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Wound Care and Reconstruction

An individually tailored program must be utilized in the treatment of wounds as well as with wound closure or coverage. 

The ideal situation utilizes a multidisciplinary approach and may include vascular, orthopedic, and plastic surgery in conjunction with nurses specialized in the treatment of wounds.  This will allow optimal therapy and possibly non-surgical treatment.

Who’s a Candidate?

The best candidates for wound care and operative intervention are those individuals that have acquired wounds exposing major structures such as bone, joint, tendon, nerve, and vessels. Common causes include trauma, tumor ablation, spinal cord injury, vascular disease and major infections. Prior to performing such a surgery, patients are evaluated for the health of the local tissue in addition to the systemic factors to make an informed decision about performing a complex operation which may require months of rehabilitation, dressing changes and possible loss of work.

What Are the Risks?

As with any surgery, there is always a possibility of complications, including bleeding, infection, neurologic changes or reaction to anesthesia. Some patients may have delayed wound healing especially in those with diabetes, obesity, in smokers, poor nutritional status and those who are immunocompromised from adjunctive irradiation and/or chemotherapy. Increased wound healing time may add to disability and could possibly lead to loss of reconstructed tissue, exposed prosthesis, and ultimately lead to an amputation. Immobilization necessary for recovery could lead to blood clots in the veins, leading to possible pulmonary embolism (blood clot in the lungs). Blood thinning medication is frequently given in the post operative period to prevent such events.

The procedure will leave noticeable, permanent scars both in the original wound site, the donor and recipient sites, along with mismatched tissue that may not have sensation. Depending on the site of the donor tissue, there could be widening of scars and decrease in the function of the donor site which can be compensated for by the surrounding tissue in the future.

Preparing for Surgery

Wound care programs and wound reconstruction is based on the individual and factors such as the severity of the deformity, injury, and tissue loss and the expected function from reconstruction or treatment program.  Also, the time away from work required for rehabilitation, and the overall systemic disease and other factors such as your age, nutritional status, ability to participate in the program, etc.,  that affects the final outcome will be discussed.  The surgeon will examine the wound and assess for infection, loss of tissue and the volume needed for its replacement, and local blood supply. You may also be required to have imaging studies prior to an operation.

There is a moderate likelihood for blood transfusion with complex operations especially those involving different specialties for treatment.

The Surgery

Wound surgery is highly variable and can be done on both an in patient and outpatient basis.  The length of surgery is relative to the extent of the wound to be treated and the amount of reconstruction necessary.  The surgery may be done under local anesthesia alone, in combination of local anesthesia and some sedation, or under general anesthesia.

There are many different types of procedures including wound debridement (wound cleaning), vacuum-assisted-closure, tissue expansion prior to closure over a wound, simple direct closure of the wound, skin grafting (using a strip of skin from your thigh to cover open soft tissue) to rearrangement of local soft tissue to close over open deep skeletal tissue.  For larger wounds, a more complex option involves tissue transfer using microsurgery to connect blood vessels. This will provide robust tissue to help in the delivery of oxygen, blood and antibacterial medications.

After Your Surgery

You may require prolonged bed-rest after the operation with a splint, cast or specialized dressing to allow healing of operative site. Pressure relief measures are important to the newly operated sites, which may or may not have sensation, to prevent future ulceration of the tissue. Small tubes may be placed to drain fluid immediately after the operation which will eventually be removed. You will generally require daily dressing changes in addition to close monitoring early on. You will feel some discomfort for the first few days, especially when you move around. Your surgeon will prescribe pain medication. The daily dressing changes will be stopped after a short period of time when the tissue has healed. About this time, you will be allowed to get physical therapy and rehabilitation, if necessary, which could be anywhere from range of motion exercises to the joints or getting out of bed and walking with assistance. You may have a gradual protocol from bed to sitting and then to standing position, based on the complexity of your reconstruction and this could take up to six weeks.

Avoid lifting or pushing heavy objects for the first two months as the deeper tissue need this much time for full healing. Return to work is dependent on the severity of the original injury, the complexity of the operation, and the time required for full healing and rehabilitation process.  This could be months to over a year.