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WOUND SURGERY
Volume 34  Number 4  October 2007

Contents

Preface xi
Mark S. Granick

Optimizing the Patient for Surgical Treatment of the Wound 607

Wesley T. Myers, Mimi Leong, and Linda G. Phillips
Plastic surgeons are consulted often to close wounds that fail or are difficult to heal.
Optimizing the patient’s medical condition before surgical closure of a wound can mean
the difference between a successful outcome and an undesirable one. It is imperative
that plastic surgeons have an extensive knowledge of the modifiable risk factors affecting
the wound-healing process and their subsequent complications. This knowledge allows
the surgeon to tailor the treatment options and intervene when appropriate to optimize
outcomes for successful surgical closure of a wound. Whether the impairments to
wound healing and closure are local or systemic, they must be addressed appropriately.

The Science of Wound Bed Preparation 621

Jaymie Panuncialman and Vincent Falanga
The concept of wound bed preparation (WBP) heralded a new era in terms of how
we treat wounds. It emphasized the difference between acute and chronic wounds,
and it cemented the idea that the processes involved in the healing of acute wounds
do not apply completely to the healing of chronic wounds. The arbitrary division of the
normal healing process into the phases of hemostasis, inflammation, proliferation,
and maturation addresses the events in acute wound healing. We have realized
that the impediments to healing in chronic wounds lead to a failure to progress through
these phases and are independent factors that make the chronic wound a much
more complex condition. A major advance in resolving or addressing the chronic
wound has been the concept of WBP. WBP allows us to address the problems of wound
healing individually—the presence of necrotic tissue, hypoxia, high bacterial burden,
corrupt matrix, and senescent cells within the wound bed. In WBP we can optimize our
therapeutic agents to accelerate endogenous healing or to increase the effectiveness of
advanced therapies.
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Surgical Wound Bed Preparation of Chronic and Acute Wounds 633

Kevin R. Knox, Ramazi O. Datiashvili, and Mark S. Granick
Our aging population has presented us with many new challenges. One such challenge
is the need to manage an increase in wound-related problems effectively and efficiently.
Over time, two parallel, yet divergent, management systems have developed. One
strategy, used by medical specialists, uses a variety of dressings, topical enzymes, and
local and systemic medications ultimately aimed at the promotion of healing by
secondary intention or, in some cases, optimization of the wound for surgical
reconstruction. In the second strategy, used by surgeons, early surgical intervention is
used to prepare the wound for reconstruction in a timelier manner while promoting the
healing process. This article reviews the development of these two distinct management
systems and their areas of commonality and sets forth a new model to support the role
of surgery in the treatment of problematic wounds.

Interactive Dressings and Topical Agents 643

Robert J. Morin and Nancy L. Tomaselli
Wound healing is a complex process that often becomes problematic in complicated
patients. When abnormal wound healing occurs, there are many possible ways to
intervene. One intervention is through the use of dressings and topical agents. This
article is a review of the latest dressings and topical agents available in the United States.
Recommendations for use are made based on the most current data in the medical
literature.

Biologic Enhancement of Wound Healing 659

Paul J. Leahy and W. Thomas Lawrence
Manipulation of the healing process through wound supplementation with agents that
are natural contributors to the healing process is an appealing concept. Early
experimental studies evaluating wounds supplemented with inflammatory mediators
used materials extracted from cell preparations and generated encouraging results.
Recombinant technology has allowed the production of larger volumes of these
mediators that can be used more practically and safely in the clinical setting. Several
clinical trials involving inflammatory mediators as wound supplements are reviewed,
and the results of many of the studies are encouraging. Wound supplements are
considered drugs, and therefore, they must be demonstrated to be safe and efficacious
before they can receive approval for human use by the FDA. It is extremely expensive to
carry out the experimental studies required for FDA approval. Because of the expense
involved, Regranex is the only supplement that has been tested thoroughly enough to
receive FDA approval for use in humans. It is hoped that additional agents will be
demonstrated to be safe and efficacious in human trials so that they might become
available in the United States in the near future.

Negative Pressure Wound Therapy 673

James T. Thompson and Malcolm W. Marks
Negative pressure wound therapy has become an increasingly important part of wound
management. Over the last decade, numerous uses for this method of wound
management have been reported, ranging from acute and chronic wounds, to closure
of open sternal and abdominal wounds, to assistance with skin grafts. The biophysics
behind the success of this treatment largely have focused on increased wound blood
flow, increased granulation tissue formation, decreased bacterial counts, and
 Contents vii

stimulation of wound healing pathways through shear stress mechanisms. The overall
success of negative pressure wound therapy has led to a multitude of clinical
applications, which are discussed in this article.

Management of Acute Wounds 685

Charles K. Lee and Scott L. Hansen
The acute wound presents a spectrum of issues that prevent its ultimate closure. These
issues include host factors, etiology, anatomic location, timing, and surgical techniques
to achieve successful wound closure. Basic surgical principles need to be followed to
obtain stable, long-term coverage, ultimately restoring form and function. Recent
advances in dressings, debridement techniques, and surgical repertoire allow the
modern plastic surgeon to address any wound of any complexity. This article discusses
these principles that can be applied to any wound.

Burn Surgery 697

Mayer Tenenhaus and Hans Oliver Rennekampff
The challenges posed by thermal injury often are daunting emotionally and physically
for the survivor, family, and staff. Morbidity and mortality have improved with advances
in emergent and multidisciplinary care; the establishment of dedicated burn centers;
and increased education, prevention, and experience. The role of surgery in the
treatment of these complex injury patterns continues to evolve, incorporating refined
concepts of tissue preservation, wound bed preparation, and early attention to
functional and esthetic parameters. Societal reintegration, psychosocial support, and
new pain control strategies have dramatically improved the quality of life for our
patients during and after the acute course of care. With improved survivability and
a changing demographic, fundamental reconstructive surgical principles have found
increased applicability and are instituted at the time of admission whenever
possible.

Evaluation and Treatment of Leg Ulcers Associated with Chronic Venous Insufficiency 717
William Marston
The successful management of patients who have leg ulcers related to chronic venous
disease requires optimal management of the wound bed, elimination of edema with
compression, and correction of venous hypertension whenever possible. Healing of the
wound itself requires compression, debridement, bacterial control, and stimulation of
the wound bed. Prevention of ulcer recurrence is most effective if the patient is amenable
to correction of the venous insufficiency. This is most successful when the superficial or
perforator veins are the primary source. Quality diagnostic studies are critical in
determining the anatomy and hemodynamic importance of various venous abnormal-
ities and can guide appropriate interventional treatment. Venous corrective procedures
usually can be performed using minimally invasive endovenous methods, which are
associated with fewer complications and more rapid recovery than are major surgical
techniques.
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Debridement of Invasive Diabetic Foot Infections 731

George F. Wallace
Diabetes pedal infections are too prevalent and will become more so as the numbers of
diabetic patients increase. The goal is to prevent amputations or at least to remove as
little of the foot as possible. Prompt surgical intervention and better diabetic pedal
education will go a long way to achieving that goal.

Diagnosis and Management of Pressure Ulcers 735

Benjamin Levi and Riley Rees
Pressure ulcers represent a significant health issue and cost for the growing number of
elderly and debilitated patients. The plastic surgeon, as part of the wound care team, has
the ultimate responsibility of forming a plan to allow for the eventual closure of the
wound. This plan should start with breaking the cycle and eliminating the risk factors
that led to the development of the wound. Simultaneously, the surgeon should order an
MRI and erythrocyte sedimentation rate and take a bone biopsy to diagnose the extent of
the wound and the bacteria present. If more than 105 bacteria are present, surgical
debridement should be performed, followed by 6 weeks of intravenous antibiotics.
Once the bacterial load has been lessened, a 6-week course of Regranex should be
applied. Finally, after the wound bed has been prepared adequately, definitive surgical
closure should be planned and performed.

Diagnosis and Treatment of Uncommon Wounds 749

Andrea L. Pozez, Sharline Z. Aboutanos, and Valentina S. Lucas
Uncommon wounds present unique challenges to plastic surgeons and other wound
care providers in regard to their presentation, recognition, and ultimate treatment. This
article presents an overview of diagnosis and actual case treatment of unusual wounds,
a review of the literature, and case studies of interest. A systematic approach to diagnosis;
careful review of history; and full understanding of topical, systemic, and surgical
therapies is paramount to proper treatment recommendations, appropriate patient
management, and successful wound-healing outcomes. The ability to identify and treat
wounds caused by an unusual etiology or presentation is an important skill.

Index 765