Manejo de Heridas: Reconstrucción

Reconstruction of large wounds can be very challenging but at the same time rewarding if approached correctly. There are several key points to keep in mind when attempting to close a large wound. Some of these include blood supply to the skin edges, level of contamination at the surgical site, tension, dead space, location, patient status, underlying etiology, and owner compliance.

Basic wound reconstruction requires the surgeon be familiar with lines of tension, tissue handling, and tension-relieving techniques. The majority of wounds can be closed with adherence to good tension-relieving principles. This may involve techniques such as undermining skin, tension-relieving sutures, skin stretching, and tension-relieving incisions. Patience in achieving ultimate wound healing is critical and the surgeon may benefit immensely by first managing the wound conservatively with the assistance of vacuum-assisted closure (VAC).

With larger wounds or defects, additional techniques such as rotational flaps, axial pattern flaps, skin grafts, or even free vascular tissue transfer flaps may need to be considered. In general, it is recommended to perform a small rotational flap or an axial pattern flap, if possible, before venturing into free tissue transfer or grafts. The advantage to axial pattern flaps is that they are based on consistent anatomical vasculature features, which allow us to define borders of the flap and consistently ensure viability. There are approximately 11 defined axial pattern flaps that can be employed for closure of a variety of defects. The flaps are named according to the artery and vein that are supplying them. For example, the caudal superficial epigastric flap is supplied by the caudal superficial epigastric artery and vein. A limitation of the axial pattern flap is that it may not reach wounds associated with the distal extremity.

Skin grafts are recommended for defects that cannot be closed through other conventional means. Although they are exciting to perform, a strict set of rules must be followed to maximize the chances of success. In order for skin grafts to survive, the recipient bed must be healthy and free of infection. Furthermore, there can be no motion at the site or fluid building up between the donor skin and recipient bed. Once the donor is isolated, all fat must be removed until a cobblestone appearance is present. The graft is applied and initially survives through imbibition. Once inoculation occurs (blood vessels form between tissue beds), it will gradually begin to establish a normal blood supply and successfully incorporate itself as long as there are no complications.

When dealing with heavily contaminated wounds, it is best to not rush into a closure as that will likely fail. Initially, open-wound management is likely to yield a better result; however, special attention must be paid to fluid and protein loss through the defect, as well as the potential for infection. In general, if there is a healthy granulation bed over the defect, there will likely not be an underlying infection. For heavy contamination, initial irrigation followed by appropriate bandaging is performed until a healthy tissue bed is established. Afterward, a non-adherent bandage is used to continue to encourage wound healing without debriding new cells. This approach can be very helpful when tissue viability is in question.