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Chronic
wounds are long standing wounds that
persist despite of excellent wound care
and even surgery. They can cause
significant pain, loss of function and
disability. Microsurgery can, in
selected cases, be a valuable treatment
option for a chronic wound.
Preoperative
Evaluation
Like any
lower wound a thorough history and
physical examination is obligatory
before developing the most appropriate
treatment regimen. The following
are critical elements:
-
Neurological
evaluation - lack of sensation on
the plantar aspect of the foot may
point to nerve injury or neuropathy
and preclude reconstruction.
-
Skeletal
examination - the requirement for
concurrent orthopedic treatment or
the need for secondary bone
reconstruction after coverage may
affect the choice and timing of flap
coverage.
-
Vascular
assessment - the presence of injury
to the vascular inflow to the foot
will often dictate the choice of
flap if microvascular
transplantation is indicated.
Clinical
Example
 The
wound pictured here persisted for over
20 years despite good wound care and
multiple skin grafts. It is on the
lateral aspect of the knee, but the knee
joint and bone are not exposed.
The foot is positioned to the left of
the picture with the patient's head at
the right. The base of the wound
granulated well but would not support
skin grafts.
The patient
was taken to the operating room and the
entire wound was surgically excised to
eradicate all non-healing tissue.
A surgical specimen was sent for
pathological examination to rule out a
tumor as a cause of the
non-healing. Culture and
sensitivity specimens were also sent to
the laboratory to rule out an infection
as a cause. The wound as it
appeared immediately after excision is
pictured on the left and the excised
specimen is pictured on the right.
 After
dressing the wound for several days with
a subatmospheric pressure dressing, the
patient was brought back to the
operating room for definitive
closure. Tumor had been ruled
out. Antibiotics tailored toward
the offending organism found on culture
were used peri-operatively. The
wound was found to be granulating well.
The
superficial femoral vessels were exposed
through a medial approach and a rectus
abdominus muscle was harvested for
coverage of the wound. The femoral
artery exposure is illustrated below. The
rectus muscle is pictured draping over the lateral knee. The foot is to the
right. With this vessel exposure
the muscle is able to reach to the
lateral knee easily.
 A
full thickness skin graft from the
abdominal donor site was used to cover
the muscle. This eliminated the
need for a split thickness skin graft
from the thigh. Because muscle
tends to ooze fluid in the
post-operative period for several days,
the skin graft is "pie
crusted" with several holes to
allow fluid under the graft to escape
and prevent graft loss due to fluid
accumulation.
 The
flap has healed well and is pictured
here at two months post-operatively,
just before the patient is going to
begin walking again. No sign of
infection or graft loss is
evident. The full thickness skin
graft provides a good color match with
the surrounding skin.
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