Short Notes in Plastic Surgery

September 30, 2011

Treatment of Wounds – Repair and Reconstruction (Part 1)

Filed under: Chapter 15 — mthatte @ 4:17 am

1. A clean incised wound should be closed as soon as possible after irrigation with saline or a proprietary anti-bacterial solution.
2. A contused, lacerated wound needs a sharp, adequate excision of its edges prior to closure because the contused skin might have been devitalized.
3. Except in very superficial wounds dermal approximation with a durable suture (with a life of three to six months) helps prevent a broad scar and a good dermal opposition means the outer sutures can be removed early.
Comments:
a) The introduction of biological glue and of sterile strips applied across wounds have changed the way the outer layer of the wounds are treated.
b) The introduction of staples in closure of surgical wounds including for flaps after they have been set into defects has reduced operating time and surprisingly crude though the staples might look, the incidence of cross-hatch marks has been almost completely eliminated. The staples do what a ‘she cat’ does to her kitten as she carries them with her teeth. The staples hold the skin at some distance from the wound without puncturing it to any appreciable depth.
c) When wounds occur in unfavourable directions i.e. across Langer’s lines they are usually closed without any primary re-adjustment of the suture line e.g. by a z-plasty, indicating that conspicuous scars are not inevitable in such a situation.
d) Superficial burn wounds heal splendidly with a variety of proprietary dermal substitutes. However when burns occur around fingers in children, when it becomes difficult to wrap the dermal substitute around them, a dressing material dipped in an antibacterial solution wrapped around the fingers secured with a dry, firm bandage can be left alone for several days till it falls off by itself when it becomes loose.
4. In large wounds where the patient is brought in a critical condition, the treatment of the affected systems takes precedence. Cardiorespiratory resuscitation, securing of an airway, treatment of sucking wounds in the chest and volume replacement begin first. If the wound is bleeding, pressure or ligatures or in cases of lacerations of major vessels, application of atraumatic clamps, removal of mangled, crushed and irreparable parts of the limbs is all that should be done as resuscitation begins. Fractures in major bones are assessed, splinted and a plan for their fixation charted out.
5. Once the patients start getting stablised, the wounds are inspected in some detail, repair of major vessels might have to be performed quickly if the viability of the limbs is threatened. If a formal secure skin cover over these vascular repairs is not feasible, local soft tissue or adjoining muscles are used to cover the repair as a temporary measure. Surface cultures, or cultures from dead tissue are sent, antibiotics are used in consultation with other specialists and debridement can begin.
6. Debridement is an artful craft where the cutting instrument must remain within the obviously dead tissue and progress is then made towards what is certainly normal and then stopped when there is evidence of some bleeding. A temptation to chop off tissue en masse is avoided. Serial debridement is always preferred to avoid any excess and also because, as the wound evolves, more dead tissue becomes apparent. Bed sores in acutely ill patients should not be attacked surgically and should be dressed till their full extent is realized.
7. At this stage if there are fractures, they will be stabilized if the patient’s condition permits and the plastic surgeon hopefully should participate in the discussion as to the nature of stabilization because then plans can be made for a flap cover.
8. Wounds that will need skin cover belong to three categories. First, a clean wound in a stable patient which can be covered soon after admission (within first 48 hours). In the second category, a similar wound in a patient who remains critical but stable e.g. on a respirator and a vasopressor drip, is a matter of judgment, choice and certain philosophy. In most units now skin cover is achieved in order to close the wound and reduce any burden that the wound may have on systemic recovery. This can be done with regional blocks or with infiltration of a large dilute solution of local anaesthetics for surface analgesia and can be done in stages over days. But if this is difficult, homografts are applied to achieve the same result to temporarily tide over the situation. In the third category, the wound is dirty, continues to undergo necrosis in its bed and the situation may or may not be complicated by the general condition of the patient.
9. Under these circumstances,
a. The wound must be inspected at least once a day when debridement of dead tissue is undertaken
b. Irrigation should be done with saline or with a proprietary antibacterial compound after instillation of hydrogen peroxide
c. In limbs a simple air pump can be used to create bubbles in an antibacterial solution in a bucket and the limb is immersed in the bucket for up to half an hour, which will help in giving painless, gentle lavage and reduce the bacterial load.
d. A forceful, power driven jet lavage system is now available to clean wounds but it can be used only under anaesthesia.
e. Hyperbaric oxygen will help wounds not only by increasing cutaneous oxygen saturation but is known to help critically ill patients in general.
f. Even in sick patients, suction appliances can be used on any part of the body to clean up the wounds without in any way interfering with the measures that are taken to stabilize patients.
g. The Edinburgh University solution, Eusol, is still used and has had several proprietary substitutes including a solution in which oxygen has been forcibly pumped (short shelf life) but this solution has had its marketing ups and downs.
h. Enzymatic preparations which dissolve dead tissue are available as ointments or in proprietary dressings but have not been fully proved as effective in cleaning large wounds.
i. Some wounds which appear indolent in spite of all the above can improve with tangential excision if some form of analgesic and short acting anesthetic is permitted even if the patient is on a respirator or on dialysis.
10. The improvement in the wound is also greatly dependent on the condition of the patient. For example, a patient with a major brain injury who is sustained on a respirator, a patient who has undergone a major abdominal surgery involving for example a liver resection or a major bowel resection followed by an ileus, or has multiple organ failure as a result of an untreated hypovolemic shock in the initial phase are poor candidates for any improvement of their wounds. It is best that nothing adventurous is done on these wounds under these circumstances. Here expensive biological dressings are a waste of money and effort during what has been described as the catabolic phase of the wound and these applications are just devoured by the multiplying bacteria that grow in the wound. Ordinary dressings will do equally well.
11. This chapter deals mainly with preparation for split skin cover in large wounds. Any situation where two or three areas require a flap, in one or both limbs or other parts of the body, must wait for some time for final treatment. To give an example, a large defect over the lower femur, a repaired popliteal artery, an exposed knee joint together with an exposed muscle mass in the calf and exposed tarsal bones will classically need multiple flap covers but here prudence will be needed because the procedures might destabilize the patient. Each case is dealt as a problem in itself.

Each individual case however must be judged on its own merit. In this case an obese patient was transferred secondarily to a speciality hospital following a vehicular accident and was running fever and had critical injuries over the tendo-achilles and the calcaneus and a part of the heel was exposed which required flap cover. After stabilising the patient the critical area – above left and middle, was covered with a free anterio-lateral thigh flap from the opposite limb – upper right, and then the wound on the front of the foot was allowed to improve – below left and then split skin grafted – middle and right below. Photograph courtesy: Parag Sahasrabuddhe, Pune.

12. There are two parts of the body where non-biological substitutes are useful and can save life where a flap is needed but is not feasible. In the anterior abdomen a large defect with bowel exposed can be temporarily sealed by a sheet made of polytetrafluoroethylene (PTFE), which then can be dressed till granulation can grow from the sides. An ordinary polyethylene sheet covered with a vaseline gauze and dressings, though inferior in quality, has been used with similar results. In the skull the loss of bone and scalp over a large area with the brain exposed can be covered with a proprietary dural substitute and the bony defect can be temporarily obliterated with a titanium net or a special cement, measured and moulded and then fixed to the rest of the bone with wires.
13. What flows from the above points is that decisions made in the treatment of large wounds need to be deliberated. The deliberation more often than not has to be conducted between various specialists. When major flaps are needed in physiologically unstable patients, they are at best left to a later date by when the patient will be in a position to undergo surgery under adequate anaesthesia. However split skin cover will have a stabilizing effect on the patient, and can be performed relatively quickly and easily.

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