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Repair and Reconstruction of Complex Wounds in Children: Strategies

Santecchia L, Zama M
Rome, Italy

Abstract
  The strategies of reconstructive surgery consist of the general types of procedures performed by reconstructive surgeons. These procedures in turn reflect the underlying problems (or elements) the surgeon seeks to address.

  There are 2 general types of procedures undertaken in reconstructive surgery: ablative surgery and restorative surgery. Even though this distinction may seem very simple and self-evident, problem analysis in reconstructive surgery must clearly be based on the recognized differences between these 2 types of procedures and the specific types of problems they should solve.

  In ablative surgery, the activities of reconstructive surgeon overlap with those of many other surgical specialists. The goal of ablative surgery is to eliminate the underlying disease or injury that constitutes the etiologic element of the surgical problem. A successful ablation must be accomplished before restoration procedures can be undertaken.

  Ablative surgery follows the principles of treatment associated with specific etiologies. In the treatment of cancer, the ablative procedure is done according to established standards of adequate resection, management of nodal involvement and metastases, and utilization of adjunctive therapies. In trauma cases, the ablative elements include control of hemorrhage, debridement of devitalized tissue, and removal of foreign body debris.

  In established chronic wounds such as osteomyelitis and pressure sores, ablation includes removal of chronic, scarred tissue involved infected bone, and such contributing factors as disrupted hip joints leading to synovial fistulae and pressure sores.
The reconstructive surgeon may perform the ablative procedures or may work in conjunction with other surgeons. In any case, the reconstructive surgeon brings an important dimension to ablation by having the potential to proceed with restoration. In cancer resections, ablation can sometimes be more aggressive with a reliable prospect of reconstruction as part of the plan.

  Traumatic injuries can sometimes be diverted from amputation to salvage through acute and secondary restorative procedures. Some lesions, such as osteoradionecrosis or arteriovenous malformation, can be spared prolonged and uncertain piecemeal treatment and go on to definitive resection supported by the prospect of reliable surgical restoration.

  Incomplete or confused ablative procedures doom restorate procedures to be compromised or lost in the underlying disorder. Such misadventures are based on misunderstanding of the etiologic element or ineffective treatment of it. Flaps or grafts placed on incompletely treated or overlooked cancers or infection will break down while the disease progresses.

  Closure attempts will fail because of incompletely debrided traumatic wounds. Flaps for a pressure sore reconstruction overlying a neglected synovial fistula from a chronically dislocated hip joint will become part of a recurrent wound.

  The reconstructive surgeon can extend the limits of ablation, decreasing the chances of residual disease, as well as coordinate the timing of restorative surgery to optimize the course and outcome of surgical sequences.

  The strategies of restoration distinguish the reconstructive surgeon as the physician most capable of providing an optimum possible outcome to patients with diseases and injuries that damage and destroy body parts.

  The strategies that the reconstructive surgeon can bring to such situations are increasingly sophisticated but such procedures must be based on a clear definition of the restorative problem elements remaining after thorough ablation.