Wound Treatment

This article covers the general principles of surgical wound closure. For wounds with significant tissue loss not amenable to direct closure, it covers the range of skin grafting and related reconstructive techniques. It complements the broader wound assessment and dressing principles addressed under wound treatment more generally.

The central principle is accurate matching of the closure or reconstructive technique to the wound. Relevant characteristics include size, depth, location, and the condition of the surrounding tissue.

Principles of wound closure and the reconstructive ladder

• The reconstructive ladder is a structured, conceptual framework for wound closure decisions. It progresses from the simplest, least invasive approach to increasingly complex reconstructive techniques.
• The general, though not absolute, principle is to select the simplest technique adequate for satisfactory wound closure and functional outcome. Do not progress automatically to a more complex approach where a simpler option would suffice.
• Primary closure is direct apposition of clean, well-vascularised wound edges. It is the simplest approach, appropriate for wounds with minimal tissue loss and healthy, mobile surrounding tissue.
• Secondary intention healing allows the wound to heal from the base upward through granulation and epithelialisation. It is appropriate for smaller, contaminated, or tissue-deficient wounds not suitable for direct closure.
• Skin grafting transfers skin from a donor site to cover a wound defect. It is an important technique for larger wounds with adequate underlying vascularity but insufficient surrounding tissue for primary closure.
• Split-thickness grafts comprise epidermis and a portion of dermis. Full-thickness grafts comprise the entire epidermal and dermal layer. Each has distinct characteristics relevant to selection according to wound location and functional requirements.
• Local, regional, and free flaps transfer tissue with its own intact blood supply, rather than relying on revascularisation from the wound bed as a graft does. They are more complex techniques.
• Flaps are reserved for wounds with inadequate vascularity for graft take. They are also used where the functional or cosmetic requirements of the defect (including coverage of exposed bone, tendon, or joint) need the more robust, durable coverage that vascularised tissue transfer provides.

• The clinical presentation prompting consideration of surgical wound closure or grafting reflects the underlying cause of the wound. Causes span acute traumatic injury, burns, surgical defects following tumour excision, and chronic, non-healing wounds not responding to conservative management.
• Assess wound bed quality, including healthy, well-vascularised granulation tissue versus non-viable or infected tissue. This determines timing and suitability for grafting, because graft survival requires an adequately vascularised recipient bed.
• Split-thickness skin grafts characteristically look somewhat glossy and contracted after healing, with reduced durability and sensation compared with the surrounding native skin.
• Full-thickness grafts give a more robust, cosmetically favourable, and functionally durable result. They need a correspondingly more favourable, well-vascularised recipient bed. They are typically limited to smaller defects, given the constraint of direct donor site closure.
• Graft failure presents as failure of the transferred tissue to take and integrate with the wound bed. Causes include inadequate recipient bed vascularity, haematoma or seroma formation beneath the graft, infection, or inadequate graft immobilisation.
• Graft failure is an important, recognised complication requiring prompt recognition and, where appropriate, further intervention.

• Full wound assessment incorporates the general principles of wound evaluation addressed under wound treatment. It adds specific assessment of wound size, depth, location, and the condition and vascularity of the surrounding and underlying tissue. This is the foundation for selecting the closure or reconstructive approach.
• Assess any contributing factor to impaired healing, including diabetes, peripheral arterial disease, smoking, and nutritional status. These bear directly on graft or flap survival and overall wound healing capacity.
• For chronic or complex wounds, identify and address any relevant underlying cause, following the general principles addressed under chronic wounds and wound treatment.
• This is an essential prerequisite before definitive surgical closure or grafting. Surgical intervention has limited value where an underlying, unaddressed contributing factor persists.

• Wound bed preparation is an essential preliminary step before skin grafting. It comprises debridement of any non-viable tissue and optimisation of the wound bed to promote healthy granulation tissue formation. Wound bed quality directly affects graft take and survival.
• Split-thickness skin grafting harvests a thin layer of skin with a dermatome, typically from the thigh or another relatively inconspicuous donor site. The graft is applied to the prepared recipient wound bed and secured with sutures, staples, or an appropriate dressing.
• The split-thickness donor site is managed as a partial-thickness wound. It generally heals through re-epithelialisation over one to two weeks.
• Full-thickness skin grafting harvests the entire epidermal and dermal thickness from a donor site, with direct closure of the donor site defect. It is generally reserved for smaller defects, particularly in cosmetically or functionally sensitive locations including the face and hands. It gives a superior cosmetic and functional outcome compared with split-thickness grafting.
• Postoperative graft care includes immobilisation of the grafted area to prevent shearing forces that could disrupt graft revascularisation. It also includes regular dressing changes and monitoring for signs of graft failure or infection.
• The graft generally needs several days to achieve adequate vascular integration before it can be considered securely established.
• Where grafting alone is inadequate because of insufficient recipient bed vascularity or specific functional requirements, consider local, regional, or free flap reconstruction. Specialist plastic and reconstructive surgical services deliver these procedures, given their substantially greater technical complexity.
• Structured follow-up includes ongoing assessment of graft or flap viability and function, and management of both the recipient and donor sites. Where relevant, add scar management and rehabilitation support. This applies to wounds requiring surgical closure or reconstruction beyond simple, direct primary closure.