Closure of Complicated Wounds

Updated: Nov 05, 2021
Author: Mark S Granick, MD, FACS; Chief Editor: William D James, MD 



Complicated wounds are those that cannot be closed primarily without complex surgical manipulation, and they often require adjunctive advanced wound care management. The exact approach to the closure of complicated wound depends on the causes for, location of, physical characteristics of, and healing potential of the wound. The closure of these wounds often falls under the purview of reconstructive surgeons or those appropriately trained in plastic surgical principles. Ideal outcomes in managing these wounds are achieved when the synergy between functional and aesthetic function is optimized.

While there are many etiologies for complicated wounds, most often they result as a consequence of significant traumatic injury or following extirpation of oncologic tumors. Given the plethora of ways in which complicated wounds may present, the field of reconstructive surgery is immensely broad, and the chosen treatment is highly individual to both patient and clinician. The focus of this article is the management of clean (ie, negative infectious and/or oncologic margin) wounds, particularly of the head and neck region. However, the fundamentals of many reconstructive techniques are discussed, which may be applied to the management of a multitude of complicated wounds.

History of the Procedure

The earliest documented surgical intervention to rebuild a complicated defect was from India in 700 BCE. Susruta used advancement of cheek tissues, Tagliacozzi used tubed skin flaps from the upper arm in the 1500s, and Lucas published his account of the Indian method of forehead rhinoplasty in Gentleman’s Quarterly in October 1794.

Independently, the Italians developed delayed flaps, tube flaps, and flap transfers by utilizing the upper inner arm skin to reconstruct a nose. This technique was published by Tagliacozzi in 1597. In modern medicine, the use of local flaps to repair facial defects began to evolve around the mid 1800s. A variety of flaps were used, but the blood supply and the dynamics of the surgery were not well understood. Sir Harold Gilles detailed the principles of flap and graft reconstruction of nasal defects in his 1957 treatise and initiated an interest in reconstructive surgery.

Local skin flaps such as those described in this article were primarily developed in the 1950s in Europe and the United States by the second generation of plastic surgeons. Ian MacGregor, however, recognized the importance of an axial blood supply in flap surgery in the 1970s. Subsequent refinements have led to muscle flaps and free flaps.


In recent years, several adjuncts have become available to surgeons dealing with complicated wounds. These are not addressed in this article, but they include acellular dermal mattrices (of which there are allograft or xenograft sources, iee, human and nonhuman sources, respectively), bilaminar matrices such as Integra, and other dermal substitutes. The reader is directed to further reading on dermal substitutes, which are beyond the scope of this article.

Relevant Anatomy

In managing a complex defect, the surgeon must first assess the size and depth of the wound, as well as the presence or absence of exposed internal anatomy or surgical hardware (eg, orthopedic internal fixation or cranial plating) in the wound. A defect containing exposed bone, nerves, blood vessels, or hardware usually necessitates a more advanced closure than would a less complicated wound.

In reconstruction involving local tissue rearrangement or pedicled flaps, the quality of the surrounding skin is also of great importance. Skin quality may vary from young, tight, and elastic to aged, dry, and lax. In the face, the wrinkled skin of an older patient produces less obvious scarring and offers the opportunity to conceal scars within skin tension lines. Skin that is more heavily pigmented or oily generally yields a less favorable scar. The presence of actinic damage, skin diseases, and premalignant satellite lesions should also be considered. Finally, location is of major concern. Defects adjacent to unique anatomical structures present a more involved reconstruction. Defects approaching the eyelids, the nasal openings, the oral commissure, and the external auditory meatus must be reconstructed so as to avoid distorting the anatomy unique to those areas. Any alteration of these surrounding landmarks can potentially compromise functional and aesthetic results.

Facial defects merit special consideration because they represent particularly visible and potentially functionally detrimental reconstructions relative to wounds elsewhere. However, the principles presented here may be applied to the management of all complicated wounds.


When repairing facial tumor defects the most important consideration is the management of the tumor. Incompletely excised tumor should not be covered over by a flap. Skin adjacent to a tumor resection margin should not be turned over to line the nasal cavity or any other site where it will be difficult to examine. Definitive reconstruction should be delayed with local wound care if possible until negative frozen or permanent margins have been obtained.

In patients who have a history of multiple or recurrent skin cancers, a strategy must be developed to allow for serial repairs. No bridges should be burned along the way.

When planning a reconstruction, function must be protected first and cosmetic issues are optimized secondarily. A good-looking static repair that compromises dynamic function is unacceptable. When considering the cosmetic issues, try to avoid crossing anatomical boundaries with a flap. The obliteration of folds and creases that occur naturally leads to an undesirable result. Burget and Menick first published their subunit principles for reconstruction of nasal defects in 1985,[1] and they have continued to publish extensively.[2, 3, 4] Indeed, larger or longer scars on the face may be less noticeable than smaller scars, if those small scars are poorly oriented or located incorrectly. Additionally, the final scars are often designed to result in a curvilinear or zigzagged manner, as these appear less noticeable to the untrained eye. Planning is paramount in obtaining a cosmetic result in closure of complicated wounds on the face.



Laboratory Studies

Laboratory studies are not required in the vast majority of wound closure settings, but in cases of complex wounds or chronic/nonhealing wounds, they may aid the surgeon in tailoring treatment. Nutrition laboratory studies, including albumin, prealbumin, and transferrin levels, can indicate if the patient is appropriately nourished and able to heal the wound. Zinc or iron deficiencies, along with other mineral deficiencies, can prolong or inhibit the wound healing process altogether. Similarly, deficiencies in vitamin C, D, and other key vitamins can prevent a patient's wounds from properly healing. In select patients, a preoperative nutritional workup may be warranted.



Surgical Therapy

Oncologic tumor resection

The paramount consideration in tumor excision should be the complete removal of the tumor. Although the surgeon should have a number of reconstructive options in mind, the planned reconstruction should not dictate the extent of tumor excision. The surgeon must remain open to alternative reconstructive techniques, despite the intended reconstruction. If the defect obtained in excising the tumor cannot be reasonably reconstructed at the time of the operation, the wound should be dressed, and the reconstruction reconsidered, delayed, or the patient referred to another surgeon specializing in these repairs. This option is clearly preferable to a suboptimal reconstruction.

Skin tumor excision can be performed in several ways. These techniques include surgical excision, micrographic excision, and electrodesiccation and curettage. Tumors can also be ablated by thermal energy or radiation. Micrographic surgery, originated by Dr. Frederick Mohs in the 1930s at the University of Wisconsin, consists of serial excision and micrographic analysis of a tumor until the margins appear histologically clear. Although micrographic excision of tumors is tissue sparing, patients with extensive tumors are preferentially treated by this technique, leaving some challenging tumor defects to repair. See Mohs Micrographic Surgery.


Undermining is performed to mobilize the tissue in areas surrounding the defect and to facilitate the draping of skin over the wound. The use of undermining allows the surgeon to move portions of the wound and not others to avoid the distortion of nearby anatomy, such as the nasolabial fold or the oral commissure. However, advancement from this technique may often be minimal and because tight closures make for unsightly scars, alternatives should be considered prior to undermining the edges of a gaping or complicated wound.

Dog ears

When using elliptical skin excisions, the long axis should be three-to-four times greater in length than the smaller axis. When an ellipse is made too short, the angle of an ellipse is too obtuse, or one side of the ellipse is of unequal length, the skin may bunch at one end of the closure. This is known as a dog ear. Excising dog ears when they occur is simple, but often results in a longer scar. This excision is accomplished most easily by extending the elliptical excision such that the angle of the ellipse is acute, (ideally less than 30º) or by cutting the corner of the excision into a Burow's triangle. Alternatively, placing a small right angle or 45° bend in the affected end of the wound closure can provide a satisfactory result. Finally, a V-shaped excision of the lateral ellipse can be used, resulting in an M-plasty closure.

Wounds of unequal length

In any wound, whether it is of equal or unequal length, closure is begun at the ends of the defect to avoid unnecessary dog ears. Any redundancies can be dealt with in the middle of the wound during closure. Irregularities or pleats in the mid portion of the wound generally resolve over time.

Preoperative Details

Key to closing any wound is an adequate assessment of the condition of the wound, investigation for the presence or absence of contamination or infection, and a determination of whether or not closure without undue tension can be achieved.[5] If necessary, repeat examinations, irrigation, and serial debridement may be used to ensure a wound bed is ready for definitive closure. In some wounds that cannot be closed primarily, negative-pressure wound therapy with a vacuum-assisted closure (VAC) device may be a viable option. [6]

Intraoperative Details

The final outcome in any closure depends mainly on appropriate assessment of the defect and the selection of an appropriate closure technique. Primary closure involving direct approximation of the wound edges is a first option. An intermediate closure consists of approximation and closure of deeper tissue levels prior to final skin closure. Complex closure entails approximation and adjustment of the wound edges by means of undermining, the excision of any dog ears, or trimming of wound edges prior to closure. Finally, the options of skin grafting, allografting, and flap repair must be considered.

When a wound cannot be closed primarily, the options are as follows: allowing the wound to heal secondarily, the placement of a skin graft of appropriate thickness, or local tissue transposition. Healing by secondary intention consists of 2 phenomena. The major method of reduction in size of the defect is wound contracture, accompanied by reepithelization to a lesser extent. Often, this wound contracture is responsible for the distortion of nearby mobile anatomical features, such as the oral commissure or the epicanthi. The contraction of scar tissue alters the orientation of the surrounding normal anatomy, which may result in an unacceptable cosmetic outcome and more importantly, poor function.

Healing by secondary intention is a viable option in fixed areas away from important anatomy, as in the case of the middle of the forehead, the cheek, or the neck. In areas adjacent to important, easily deformable anatomical structures, transposition flaps are often a better wound closure approach. Compared with secondary intention healing, coverage with flaps additionally leads to faster recovery, less scar contraction, and improved cosmetic appearance. A brief explanation of these different flaps is included below.

Flap coverage

Local flaps offer several advantages. Flaps provide skin where it is needed to fill a defect. The skin provided is a close match in both color and texture, the donor site can be closed directly, and scar contracture is minimal. However, these flaps require experience and planning. The choice of the flap to use depends on the location and the size of the defect and the quality of the surrounding skin and where adjacent excess tissue is located. Of paramount importance in any flap reconstruction is the preservation of a suitable blood supply to all mobilized tissues. Anticipating the appearance of the donor site scar is necessary, and when possible, plan to leave the scar in a natural crease line (eg, the nasolabial fold).

Transposition flaps

Local transposition flaps involve the movement of adjacent skin from an area of excess to the area of deficiency. Rhomboid flaps, Z-plasties, and W-plasties are variations on this basic theme. They involve the transposition of a skin and subcutaneous tissue flap based on the perfusion of the subdermal plexus (so-called “random” flaps as they are not based on a named vessel) into an adjoining defect. These flaps are designed so that the donor scar is well camouflaged. They must be meticulously designed according to the specific requirements of the reconstruction. However, transposition flaps are quick and easy for the experienced surgeon and are versatile solutions to many coverage problems.

Banner flaps are transposition flaps designed as a pendant of skin tangential to the edge of a round defect. The flap is elevated, and the donor site closed. The flap edges are then trimmed to better fit the defect, and the recipient site is closed.

The bilobed flap is a variant of the banner flap, in which two adjacent segments are raised, one smaller than the other. The two flaps are oriented perpendicularly to one another. The smaller flap (usually one half the diameter of the larger flap) is used to fill the larger donor site, and the small donor site is closed primarily. The original defect is then closed by means of the larger of the two lobes. The final result is the 180° rotation of excess tissue to fill the skin deficit. Bilobed flaps are most commonly used in the closure of nasal defects, and they are a means to transfer excess adjacent skin into the area of deficiency.

See the images below.

Preoperative planning for a banner flap to repair Preoperative planning for a banner flap to repair a facial defect (same patient as in Image 2).
Postoperative photo showing the completed banner f Postoperative photo showing the completed banner flap repair (same patient as in Image 1).
A nasal defect after excision of squamous cell car A nasal defect after excision of squamous cell carcinoma and prior to repair with an interpolated flap (same patient as in Images 4-6).
The preoperative plan for the interpolated flap is The preoperative plan for the interpolated flap is designed to leave the donor scar in the natural wrinkle line of the nasolabial fold (same patient as in Images 3 and 5-6). The interpolated flap is most similar to a banner flap, and, in this case, it is folded over to reconstruct the nasal ala.
Intraoperative appearance of the interpolated flap Intraoperative appearance of the interpolated flap, folded upon itself to provide greater thickness and coverage of skin and mucosal surfaces (same patient as in Images 3-4 and 6).
Final appearance of the interpolated flap repair, Final appearance of the interpolated flap repair, illustrating the advantage of placing the donor scar along a natural wrinkle line (same patient as in Images 3-5).

Rhomboid flaps

Rhomboid flaps are rhomboid-shaped skin flaps transposed into like-shaped defects leaving an angulated donor site, which can then be closed primarily. A corner of the rhombus is extended at a length equal to one of the short diagonals. This new limb is joined by another at a 60° angle. Because all rhomboids possess four corners that can be extended, any rhomboid defect is amenable to any of four possible rhomboid flaps. The end result is a scar of geometric appearance, which is best when hidden in the natural crease lines of the skin. Rather than the customary angles of 60° and 120° in the rhomboid flap, variations of the rhomboid flap using 30° and 150° angles are possible. This allows coverage of rhomboid defects with unequal sides. Because this approach involves more meticulous planning, first converting the defect into a rhombus of 60° and 120° angles is sometimes simpler.

When a larger wound needs to be closed, the circular defect can be converted into a hexagon and closed with three rhomboid flaps. This procedure is even more complicated to plan, and it leaves a stellate-shaped scar. The scar is difficult to merge into natural crease lines and is consequently noticeable as a geometric scar. Use this technique with caution.


The Z-plasty is a double transposition flap, and it is often an appropriate option in scar revision or in the release of scar contractions. These flaps are well suited for the correction of skin webs and disrupting circumferential scars or constricting bands. Furthermore, the Z-plasty elongates the operated tissues.

The Z-plasty entails the exchange of two adjacent triangular flaps. The incision consists of a central limb and two limbs oriented to resemble a Z. All limbs are the same length to facilitate closure. The length of the central limb dictates the absolute gain in length after Z-plasty, while the angles chosen determine the percent of length increase. The typical Z-plasty has 60° angles, resulting in a gain in length of 70% relative to the central limb. The angles may range from 30-90°, providing gains in length of 25% and 120%, respectively. However, these gains are theoretical, and smaller gains are seen in practice because of restrictive skin factors. In addition, because the Z-plasty relies on healthy adjacent skin, it is a poor choice for the correction of burn wound contractures. However, the gain in length granted by the Z-plasty is well suited to other scar contractures, and the changed axis of the final scar often provides a more aesthetic result in facial scar revision.

When laying out the Z-plasty, the final position of the central limb is plotted first. This final position is perpendicular to the original central limb incision, and it should be oriented parallel to the skin lines. Consecutive Z-plasties result in further transposition of skin and obliteration of straight-line scars. Multiple Z-plasties produce transverse shortening and lateral tension on the wound.


The W-plasty is similar to a Z-plasty in its ability to break up a linear scar, though, here, multiple smaller triangular flaps are interposed among one another. The base of each triangle is aligned with the vertex of the one opposite it. However, unlike the Z-plasty, the W-plasty does not confer any gain in length to the contracted scar line. The W-plasty increases rather than decreases lateral tension, and skin must be sacrificed in its construction. Therefore, the procedure should only be undertaken in areas of scar with excess adjacent skin. As the ends of the scar are approached, the triangles should decrease in size, and the limbs of the triangles should decrease as well.

Rotation flaps

Rotation flaps are semicircular flaps raised in a subdermal plane and rotated from the donor bed around a pivot point adjacent to the defect. The defect site is visualized as a triangle with its base as the shortest side. After the flap is rotated into the defect, the donor site is closed primarily, yielding an arcuate scar. Considerable tension may be present in this flap, which needs to be recognized. The line of maximal tension is directly opposite the pivot point and adjacent to the defect. Excessive tension along this line may result in ischemia and subsequent necrosis of the flap. Rotation flaps require a great degree of planning, and little gain is realized relative to the size of the flap. In some cases, the donor site cannot be primarily closed and may require a skin graft. However, depending on the location of the defect to be repaired, rotation flaps may be preferable to transposition or advancement flaps. See the images below.

A large lesion of the right cheek amenable to repa A large lesion of the right cheek amenable to repair with a rotation flap (same patient as in Images 8-9).
An intraoperative illustration of the rotation (ce An intraoperative illustration of the rotation (cervicofacial) flap transposed into the defect site (same patient as in Images 7 and 9).
Postoperative appearance of the completed rotation Postoperative appearance of the completed rotation flap repair of the right cheek defect (same patient as in Images 7-8).
A leiomyosarcoma of the scalp to be excised and cl A leiomyosarcoma of the scalp to be excised and closed via opposing rotation flaps (same patient as in Images 11-13).
A scalp defect following excision of a leiomyosarc A scalp defect following excision of a leiomyosarcoma. Preoperative marking for repair with opposed rotation flaps is seen in blue. The anterior portion of the scar is oriented parallel to the patient's original hairline (as indicated by the dashed line) (same patient as in Images 10 and 12-13).
Postoperative appearance of the opposed rotation f Postoperative appearance of the opposed rotation flaps scalp repair (same patient as in Images 10-11 and 13).
Final appearance of the rotation flap scalp repair Final appearance of the rotation flap scalp repair (same patient as in Images 10-12).

Advancement flaps

Advancement flaps involve raising skin in a subdermal plane and moving its leading edge into the defect. The movement of the flap is longitudinal rather than rotational. Again, these flaps may be a multitude of sizes as per the size of the defect. Burow's triangles are often excised at the base of the flap to provide for greater length of transposition to cover larger defects. These flaps have limited coverage potential and limited utility.

V-Y plasty

In performing a V-Y plasty, the skin flap is not elevated, and it remains attached to the underlying subcutaneous tissues. A V-shaped flap is designed adjacent to the defect. The surrounding skin is incised, and the V-shaped tissue is advanced into the wound. The flap lends itself to disguising the scar in natural crease lines. Alternative ways to elevate a V-Y flap include central undermining and lateral pedicles or partially undermining the central attachment. The donor site is closed primarily, yielding a Y-shaped closure. This technique is well suited to elongating the nasal columella and correcting the whistle deformity of the lip, but it is applicable to many defects elsewhere on the skin. See the images below.

A lesion due to amyloidosis amenable to a V-Y clos A lesion due to amyloidosis amenable to a V-Y closure (same patient as in Images 15-16).
Postoperative appearance of the V-Y advancement fl Postoperative appearance of the V-Y advancement flap (same patient as in Images 14 and 16).
Final appearance of the V-Y advancement flap closu Final appearance of the V-Y advancement flap closure (same patient as in Images 14-15).

Island flaps

Island flaps, as their name implies, involve the transposition of an island of skin that is raised on its blood supply. The skin island is moved into the defect, and the donor site is closed primarily. Often, this involves tunneling the flap under adjacent skin on its vascular pedicle. In areas, such as the eyebrow, the island flap provides a supply of like tissue without allowing for the distortion of the normal anatomy. The nasolabial island flap is frequently used as a flap based on a single pedicle to reconstruct defects of the nasolabial fold or portions of the nose. More recently, a bipedicled flap has been proposed to provide nasolabial skin for repair of cheek defects. Regardless of location, a circular island flap may pincushion, and this should be recognized, planned for, and avoided.

Perforator flaps

So-called perforator flaps are those based on a vascular pedicle, which is usually isolated by means of Doppler or ultrasonographic probes. Once isolated, the vessel is used to design a flap consisting of the perforator vessel and the soft tissues (including skin) that it supplies. The skin and soft tissues are then transported from their donor bed to a recipient site. These perforator flaps can be used as pedicled flaps, or they may be transferred with a microvascular anastomosis to a vessel adjacent to the recipient site. Pedicled flaps can be mobilized into the defect in a variety of ways including, transpositions, rotations, or tunneled approaches. A pedicled flap based on the angular artery and rotated in a V-Y manner is a greatly useful approach to defects of the nasal sidewall and ala.[7]

Beyond local reconstruction

For significant oncologic and traumatic tissue defects, local flaps are often insufficient to cover a wound properly. In these cases, distant tissue may be imported by using various other reconstructive techniques, such as skin grafting, pedicled flaps, or free flaps. If the wound is appropriate and the patient amenable to delayed or staged reconstruction, other advanced techniques such as vacuum-assisted wound therapy, tissue expansion, or skin substitutes may be used. While a full review of these techniques is outside the scope of this article, the fundamentals and some cases are discussed to foster an understanding of the full scope of reconstructive possibilities.

Skin grafting

While skin flaps bring with them a blood supply, skin grafts are avascular and must “take” in the wound bed they are placed. They are categorized as either split- or full-thickness, which is based on the proportion of dermis (partial or full, respectively) included. Skin grafts may be obtained from anywhere on the body where there is skin. They must initially survive on the nutritional plasma-rich exudate of the wound bed prior to revascularization and are at risk of failure if not properly performed and managed. Given this initial nutritional source, skin grafts do not take when placed over neurovascular structures, bone without periosteum, or tendon without paratenon, and more durable coverage is required. Otherwise, the take of a graft is based on a multitude of factors, including graft thickness, wound bed vascularity, the absence of infection, meticulous hemostasis, and avoidance of postoperative shearing forces. Once harvested, skin grafts are secured within the recipient bed, maintained in place with various forms of bolsters, and “unveiled” approximately 5 days postoperatively. Following this, careful avoidance of shear forces and local wound care is sustained until the graft fully matures.

Split-thickness skin grafts (STSGs) are generally harvested using a device with a sharp razor set between 0.012-0.018 inch (0.3-0.4 mm) thick from the upper lateral thigh or back, in order to maximize size while concealing the donor site. STSGs have the advantages of being able to be meshed to increase their surface area and being able to be harvested from the same donor site after interval healing has occurred. While aesthetic outcomes following STSGs vary, when selected appropriately, they allow for a low-morbidity method of reconstructing large wounds without exposing critical structures. For these reasons, STSGs are often the first-line reconstructive modality for large body-surface-area burn wounds. An example of a STSG used to resurface a previously gangrenous ischemic limb is demonstrated in the images below.

Patient with an ischemic wound of left lower extre Patient with an ischemic wound of left lower extremity status post ileopopliteal bypass revascularization (same patient as in Images 18-20).
Left lower extremity wound immediately following e Left lower extremity wound immediately following eschar debridement (same patient as in Images 17, 19-20).
Defect prepared for reconstruction following seria Defect prepared for reconstruction following serial debridement with interval dressing changes and vacuum-assisted closure therapy (same patient as in Images 17-18, 20).
Left lower extremity wound fully healed at 2 years Left lower extremity wound fully healed at 2 years following meshed split-thickness skin grafting (same patient as in Images 17-19).

Full-thickness skin grafts (FTSGs) are generally harvested as defatted full-thickness skin excisions from areas with sufficient skin laxity for primary closure, such as the inguinal, medial forearm, lower abdominal, supraclavicular, and preauricular and postauricular regions. Recipient site skin color, texture, thickness, and hair matching are important considerations in donor site selection. FTSGs are generally used in functionally or cosmetically sensitive areas where total subunit reconstruction or resistance to contraction is of utmost importance. They are bolstered and unveiled similarly to STSGs, but generally they require a shorter period of postoperative dressing changes and overall healing time.

Axial pedicled flaps

When large portions of tissue are required for complex wound closure, there are often regional pedicled flaps available. These flaps are so named because they have well-described blood supplies based on known vessels. These vessels are surgically identified, dissected down, and the flap transposed into the defect while attached to this vascular leash, the so-called pedicle. Available options are highly dependent on the location and nature of each defect. In general, considerations for pedicled flaps include size, vascular anatomy and geometry, tissue type (eg, skin, muscle, cartilage), pedicle length, arc of rotation, donor site morbidity, sensation, and any (un)anticipated future reconstructive needs. In the images below is demonstrated the use of a pedicled flap based on the medial plantar digital artery of the first plantar metatarsal artery for closure of a lateral plantar foot defect. Demonstrated is how this flap of tissue was templated for size and elevated as an island from the medial second toe; the pedicle was dissected proximally into the foot for length and then tunneled under the skin into the defect for final inset. Complications following axial pedicled flaps generally stem from technical errors such as inadequate debridement of the recipient site leading to infection, harvest of pedicled tissue outside of its vascular supply leading to necrosis, and kinking, twisting, or stretch-related tension of the pedicle following inset leading to ischemia or venous congestion.

Lateral plantar foot ulceration, just proximal and Lateral plantar foot ulceration, just proximal and in line with the fourth webspace, prior to excision and reconstruction (same patient as in Images 22-23).
Intraoperative markings for the proposed pedicled Intraoperative markings for the proposed pedicled flap, based on the medial plantar digital artery of the first plantar metatarsal artery (FPMA). Note the vertical marking signifying the pedicle (FPMA) course and length, as well as the proposed segment of tissue in the first webspace to be used for reconstruction (same patient as in Images 21, 23).
Postoperative clinic visit showing transposition/r Postoperative clinic visit showing transposition/rotation and inset of medial plantar digital artery island flap into defect. The extent of proximal pedicle dissection can be seen by the longitudinal scar in line with the first webspace (same patient as in Images 21-22).

Free tissue transfer

For complex wounds that necessitate soft and/or bony tissue reconstruction, yet have none-to-poor locoregional options, free tissue transfer serves as an invaluable technique in the reconstructive surgeon’s armamentarium. These flaps are termed free as they are “freed” from the body prior to reattachment at another location somewhere else. Similar to pedicled flaps, the portion of tissue selected for use in reconstruction is elevated and dissected out onto its (neuro)vascular pedicle. At the same time, a chosen recipient artery, vein, and possibly nerve are prepared outside the zone of disease at the defect site. The free flap pedicle is then divided, or cut, placing the free tissue under ischemia time, and it is transferred to the recipient site where it is “plugged-into” it’s new vascular supply. This involves the hand-sewing of vessels to one another (sometimes as small as 1 mm in diameter) under microscope magnification.

These procedures are performed by surgeons with extensive training and experience in microsurgical reconstruction and represent the highest level of complex wound closure. This requires an intimate knowledge of human arterial, venous, nervous, and lymphatic anatomy; high technical prowess; and intensive postoperative monitoring and recovery. The field of microsurgery is an expansive specialty within itself, whose specific details are beyond the scope of this article; however, an example of complex lower extremity reconstruction is provided. This patient presented with a nonhealing wound of the ankle and distal-third of the leg with exposed Achilles tendon without paratenon, precluding the use of skin grafting. Reconstruction with a free radial forearm flap using fasciocutaneous skin from the volar forearm based on the radial artery and then plugged into the posterior tibial vessels was performed, with excellent recipient site functional and cosmetic result.

Significant posterior ankle defect with exposed Ac Significant posterior ankle defect with exposed Achilles tendon, precluding skin grafting (same patient as in Images 25-26).
Templated design of a 4 x 12 cm free radial forear Templated design of a 4 x 12 cm free radial forearm flap based on the radial artery (same patient as in Images 24, 26).
Recipient site following free radial forearm flap Recipient site following free radial forearm flap anastomosis to the posterior tibial vessels, flap inset, and closure demonstrating excellent coverage, contour, and plantarflexion function (same patient as in Images 24-25).

Vacuum-assisted closure therapy

Negative-pressure wound therapy, also known as wound vacuum-assisted closure (VAC) therapy, is a method of supplementing healing by secondary intention, whether as definitive reconstruction or in preparation for another procedure. This usually consists of a proprietary pored sponge placed within a wound bed, sealed with occlusive dressings, and attached to a vacuum suction device, usually set to negative 125 mm Hg of continuous suction. This dressing is then changed every 3-5 days, or sooner as necessary. This mechanism of therapy macroscopically decreases the size of the wound by bringing wound edges closer together, and microscopically increases the surface area of granulating tissue due to the sponge porosity. Additionally, the suction serves to rid the wound bed of excess exudate, edema, and harmful inflammatory mediators. VAC therapy is contraindicated for use over neurovascular structures, within infected or malignant wound beds, and over normal skin. VAC therapy has significantly revolutionized the management of chronic wounds requiring long-term dressing changes and is an indispensable modality for the temporization and optimization of complex wounds requiring reconstruction.

Tissue expansion

For larger wounds for which only skin coverage is required and grafting is not possible or advisable, tissue expansion offers an excellent option for closure. A special device, aptly named a tissue expander, is placed subcutaneously near the area in question, and over subsequent weeks is serially inflated to expand the overlying skin envelope. This results in an overall increase in vascularity and tissue surface area due to a combination of mechanical and biological factors, deemed “tissue creep,” at the cost of decreased overall tissue thickness. Muscle may also be expanded alongside the skin, as is commonly used in breast and scalp reconstruction, but this results in thinning and bulk loss. This technique is reliable, versatile, and robust, and may be performed throughout the head and trunk; it ultimately allows for the reconstruction of “like with like.” The major disadvantages of expansion are the ability of and need for staged reconstruction, patient discomfort with constant expansion pressure, and the risk of implanted foreign body infection. External tissue-expansion devices have entered the market, which serve to autonomously harness the same mechanical and biological creep factors without the need for weekly volume expansions. Demonstrated in the images below is a patient who presented with significant alopecia (loss of hair) across the scalp from ear to ear. She underwent placement of a posteriorly based tissue expander, followed by serial expansion over several weeks. Finally, the diseased skin was excised and the expanded hair-bearing scalp skin was advanced to result in near-anatomic recovery of hair appearance.

Patient with significant scalp alopecia extending Patient with significant scalp alopecia extending from ear to ear (same patient as in Images 28-30).
Design and inset of a posteriorly based tissue exp Design and inset of a posteriorly based tissue expander for staged reconstruction (same patient as in Images 27, 29-30).
Patient following serial expansion, removal of exp Patient following serial expansion, removal of expander, and scalp flap advancement of hair-bearing tissues (same patient as in Images 27-28, 30).
Postoperative result showing near-anatomic reconst Postoperative result showing near-anatomic reconstruction of hair-bearing scalp tissues (same patient as in Images 27-29).


Follow-up care is an important aspect of the treatment of any surgical wound. Adequate postoperative wound care and management can help prevent infection, gauge reconstructive progress, and allow for frequent monitoring of the surgical site. The timing of suture removal is critical in preventing suture cross marks and epithelial cysts. Patients need to be advised as to the proper management of new scars and monitored to be certain that the healing process is progressing normally. As in any condition, follow-up and continuity of care is a vital aspect of good medical practice. It is important to counsel patients that 3-6 months will elapse before any flap or scar matures and has the general features of its final appearance.


Early complications of flap reconstruction

The possible complications following flap reconstruction range in severity and require distinct approaches depending on the complication type. Fortunately, most of the complications are preventable as well as amenable to treatment. The more common early complications following skin flap reconstruction surgery are the development of infection, hematoma, seroma, or wound dehiscence. Infection is uncommon in clean surgery, and perioperative antibiotics are used as indicated. When a wound becomes cellulitic, then antistaphylococcal and streptococcal medicines are administered. Abscessed wounds require incision and drainage. Culture and sensitivity should be undertaken, and the appropriate antibiotic should be administered.

Good hemostasis is paramount in the prevention of hematomas and seromas. Hematomas should be drained or aspirated whenever possible to prevent induration and irregularity of the operative field. Seromas often resolve without treatment, but they may be aspirated as needed. Wound dehiscences can occur as the result of poor surgical technique, poor patient compliance, or poor patient healing ability. Patients with renal failure, those undergoing chemotherapy for cancer, those who are malnourished, or those who have been irradiated heal poorly. A judicious method of dealing with minor dehiscence is to allow the patient to heal spontaneously and to attempt repair at 6 months after the scar has matured and normal healthy tissue surrounds the original defect.

The complication of flap necrosis is a more serious one and is usually due to a design flaw or an error in execution of the reconstruction. These errors include the use of too small a flap for a given defect, damage to the flap's blood supply, extending the flap beyond its blood supply, or closing the defect in such a way that it is subject to too much tension. Flap necrosis usually can be avoided by more precise flap design and avoidance of undue tension upon closure of the wound. If the removal of sutures that are too tight or a correction of a hematoma delays the repair, this is a small price to pay for the avoidance of flap necrosis and a better result. Treatment of distal necrosis is conservative and may include allowing certain areas to heal by secondary intention and/or subsequent surgical revision of the area. However, in areas where the flap was placed to prevent a deforming scar contracture, such as the eyelid, a new reconstruction should be performed as soon as the wound condition permits.

Late complications of flap reconstruction

These complications are avoided for the most part by experience and careful planning of the flap reconstruction. Unfavorable scarring is a complication that occurs when scars are placed outside of the direction of the skin tension lines. Scars that lie in the wrong direction can be revised with a Z-plasty or a W-plasty. Pin-cushioning (trap door deformity) of the flap is another complication that arises from a curvilinear scar. Correction of the pin-cushion deformity should not be performed until the scar fully matures. Options for correction include excision of the old scar, defatting of the flap, and closure with Z-plasties or a W-plasty.

Hypertrophic scars are uncommon on the face; however, keloids are not uncommon in certain populations and may present significant challenges. These scars are not only unsightly, but often present with significant pain and pruritus. Any patient with a personal or family history of keloids or a personal history of hypertrophic scars must be warned about the risk of developing a keloid or a hypertrophic scar. Once a keloid forms, many treatment options are available, most of which are only partially effective in minimizing the scar. Pressure, topical silicone, steroid injections, and massage are the standard treatments, although reexcision in conjunction with intralesional steroids and postoperative radiation may also be considered for unresponsive lesions.

Outcome and Prognosis

If local flaps are insufficient to cover a wound properly, distant tissue may be imported by using techniques, such as skin grafting, pedicled flaps, axial flaps, fasciocutaneous flaps, myocutaneous flaps, or free flaps. If the removal of sutures that are too tight or a correction of a hematoma delays the repair, this is a small price to pay for the avoidance of flap necrosis and a better end result. The primary goal in tumor surgery is to adequately treat the tumor. Only then can a definitive reconstruction be undertaken. The reconstruction must preserve function and provide the best possible cosmetic result.

Future and Controversies

The future may hold many promising options for repair of complex defects. Advances in tissue expansion techniques, prefabricated skin flaps, advanced wound therapies, skin substitutes, angiogenesis, in vitro tissue culture, and applications of stem cell therapies may facilitate closure of complicated facial wounds. However, local skin flaps and other techniques described in this article should continue to play a major role.[8]