techniques and an increased rate of free ap success,
microsurgery has become a benecial reconstructive option, and in some situations, free
aps may take their place at the top of the reconstructive ladder. Microsurgery was technically
demanding but very effective for reconstructing
complex defects, which were difcult to close by
conventional reconstructive procedures.
Considering this point, Mathes and Nahai suggested the reconstructive triangle, including
aps, tissue expansion, and microsurgery for
choosing the reconstruction method [11]. The
reconstructive triangle did not suggest a stepwise progression from simple to complex. The
triangle concept allowed for a free shift among
pedicled aps, tissue expansion, and free tissue
transfer. This model does not guide the surgeon
in choosing a suitable option for reconstructing
the difcult defects, so it is not helpful as a clinical guide [12].
In 1994, Gottlieb and Krieger introduced the
model of the reconstructive elevator, emphasizing that the simplest method may not always be
the best in the modern plastic surgery era [13].
The reconstructive elevator allowed the surgeon
to skip simple methods and use much more complex methods to achieve the best results when
conditions were appropriate. Erba et al. offered
the reconstructive matrix paradigm in 2010. The
reconstructive matrix is a grid with three axes:
technological sophistication, surgical complexity, and patient safety. There are innitive possibilities in this three-dimensional matrix, and it is
possible to decide using the best reconstructive
methods for the patient [14]. Today, in the era of
supermicrosurgery, where microsurgical techniques have advanced and become rened, free
tissue transfer is no longer the last alternative.
Complex reconstructive methods, including perforator aps, often provide safe and superior
results over simpler options to restore anatomical
structures.
42.2 Advanced Reconstruction
The following categories of difcult wounds
require advanced reconstruction methods:
1. Enterocutaneous stula with large defect of
inWound Care
abdominal skin and fascia (Fig.42.1).
Combined single-stage enterolysis with
pedicled seromuscular bowel aps to secure
the repair site of the intestine, myocutaneous,
and fasciocutaneous aps to reconstruct the
complex abdominal wall defect.
In our unit, between 1990 and 2016, a retrospective review was carried out for 18
patients with an average age of 39years (ranging from 26 to 59years). Thirteen cases were
associated with trauma, four were complications of previous mesh repair, and one was
after an aortic dissection. The average diameter of the defect size was 22cm (ranging from
20 to 24 cm). Surgical technique involved
enterolysis using microscope magnication to
prevent unnecessary damage of serosa and to
minimize the length of bowel resection; a
pedicle seromuscular bowel ap to reinforce
the bowel anastomosis; and using musculocutaneous/fasciocutaneous aps to reconstruct
the abdominal wall. A drain tube was inserted
around the repair site of bowel anastomosis. A
jejunostomy was performed to provide good
nutrition after surgery.
Fifteen patients required rotational aps
with an average skin paddle area of 442.7cm2
(ranging from 440 to 260cm2), and 10 patients
required a seromuscular patch with an aver-
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a
b
c
d
Fig. 42.1 (a) The patient had an enterocutaneous stula,
which had been treated conservatively for 6months but
failed. He was transferred to the plastic surgeon for an
operation. A combined ALT+VL+TFL ap was designed
for reconstruction. The skin incision was made outside the
area of macerated skin. The peripheral approach has the
benet of dissection from the normal (virgin) areas, which
makes dissection easier, and careful dissection was performed under the operating microscope to avoid unneces-
sary damage to the serosa. The minimal segment of the
diseased bowel was resected. (b) The resected segment of
the bowel can be fashioned into a seromuscular ap, which
still has a vascular connection with the adjacent intestinal
loop. (c) The seromuscular ap can be used to wrap around
the anastomotic site of the intestine to prevent leakage in
the environment of infection. (d) The healing of the wound
was smooth, and the patient could go back to work and
enjoy a normal life again
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H.-C. Chen and B. Kaya
age length of 5cm (ranging from 4 to 6cm).
Complications included three wound dehiscence and one abdominal wall bulging. Flap,
survival was 100%. The majority of patients
(12 out of 18) were able to resume normal
activities, and the remaining (n=6) were able
to resume most activities. The mean follow up was 24 months (ranging from 22 to
26months) with clinical examination.
In this category of patients, the following
principles were followed: (a) eliminating the
source of infection, such as continuous or
intermittent gastrointestinal juice; (b) dissection of the intestine from a peripheral virgin
zone with the use of an operating microscope
to avoid unnecessary damage of intestinal
serosa and to minimize the length of bowel
resection; (c) using aseromuscular ap to
ensure healing of the bowel anastomosis in
the presence of infection; and (d) using tissue
of optimal blood supply for reconstruction
after excision of the damaged abdominal wall
due to spillage of intestinal content.
2. Microsurgical debridement for chronic intractable ulcer due to rare fungus infection
(Fig.42.2).
Some chronic ulcers are caused by rare
fungus infections, such as Scopulariopsis
brevicaulis. The wound can be very recalcitrant, persists for years, and causes chronic
discharge of pus with a lot of pain. Even with
repeated debridement with thorough irrigation and the use of all available antifungal
agents, the infection may persist because the
fungal spores can spread during extensive
debridement. The nal solution is debridement under the microscope before coverage
with a skin graft or other aps.
3. When free aps are required but there are no
available recipient vessels, and the wound is
infected (Fig.42.3).
Under this situation, a vascular cable ap
(instead of a long vein graft) is required.
Usually, we use a forearm ap as a vascular
cable ap with its two ends wider than the
central part (dumbbell shape), so that all the
anastomoses can be well protected in the forearm ap, and the vascular cable ap can carry
blood supply and venous return from a distant
site to the ap, which is aimed for
reconstruction.
4. Conjoined ap, such as combined latissimus
dorsi ap and groin ap, for reconstruction of
a very long or wide defect with exposure of
major organs or structures, for example, when
there is a very long defect in the upper or
lower limb (Fig.42.4).
The conjoined ap can be divided into four
types. In the rst type, both ends are pedicled.
In the second type, the latissimus dorsi end is
pedicled but the groin ap end is free (requiring vascular anastomoses). In the third type,
the latissimus dorsi end is free, but the groin
ap end is pedicled. In the fourth type, both
ends are free.
The application of a conjoined ap depends
on the requirement of an individual case. It
can also include functioning muscle ap
reconstruction, e.g., for coverage of the upper
limb and reconstruction of elbow exor due to
loss of biceps muscles.
5. Reconstruction of large chronic empyema of
chests with large defect of the chest wall
(Fig.42.5).
Chronic empyema of the chest cavity can
be very difcult to treat by chest surgery
alone. Since the development of free ap
transfer, the empyema cavity can be obliterated with a large volume of free tissue transfer, which also brings good blood supply and
conveys antibiotics to combat infection.
6. Chronic ulcer due to advanced lymphedema
of the lower limb with extensive brosis and
infection (Fig.42.6).
In this situation, the lymphatico-venular
anastomoses and other drainage procedures
may not be able to solve the problem. Our
strategy is a combination of (1) modied
Charles’ procedure, (2) lymph node ap transfer for lymph drainage of the foot, and (3)
treatment of toes/web spaces to eradicate the
infection source.
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a
b
c
Fig. 42.2 (a) The 30-year-old lady fell from the motor-
cycle and got infected with fungus. In the past 3years, she
had been operated on more than 40 times including multiple debridements, irrigation with copious amounts of
normal saline and skin grafting, even regional aps. (b)
MRI showed multiple foci of fungus infection in the subcutaneous tissue around the right knee and in the leg. (c)
After meticulous debridement under the operating microscope, the wound healed nally. The whole treatment
course was nearly 4years
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e
f
Fig. 42.3 (a) The patient sustained extensive crush injury
to the right lower extremity. The cardiovascular surgeon
inserted Gortex grafts for both the femoral artery and vein.
Subsequently, a surgeon used an ALT ap for coverage of
the leg defect but failed. On evaluation, there were no
recipient vessels in the right lower limb due to vascular
damage. (b) A free forearm ap was designed on the left
forearm. (c) The forearm ap was used as a vascular bridge
ap to bring the blood supply from the left leg to the second ap for reconstruction of the right leg. (d) The right
latissimus dorsi, distal half of serratus muscle, and two ribs
were used for reconstruction, supplied by the normal vessels of the left leg via the vascular bridge ap of the radial
forearm free ap. (e) Good healing of wound and bone. (f)
good healing of tibia at 2 years of follow up
ab
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c
d
e
Fig. 42.4 (a) The patient had breast cancer with delayed
treatment. (b) A large tumor was resected including three
ribs. (c) The wound was very large extending from the
chest to the upper abdomen, and the lung was exposed. (d)
A conjoined ap was elevated combining left latissumus
dorsi myocutaneous ap and groin ap, both were pedicled aps. (e) The wound healed well
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