[abstract] DECISION MAKING FOR CLOSURE/COVERAGE OF PROBLEM WOUNDS

Abstract

BACKGROUND: The intermediate management goal for every problem wound is to reach a stage that decision making for

closure/coverage becomes necessary. Although there are nearly a dozen choices, the best choice must be based on the vitality

of the wound itself. This presentation provides tools for selecting the optimal closure/coverage technique based on the

metabolic requirements and perfusion/oxygenation status of the wound base. MATERIALS AND METHODS: Extensive experiences

gained by working with patients referred to our wound healing program have generated a hierarchy of wound coverage/closure

techniques based on the metabolic requirements of the closure technique and the perfusion/oxygenation status of the wound

base rather than just the reconstructive ladder popularized in the surgical literature. From this information, a best fit

can be made for the coverage/closure choice and the quality of the wound base. RESULTS: Epithelialization under a dry, firm

eschar and around the open wound margins are the least perfusion dependent of any closure type. Next in the hierarchy is the

simple closure of the skin edges followed by skin grafting. Local flap closures follow in the demand hierarchy. Distant

flaps are often the next option. The microvascular free flap is often the final and most surgically invasive option only to

be potentially physiologically exceeded by the most energy demanding, the filling-in of a cavitary wound. Bioengineered

dressings may have a useful role by making it possible to "jump" one or two levels in the hierarchy. CONCLUSIONS:

Predictable wound coverage/closure outcomes are anticipated when the vitality of the wound base is paired with the metabolic

demands of the closure/coverage type. If coverage/closure technique fails, then careful reevaluation of the wound and

consideration for a new, level appropriate, choice on the hierarchy must be given.