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38 Surgical Debridement inWound Care
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13. Pascone M, Papa G, Ranieri A.Use of a novel hydrosurgery device in surgical debridement of difcult-toheal wounds. Wounds. 2008;20(5):139–46.
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Care: FromSimplest toMost
Complex
MarcoPappalardo, FrancescaLolli,
MelbaLattanzi, andGiorgioDe Santis
39
39.1 Introduction
Management of chronic ulcers is one of the major
challenges to healthcare systems worldwide. In
the United States alone chronic ulcers affect
around 2.4–4.5 million people [1, 2]. It is mainly
a condition of the elderly, and it is associated
with high treatment costs due to the difculty in
treating [3, 4]. In the United States, around $26.8
billion is the total annual cost of chronic injuries
[1, 5]. In the UK, a range from £1.4 to 2.1 billion
perannum represents the estimated cost for pressure injuries to the NHS [6].
Chronic ulcers can be categorized as venous
or arterial vascular ulcers, diabetic ulcers, and
pressure ulcers [7]. These conditions present similar features, including prolonged inammation,
infections, the presence of drug-resistant microbial biolms producing hypoxia, ischemia, and
necrosis.
Pressure ulcers are linked with particular positions giving protracted pressure on the skin and
underlying soft tissue, such as sacral pressure
ulcers in the supine position and ischial pressure
M. Pappalardo (*) · F. Lolli · M. Lattanzi ·
G. De Santis
Division of Plastic and Reconstructive Surgery,
Department of Medical and Surgical Sciences,
Policlinico University Hospital, University of
Modena and Reggio Emilia, Modena, Italy
e-mail: marco.pappalardo@unimore.it; giorgio.
desantis@unimore.it
ulcers in the sitting position, occurring most frequently in patients with long-term immobilization [8].
Indeed, during the COVID-19 pandemic,
patients presenting severe acute respiratory distress syndrome (ARDS) requiring prone positioning to maximize mechanical ventilation
frequently suffered pressure sores in atypical
locations such as forehead, chin, shoulders, chest,
iliac crest, pelvis, genitalia, knees, dorsal feet,
and toes [9, 10]. Increased awareness, improved
preventive measures, and earlier diagnosis and
intervention remain the mainstay in the management of chronic pressure ulcers. Then, reducing
further progression and deterioration of ulcers
are, indeed, important.
For grade I and II pressure sores, conservative
treatment is suggested aiming to remove and
address any inuencing risk factor. In patients
with grade II or above pressure ulcers, debridement of devitalized tissue from the wound bed is
necessary to promote wound healing. Wound
care includes several tools, including growth factors, extracellular matrices, engineered skin, and
negative pressure wound therapy (NPWT) [4].
Reconstructive surgical procedures may be
indicated in grade III–IV pressure ulcers. Many
reconstructive surgery options are available for
the treatment of such ulcers, from simple interventions such as direct closure and skin grafting
with or without skin substitutes to more complex
procedures such as soft tissue ap reconstruction.
© 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_39
439
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No clear guidelines are reported regarding one
particular soft tissue ap for the reconstruction of
pressure sores at different stages.
This chapter provides a brief overview of the
treatment of chronic and pressure ulcers and soft
tissue injury in several anatomical locations, with
particular emphasis on proper reconstructive surgical procedures.
39.2 Management ofChronic
andPressure Ulcers
A multidisciplinary approach is crucial for the
appropriate treatment of patients with chronic
wounds, including clinicians, infectious disease
doctors, plastic surgeons, orthopedic surgeons,
anesthetists, physiotherapists, nutritionists, tissue
viability nurses, and social workers [11, 12].
The goals of treatment for patients with
chronic pressure wounds are preventing complications, especially infection; preventing the
wound from increasing in size; and preventing
the injuries from going to other locations, and
closure of the wound [13]. However, the surgical
closure of chronic pressure injuries is often complicated by high recurrence rates reported in the
literature.
Before considering a patient a potential candidate for surgery, several considerations need to
be taken into account. Assessment of the patient
is fundamental, including his overall health and
physical, nutritional, social, psychological status,
and education. Then, assessment proceeds with
ulcer evaluation, wound care, management of
infection, and surgical procedures in selected
patients [14]. Preoperative imaging modalities
such as computed tomography and magnetic resonance during preoperative workup can be helpful for the diagnosis of osteomyelitis; however,
bone biopsy and culture are required to conrm
the diagnosis.
Experienced doctors should consider the
patient’s social status and his compliance when
deciding the appropriate treatment for a chronic
pressure injury [15]. Factors that predispose
patients to pressure-induced injuries are sometimes the same factors associated with recurrence
after surgical reconstruction; hence, patient
selection and preoperative preparation are
crucial.
The clinical stage is fundamental for the individualized management of pressure ulcers and
soft tissue injuries. The most adopted staging
system is the National Pressure Sore Advisory
Panel Consensus Development Conference 2007
[16].
Stage I and II injuries are generally treated
conservatively with proper wound care and the
removal of factors causing the initial injury.
Treatment of stage III and IV ulcers often requires
surgical management to achieve wound closure,
signicantly improving the quality-of-life of
these patients [17, 18].
39.3 Conservative Treatment
andWound Care
For all patients with chronic ulcers, the principles
of wound care should be applied. Surgical
debridement of devitalized tissues and dressing
care to provide control of the wound are paramount in wound care [19].
Grade II chronic pressure ulcers showing a
necrotic or shedding wound can be treated with
debridement at the bedside to increase the wound
healing and, indeed, precisely stage the ulcer.
The necrotic eschar is surgically debrided, and
healing is achieved by secondary intention from
the periphery. For extensive grade III or IV
chronic pressure ulcers, proper surgical debridement in the operating room is safer and more
effective due to pain and discomfort of the
patients, risk of bleeding, and not adequacy of
debridement. Indeed, accurate hemostasis is
imperative due to the high propensity of these
wounds.
There is a plethora of available dressings,
growth factors, and adjunctive therapies without
evidence that any type of wound care protocol is
superior [19]. Appropriate wound care using
dressings are able to keep a clean moist environment and maintaining the surrounding skin dry.
Indeed, patients with poor clinical conditions
or where extensive soft tissue reconstruction is
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not possible are generally treated with in-bed
debridement and conservative management of
the wounds. In such instances, minimal-serial
debridement with secondary-intention healing is
attempted, and it is considered an acceptable
option. However, this method can impact the cosmetic result leaving scarring areas.
Alternative therapies, such as negative pressure wound therapy (NPWT) may be considered
for certain types of ulcers. This tool offers controlled, continuous-intermittent sub-atmospheric
pressure over an open wound, improving the
local wound environment, and speeding healing
and wound closure. NPWT is able to facilitate the
production of granulation tissue and gradual
healing of less complex defects. Recently, NPWT
has been used for the temporization of traumatic
wounds, as well as the management of chronic
wounds [20, 21]. NPWT is able to approximate
skin aps, increase tissue perfusion, decrease the
dead space, and favor marginal apposition of the
wound edge, improving wound healing, especially in patients treated with direct closure or
skin graft. Hence, this method is very useful for
older patients not able to tolerate surgical treatment, as well as for patients with a paucity of
local reconstructive options [22]. NPWT can also
deliver instillation of antiseptics to the wound
bed.
It has been reported that approximately 75%
of grade II pressure ulcers heal with proper conservative treatment [23]. We generally prefer to
treat grade II pressure ulcers using parafn gauze
together with hyaluronic acid and collagenase
ointment monitoring the healing process. In
patients with infection and a large amount of
brin, we prefer chemical debridement with
chloramphenicol and collagenase.
Instead, grade III and IV chronic pressure
ulcers more frequently require surgical treatment [24].
39.4 Surgical Indications
Indications for the surgical management of
chronic wounds include substantial necrosis,
osteomyelitis, wounds producing systemic infec-
tion, sepsis, or bacteriemia, as well as the deterioration of patient’s functional status [25].
39.5 Surgical Debridement
The aim of surgical debridement is to achieve
a viable wound bed removing all potentially
contaminated and devitalized tissues as initial
management. In the wound-healing process,
debridement should be performed aggressively, also referred to as radical wound
debridement [26]. Osteotomy of bony prominences should also be performed to leave a
smooth surface and decrease local pressure.
During debridement, microbiological swabs
and tissue biopsy should be taken to rule out
any bacterial growth. Patients with deep pressure ulcers involving the bone need bone biopsies to exclude osteomyelitis [27].
Following initial debridement, definitive
reconstruction of the defect is performed at
the same stage or later in a second-stage,
depending on the amount of necrotic tissue,
the ability to perform proper debridement, the
nutritional status of the patient, general condition, and the surgeon’s decision. In the literature, there are advocates for both approaches
to pressure ulcer reconstruction: single-stage
(debridement plus reconstructive surgery) and
multiple-stage; however, no randomized trials
have been reported comparing the two methods regarding complications and recurrence
rates [28].
Delayed reconstruction is generally preferred
in infected wounds to achieve microbiological
diagnosis and proper antibiotic treatment. Singlestage procedure may be performed in case a
wound is not grossly contaminated [29]. We generally prefer a multiple-stage approach to achieve
a meticulous debridement, an appropriate antibiotic therapy due to the availability of swabs culture for the reconstructive stage of the procedure.
Indeed, multiple wound debridements may be
necessary in some cases to achieve adequate
wound bed, remove necrotic tissue, and control
infection before planning a denitive surgical
reconstruction.
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39.6 Reconstruction Methods
Following thorough debridement and wound bed
preparation, several reconstruction options can
be chosen depending on the defect. Plastic and
reconstructive surgeons used to follow the
“reconstructive ladder” to manage complex
defects. The aims of reconstructive procedures
are to achieve adequate wound coverage, offer
proper soft tissue padding to protect the area
from the pressure forces, prevent recurrence, and
increase wound closure and healing, with minimal donor-site morbidity [30].
39.6.1 Primary Closure
Primary closure is the simplest method and
depends on the availability of skin following the
debridement of the wound. In pressure ulcers,
this method is rarely possible due to the amount
of underlying soft tissue injury [25].
Since pressure-induced injuries are frequently
large, direct excision and primary closure of them
can produce wound dehiscence, especially when
the patient moves due to the tension across the
wound edge. Indeed, a high recurrence rate has
been reported after the direct closure of chronic
pressure ulcers [31]. Hence, primary closure is
only suggested in small non-contaminated and
supercial ulcers.
39.6.2 Skin Grafting
Skin grafts may be used only in small and supercial chronic wounds. Skin grafts require an
accurate wound bed preparation, and it is performed only in wounds without exposure of vital
structures such as the bone or tendons [32]. A
skin graft after granulation over an exposed bone
can still achieve skin coverage but it can lead to
complications, including further soft-tissue
defects, unstable wounds, osteomyelitis, functional loss, and increased costs.
It is a suboptimal reconstructive treatment for
pressure injuries due to the inability to provide
enough bulk to bony prominences, often leading
to recurrence [33].
39.6.3 Flaps
Several ap options have been introduced for
chronic ulcer reconstruction depending on the
defect type and size. Many types of musculocutaneous, fasciocutaneous, and perforator-based
aps have been reported in ulcer surgery [34].
Using a well-vascularized local or a free soft
tissue ap with adequate padding in the pressure
points and tension-free closure [35], the reconstructive surgeon can provide better form and
functional results. Indeed, additional tools such
as tissue expansion and NPWT can provide further help in the reconstruction of ulcer defects
[36].
Locoregional aps, including skin, fascia, or
muscle, are the most common techniques used
for this purpose.
Historically, musculocutaneous aps were
favored due to their reliability, good vascularity,
and their bulk with the ability to ll large deep
defects. More recently, fasciocutaneus and perforator aps also gained popularity for the reconstruction of ulcer defects [37]. However, muscle
aps have a low tolerance for ischemia. On the
other hand, fasciocutaneous aps present several
advantages including less sensitivity to ischemic
injury, higher mechanical resistance to pressure
forces, less functional morbidity in mobile
patients, and with preservation of muscle aps
for recurrences [38, 39]. Fasciocutaneous aps
have been used for the reconstruction of grade III
and IV pressure injuries. Recently, fasciocutaneous and perforator aps have been performed in
patients with underlying osteomyelitis, with a
ap survival of 95.8% [40].
A systematic review comparing musculocutaneous, fasciocutaneous, and perforator aps did
not nd any signicant difference regarding complication rates or recurrences between the ap
types [34].
Chronic ulcers needing microsurgical reconstruction are those that cannot be closed by local
aps or skin grafts, complex wounds with
exposed tendons and bones, or wounds with prolonged infections, skin necrosis, and osteomyelitis [41]. Hence, when a chronic wound is stalling,
complex, and challenging to treat with local tissues, microsurgical reconstruction together with
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a multidisciplinary team can provide adequate
and timely reconstruction.
Free aps such as latissimus dorsi (LD),
anterolateral thigh, and tensor fascia lata aps,
among others, have been reported for the reconstruction of chronic pressure ulcer defects. Free
latissimus dorsi (LD) ap is generally not performed in paraplegic patients, as they rely on
upper-body strength for mobilization. Using a
Table 39.1 Reconstructive modalities of pressure ulcers in various anatomical locations
Ulcer
Location Cause Reconstructive procedure following surgical debridement
Sacral Prolonged position without proper
Ischial Prolonged sitting without proper
Trochanteric Direct pressure from a prominent
Heel Pressure in the posterior aspect of the
Elbow
(Olecranon)
pressure relief or mobilization
pressure relief or cushion
greater trochanter in insensate and
sensate patients
heel in immobile or bedridden patients
Continuous mechanical shearing and
pressure forces in the periolecranon
region
partial split latissimus dorsi ap is an adequate
option to preserve muscle function if the defect is
not too large [42].
Flap selection clearly is different according to
the ulcer location (Table 39.1). Most pressure
ulcers are located in the sacral and ischial regions
in the back part of the body. Hence, reconstruction of these regions requires a prone position
except for the trochanteric region.
Flap Reconstruction with:
• Gluteus Maximus Myocutaneous Flap (rotation, V–Y
advancement, sliding island, splitting
• Superior Gluteal Artery Perforator (SGAP) Flap
• Inferior gluteal artery perforator (IGAP) ap
Flap Reconstruction with:
• Gluteus Maximus Myocutaneous Rotation Flap
(rotation, split)
• V-Y Hamstring Muscle Advancement Flap
• Tensor Fasciae Latae Musculocutaneous Flap
• Combined Gracilis Muscle Flap for Ischial coverage and
Medial Thigh Rotation Fasciocutaneous Flap
• Rectus Abdominis Flap
• Gluteal Fasciocutaneous Flap (rotation)
• Medial thigh Fasciocutaneous Flap
• Posterior thigh Fasciocutaneous Flap V-Y
• IGAP ap
Flap Reconstruction with:
• Tensor Fasciae Latae (TFL) Flap (V-Y advancement,
rotation, transposition, islanded, perforator)
• Anterior Lateral Thigh Flap and Vastus Lateralis Flap
• Distal Gluteus Maximus Myocutaneous Rotation Flap
• Rectus Femoris Muscle Flap
Skin grafts
Flap Reconstruction with:
• Medial Plantar Flap
• Reverse Sural Flap
• Perforator- Propeller aps
• Free Gracilis Flap
• Free Radial Forearm Flap
• Free Anterior Lateral Thigh Flap
Flap Reconstruction with:
• Lateral Arm Fasciocutaneous Flap
• Radial Forearm Flap
• Oblique External Fasciocutaneous Flap
• Anconeus Muscle Flap
• Brachioradialis Musculocutaneous Flap
• Flexor Carpi Ulnaris Muscle Flap
• Extensor Carpi Radialis Longus Musculocutaneous Flap
• Perforator Flaps (from the dorsal aspect of the upper
forearm)
(continued)
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Table 39.1 (continued)
Ulcer
Location Cause Reconstructive procedure following surgical debridement
Posterior
Scalp
(Occiput)
Chin Prone positioning to maximize
Direct pressure from special head
stabilization equipment in patients with
prolonged immobilization requiring
mechanical ventilation
mechanical ventilation in COVID-19
patients
Secondary treatment of alopecia with tissue expansion
and local aps
Skin grafts
Flap Reconstruction with:
• Scalp Flaps (transposition or rotation)
Local Flaps
Secondary autologous fat grafting to reduce the patient’s
pain, improve chin contour and scar contracture
M. Pappalardo et al.
39.7 Reconstructive Procedures
by Site
39.7.1 Sacral Ulcers
Local aps, such as musculocutaneous and fasciocutaneous, can be used for the reconstruction
of sacral defects. Flaps can be designed as
advancement, rotation, or in islanded fashion.
They can be unilateral or bilateral, depending on
the size of the defect.
Musculocutaneous and muscle aps are preferred for large-deep sacral defects in thin
patients for whom fasciocutaneous aps may not
be adequate to provide wound coverage and padding. Gluteus maximus musculocutaneous ap
based on one or both the superior gluteal or inferior gluteal vessels is the main ap used for sacral
coccygeal defects. It can be designed as a rotation
[43], V-Y advancement [44, 45], or transversesplitting partial gluteal aps [46]. The ap choice
depends on the ulcer size and if it is primary or
recurrent ulcer. A primary ulcer can be closed
with a simple ap, whereas a recurrent ulcer
requires a large-complex ap. In ambulatory
patients, it is not suggested to totally detach the
gluteus maximus inferiorly to prevent a functional decit, using the muscle only after exhausting other surgical options.
Fasciocutaneous options include the superior
gluteal artery perforator (SGAP) ap and inferior
gluteal artery perforator (IGAP) ap, [47, 48]
and are useful especially in ambulatory patients.
They can be designed as V-Y advancement, rotation, Limberg, hatchet, transverse lumbar, or
combinations of aps. The SGAP ap was rst
described in 1993 by Koshima et al. for the
reconstruction of a sacral pressure defect [49].
This perforator ap shows good vascularity and
is generally performed as an alternative choice
for microsurgical breast reconstruction [50]. It
has also been described for sacral and lumbar
reconstruction [51, 52]. Overlapping tissue layers
by partially de-epithelializing and burying the
V-Y advancement ap are commonly performed
to avoid a single weak suture line between the
skin and areas of bony debridement with longterm durability. However, these areas can require
longer healing time and further surgery in the
case of complications.
39.7.2 Ischial Ulcers
Ischial pressure ulcers are the most frequent
ulcers in paraplegic patients on the pelvis, presenting a high incidence of recurrence [53]. The
main cause of this injury is prolonged sitting
without proper pressure relief or cushion. Ischial
pressure sores often show small skin defects with
a large-penetrating cavity underneath. There are
various types of aps available to reconstruct an
ischial pressure ulcer. Reconstruction of ischial
defects should be planned considering that the
patient needs hip exion to facilitate sitting.
Fasciocutaneous aps include gluteal rotation,
medial thigh, posterior thigh V-Y, hatchet
advancement aps, and IGAP aps [54, 55].
Musculocutaneous options described most commonly include inferior gluteus maximus musculocutaneous rotation ap based on inferior gluteal
perforators vessels [56], V-Y hamstring muscle
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a
b
c
Fig. 39.1 A 58-year-old paraplegic woman with an
ischial pressure sore measuring 13×9cm2 after failure of
a 5-month conservative treatment (a). Patient underwent
surgical debridement followed by dual-plane closure of
the defect combining a pedicled gracilis muscle ap with
advancement ap [57], transversely split gluteus
maximus advancement, TFL musculocutaneous,
gracilis muscle based on medial femoral circumex
artery [58], biceps femoris advancement/folding
based both on profunda femoris perforators, and rectus abdominis aps (Fig.39.1) [59].
a V-Y fasciocutaneous thigh ap vascularized by two perforator vessels coming from the profunda femoris artery,
assessed preoperatively by Doppler-US (b). Intraoperative
view at the end of the surgical intervention (c)
39.7.3 Trochanteric Ulcers
Trochanteric pressure ulcers, although less frequent, often are higher-grade pressure ulcers due
to the mobility and direct pressure of the greater
trochanter and a large amount of soft tissue
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M. Pappalardo et al.
undermined. Skin ulceration is often accompanied by the extension into the trochanteric bursa.
Musculocutaneous aps are generally preferred over fasciocutaneous aps due to the signicant bony prominence of the trochanter
regions as well the paucity of the fasciocutaneous
tissue available with adequate thickness providing durable padding.
The most commonly performed musculocutaneous ap for trochanteric defect coverage is the
tensor fasciae latae (TFL) ap based on the lateral femoral circumex artery. The TFL ap
presents several advantages, such as predictable
and reliable blood supply, minimal donor-site
morbidity, and minimal effect on lower extremity
motor strength. TFL can be harvested as a V-Y
advancement ap, as a rotation ap, transposition
ap, or islanded in a perforator fashion [60].
Indeed, anterior lateral thigh, vastus lateralis, distal gluteus maximus myocutaneous rotation ap,
and rectus femoris muscle aps are also used for
trochanteric defect coverage [60].
tion of heel pressure ulcers are prolonged immobilization, diabetes mellitus, reduced perfusion
(peripheral artery disease) of the lower extremity, and poor physiological condition [61, 62].
Wound healing may lead to wound dehiscence
and rapid recurrence in poorly vascularized
limbs. Hence, it is fundamental to check the
limb vascularity when considering ap reconstruction of heel ulcers. Preoperative evaluation
includes radiographic imaging to rule out osteomyelitis. A vascular mapping of lower limbs is
highly suggested before attempting a microsurgical reconstruction to evaluate the patency of
recipient vessel. The rst surgical step for heel
ulcers is debridement, also involving the calcaneal bone if necessary.
Flap options for reconstruction of heel defects
include locoregional aps such as medial plantar
artery [63], reverse sural artery [64], perforatorspropeller aps, and rarely transposition aps
[65]. Microsurgical ap reconstruction is more
needed for this region compared with other anatomic areas [66].
39.7.4 Heel Ulcers
The posterior heel is particularly predisposed to
the development of pressure injuries in bedbound patients. The posterior aspect of the heel
has thinner skin and small fat overlying; hence,
defects at this level with tendon and/or bone
exposure represent a challenge for surgeons due
to the lack of local tissue available.
Traditionally, upper-middle third of the lower
leg can be managed with locoregional muscle
aps such as gastrocnemius and soleus muscles
or with local perforator-propeller skin aps.
However, in the lower third of the leg and in the
foot, due to the scarcity of available local tissues,
microsurgical reconstruction is warranted when
the defect is moderate or large in size. Pressure
ulcers in this region require a durable and wellvascularized soft tissue ap with adequate
volume.
Heel ulcers with stage I or II are commonly
treated conservatively by pressure off-loading
with specially designed boots and attentive
wound care. Factors associated with the forma-
39.7.5 Elbow Olecranon Ulcers
Elbow pressure ulcers may involve the olecranon
or medial elbow bony prominences in patients
with continuous mechanical shearing and pressure forces in the periolecranon region. Injuries
in this area are often associated with chronic bursitis [67].
For small, simple injuries, conservative management with or without direct closure is performed. In case of more complex wounds, ap
options include local rotation, transposition or
island fasciocutaneous aps [68], perforator aps
from dorsal aspect of upper forearm [86], radial
forearm ap [69], or reverse lateral arm ap [70],
and muscle aps [71, 72].
39.7.6 Posterior Scalp (Occiput)
Ulcers
Posterior scalp pressure ulcers can be found in
patients requiring mechanical ventilation in
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intensive care unit due to prolonged immobilization or head stabilization equipment, such as
neck collars or intracranial pressure monitoring
[73]. The management of these injuries is mostly
conservative with wound care, and improvement
usually depends on the patient’s clinical condition and removal of head equipment. A long-term
sequela of posterior scalp pressure ulcers is alopecia [74]. Secondary treatment of alopecia
includes excision and primary skin closure, or in
case of large defect tissue expansion and local
aps may be used.
In case of extensive, more complex scalp
chronic pressure injuries following debridement
and wound care, skin graft or local aps are warranted. Deep pressure ulcers exposing the cranial
bone or with concomitant osteomyelitis require
extensive debridement and reconstruction with
locoregional transposition or rotation scalp aps.
39.7.7 Atypical Locations ofPressure
Ulcers during COVID-19
Pandemic
Due to the spread of the COVID-19 pandemic,
many patients required intensive care treatment
with prone therapy to maximize mechanical
ventilation due to severe acute respiratory distress syndrome (ARDS) [75, 76]. Although
prone positioning is recommended by critical
care guidelines for patients with ARDS,
COVID-19- related, long periods (>16 h per
day) in this position may induce several complications [77]. The most frequent complication of
this rescue treatment is pressure ulcers in highrisk and uncommon body areas [78]. Etiological
factors of these pressure-induced injuries
involve duration and quantity of pressure with
the long-term exclusion of blood ow to tissues,
friction and shearing forces on soft tissues, and
bony prominences with tissue perfusion pressure for a long period of time. In patients requiring prone positioning, pressure ulcers can be
found in forehead, chin, shoulders, chest, iliac
crest, pelvis, genitalia, knees, dorsal feet, and
toes. Pressure-induced necrosis of the chin has
rarely been described complication in routine
practice [79]. Ibarra etal. reported that the total
number of days in prone positioning for more
than 24h is the most important risk factor associated with pressure-induced injuries [80]. It is
critical to roll the patient regularly to reduce
pressure forces in high-risk areas and use proper
pressure-redistribution surfaces.
Recently, we have reported ve COVID-19
patients treated in the ICU with prone mechanical ventilation who developed pressure ulcer
necrosis of the chin [81]. The plastic surgery
team treated these injuries with initial in-bed surgical debridement on an average of 1week after
the ulcers became necrotic, followed by conservative treatment. Complete healing was achieved
in around 2.5months, however, leaving an area of
patchy alopecia and scar. Although local aps
can have advantages such as faster healing, better
cosmetic result, and less number of medications
needed, however, COVID-19 patients affected
are very fragile and, hence, conservative management of the wounds was adopted. Secondary
autologous fat grafting (AFG) [82, 83] was performed in patients with secondarily healed
wounds in the chin as a revision procedure to
reduce the patient’s pain, improve chin contour,
and minimize cosmetic sequelae and scar contracture (Fig. 39.2). The average of fat grafting
injected into the chin was 8mL.All patients were
satised based on scar appearance, chin contourprojection, and none of them complained pain.
Hence, the Vancouver scale showed an improvement in chin scars.
Autologous fat grafting has been largely used
to reduce scar retraction and contracture and in
therapeutic scar patch as well as in regenerative
medicine [84–86]. It has been reported the possibility to increase wound healing by performing
autologous fat grafting before wound closure as
an adjuvant treatment to avoid scar contracture
and reduce pain [87–89]. In our study we used
secondary autologous fat grafting when patients
conditions were settled in order to correct and
improve the chin contour.
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