Issue Introduction: Surgical Perspective

This month’s issue of WOUNDS is focused on the operative approach to wounds. Today the treatment of wounds emphasizes the nonoperative approach. Most think that debridement is the only time something sharp should be brought near the wound. Even then, we have other options such as enzymes, biologic treatments such as maggots, and autolytic techniques. But as the Father of American Surgery, Sir William Osler, once said, “Many a wound ‘requires cold steel, not the folly of a physician.’” Truly, there are times when wounds require operative intervention, which can come in several forms. In this issue are 4 articles showing how operative intervention can improve the healing of difficult wounds.   Split-thickness skin grafting is useful in the treatment of certain hard-to-heal wounds.¹ Chiummariello et al have shown that using negative pressure dressings to fix the split-thickness skin graft to the wound is beneficial. They also demonstrate an alternative method of applying the negative pressure to the skin graft and the wound. The result of their approach is good and cost effective. This is certainly a technique that should be considered when using a split-thickness skin graft in the closure of any wound, either acute or chronic. Kuang-Ling Ou and colleagues take skin grafting a step further by showing large wounds that are best treated with pedicle flaps. These specialized methods of skin replacement are critical in the treatment of very large wounds and those in which multiple layers of tissue have been lost. It is imperative that we all know the indications for these procedures so that patients with these types of wounds can be appropriately referred for treatment.   In their paper, Rader and Wilson remind us of an often unrecognized ulceration, necrobiosis lipoidica diabeticorum. Although first described in German literature in 1929, it still is not well understood.² The ulcerations usually appear on the anterior tibial area of the leg and are generally seen in patients with diabetes mellitus. The authors point out how hard it is to get one of these ulcers to heal with standard wound care, but debridement and treatment with bioengineered dermal tissue results in faster and more satisfactory healing. In my experience, this is the only way to effectively heal these ulcers and keep them healed. Often the entire lesion needs to be excised so that all the abnormal collagen can be removed, thereby allowing the tissue engineered dermal product to stimulate wound closure. Experience has shown this results in a more satisfactory long-term wound closure.   Operative procedures are critically important in the treatment of many diseases, but the complication of a surgical site wound infection can be a major problem. It is enough of an issue that special emphasis is being put on the avoidance of them.^3,4 Leaper, Fry, and Assadian have provided us with an excellent overview of surgical site infections, ways to try to avoid them, and the approaches to treatment if one should occur. This is an excellent review for all who see patients with postoperative problems.   The articles included in this issue should give the reader a brief glimpse at some of the operative approaches to wounds and the management of patients who have operative procedures. We look forward to more innovative and helpful operative approaches to wounds in future issues.