Single-stage Reconstruction for Soft Tissue Defects: A Case Series
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Index: Ostomy Wound Manage. 2012;58(6):30–37.
Various techniques for obtaining expedient aesthetic coverage of soft tissue defects with limited donor site morbidity have been developed, including the use of a dermal regeneration template (DRT) as the first step in a two-stage surgical approach. Use of DRT in reconstruction has increased as a result of reports suggesting improved cosmetic results and reduced scarring compared to split-thickness skin grafts (STSG), but this approach requires a return to the operating room. To evaluate outcomes of a single-stage procedure, a prospective evaluation of patients with complicated soft tissue defects measuring <200 cm2 was conducted.
Following trauma or resection of a tumor, 20 patients underwent single-stage reconstruction with surgical debridement and application of a single-layered DRT and a meshed STSG. Negative pressure wound therapy (NPWT) was applied as a bolster with continuous -125 mm Hg pressure for 5 days. After 5 days, traditional dressings were applied and patients were followed until healed with a minimum follow-up of 5 months to a maximum follow-up of 19 months. Participants included 20 patients (14 men, six women; average age 60 years old [range: 27–92 years]; average wound size 104.5 cm2 [range: 40.0–180.0 cm2]). Wounds were located on the lower extremities (10 patients), upper extremities (seven patients), and trunk (three patients). Average graft take was 98.3% with an average take time of 5.6 days (SD 0.50). No significant differences in graft take rates between male and female patients, smokers and nonsmokers, and patients with and without diabetes mellitus were observed. Wound location also did not affect graft take rates. No wound breakdown, adverse events, or re-operation occurred during follow-up. In this case series, single-stage reconstruction using DRT, STSG, and NPWT was used with good outcomes and second-stage reconstruction surgery was avoided. Prospective, randomized, controlled clinical studies to compare the various surgical and wound care approaches to closing these tissue defects are warranted.
Keywords: negative pressure wound therapy, wound closure technique, skin transplantation, case series, single-stage reconstruction
Potential Conflicts of Interest: Dr. Gabriel discloses he has received consultant, lecture, and manuscript preparation funding from KCI, San Antonio, TX.
Aesthetic coverage of soft tissue defects is an ongoing challenge in plastic surgery. Thorough evaluation of wound characteristics and patient comorbidities is critical for achieving optimal goals of wound healing, which may include obtaining durable coverage, minimizing donor site morbidity, and maximizing function.1,2 The introduction of advanced wound care technologies, including negative pressure wound therapy (NPWT) utilizing reticulated open-cell foam, has resulted in a decreased requirement for complex surgical procedures (eg, orthopedic), particularly microsurgical free tissue transfers.3,4 In a study of 296 consecutive open tibia-fibula fractures over a 12-year period, Parrett et al3 found that local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures increased from 22% to 39% for reconstructions between 1992 and 2003. The authors concluded the observed trend toward less complex reconstructive procedures was related to, among other factors, the use of improved wound care technology, including NPWT.3
Reconstruction techniques of lesser complexity that often follow the use of NPWT include local flaps or skin grafting.