The Role of the Plastic Surgeon in Wound Care

Wound healing abnormalities can arise during various stages of patient care. A patient may present to their primary care doctor for a wound that will not heal despite various over-the-counter remedies. A patient may require postoperative intervention owing to impaired wound healing resulting from intrinsic factors. In some cases simple moist wound care and control of the bacterial bioburden are sufficient, but in other cases, more advanced and complex management is required to ensure optimal wound healing and patient safety.¹ Identifying cases that warrant consultation by a plastic surgeon is especially critical in ensuring that healthy grafts and flaps can be used in a timely manner.² Such cases include large wounds; wounds in sensitive areas (eg, face, hands, feet); wounds with exposed vessels, nerves, and bone; and wounds for which SOC was unsuccessful; as well as cases involving the use of advanced biologics.

An important concept in wound care as it relates to plastic surgery is the so-called reconstructive ladder, which is a paradigm for wound healing that originated in the field of plastic and reconstructive surgery. This wound care framework is critical for general practitioners and wound care specialists as well as plastic surgeons to foster understanding of the indications for plastic surgery intervention. This interdisciplinary understanding is the key to prompt, satisfactory wound resolution. Essentially, the reconstructive ladder is an algorithm for tailoring wound closure techniques to the particular wound presentation. Simple wounds can be closed via primary or secondary closure, whereas increasingly complex wounds warrant increasingly complex techniques such as grafts, flaps, and tissue expansion. If a generalist or primary care provider can rapidly identify a wound presentation that warrants a plastic surgery technique, the referral process—and ultimately, the healing process—can be expedited.

General guidelines for the necessity of reconstructive surgery in wound healing have been reported previously.^1,3 The aforementioned conditions that require consultation with a plastic surgeon are particularly important because early intervention can reduce overall healing time and costs; however, these large, published studies have focused mostly on outpatient care.^4,5 Plastic surgeons are consulted to assist with complex wound closure in both acute and chronic wounds. Wounds with exposed deep structures, large wounds with expected long healing times, and wounds that do not improve with SOC are all candidates for intervention by a plastic surgeon. This review provides detail regarding each of these indications, as well as pearls related to management and referral to a plastic and reconstructive surgeon.

Databases searched included PubMed, Google, and PubMed Central using the terms “large wounds” and “wound closure”; the search period was literature published between 2004 to 2018.

Large wounds

Wound size may determine whether a general surgeon or surgical subspecialist should transfer care to a plastic and reconstructive surgeon. Sanniec et al⁶ showed that delayed reconstruction or the need for tissue resection greater than 500 g were the most predictive factors for wound healing complications. Therefore, careful consideration must be made when determining the wound conditions for treating large wounds.⁷ One standard management technique includes the use of STSGs. In one study, the use of STSGs in several patients was strongly associated with improved wound healing, resulting in reduced cost and faster time to healing.⁸ Porcine studies have shown the use of NPWT over the graft to be a catalyst for successful STSG placement and the wound healing course.^9,10Figure 1 demonstrates a complex case in which the expertise of a plastic surgeon to achieve closure of a large abdominal surgical wound would be beneficial.

Wounds with exposed vessels, nerves, tendons, and bone

In managing wounds that contain exposed blood vessels, nerves, tendons, and bone, flap closure is often the first-line treatment.⁸ Per the reconstructive ladder, such wounds may not be suited to primary closure or even skin grafts; instead, they may require flap coverage, which is an advanced tool in the plastic surgeon’s armamentarium with a diverse array of applications.^1,8 In contrast, for large wounds with a clean, clear bed containing granulation tissue, or viable fascia or muscle, a skin graft is ideal for closure.⁸ Thus, the presence of exposed nerves, blood vessels, tendons, or bone within a large wound are all strong indications for immediate referral from a primary care team to a plastic surgeon. For example, a turnover sartorius flap (Figure 2) is the best option for coverage of exposed groin vessels.

For wounds involving exposed bone or over fracture sites, time is of the essence because the possibility of contamination and infection is considerable and can cause severe complications leading to a poorer overall prognosis. Diwan et al¹¹ found that for the best possible results when managing a large open fracture wound, debridement, multidisciplinary wound assessment (often involving an orthopedic surgeon as well as a plastic surgeon), and soft-tissue reconstruction should be completed in the first 48 to 72 hours following presentation. Local or free muscle flap coverage is the best choice. In a study of success rates of flaps used in the management of severe open tibial fractures, Naique et al¹² noted that 5 of 6 failures occurred in patients in whom soft tissue reconstruction was delayed for 5 days or more. In addition, that study noted that all 6 failures occurred in patients who underwent initial debridement in a tertiary care center and received delayed definitive treatment. Some of these initial debridement procedures were performed inadequately or incompletely. As a result, revision was necessary in some cases and poorer surgical outcomes were observed. The authors of that study concluded that adequacy of early care and surgical expertise is even more important than early implementation of treatment, thus underscoring the necessity of specialized attention in wounds of this nature.

Wounds in sensitive areas

Wounds of the face, head, hands, or feet often require rapid, purposeful decision-making by the primary care provider or emergency department staff, because how these wounds are treated may have lasting functional and aesthetic ramifications for the patient. According to Kretlow et al,¹³ simple facial soft tissue lacerations that can be primarily closed in the emergency department should be closed as soon as possible to minimize the risk of infection and improve the aesthetic outcome. The authors concluded that closure within the first 8 hours of injury is optimal. However, rapid primary closure in the emergency department is not always the best course of action. Kretlow et al¹³ noted that wounds overlying facial nerve or parotid gland injuries, wounds presenting with tissue trauma requiring remodeling, or wounds with associated injuries requiring surgical intervention (eg, bony injuries, fractures) are all indications for intervention by a reconstructive surgeon. Those authors also provided guidelines for differential management of wounds of the head and face depending on the specific anatomic location. For example, smaller lacerations of the scalp (< 3 cm) and most lacerations of the ear can be primarily closed in the emergency department. However, larger scalp defects, most eyelid lacerations, forehead lacerations, and the majority of defects of the nose warrant consultation with a plastic surgeon.¹³ Lacerations and defects of the cheek and lip likely warrant consultation with a plastic surgeon as well, because these are areas of high aesthetic sensitivity. Examples of the advanced care provided by plastic surgeons to manage wounds of the face include use of full-thickness skin grafting to close a wound of the temple (Figure 3) and a nasolabial fold flap to close a Mohs defect of the left nasal sidewall (Figure 4).

Hand injury is one of the most frequent and complex forms of trauma presenting to the emergency department, and many plastic surgeons specialize in managing hand injuries. Similar to wounds of the face, wounds of the hand must be managed carefully and methodically by the primary care team to avert potential long-term morbidity and loss of function.^14,15 One aspect of such care involves recognizing the indications for timely referral to a hand specialist. In a case study and literature review, Cheung et al¹⁵ noted several emergency department presentations that warrant rapid referral to a specialist. For example, an open fracture of the hand should result in immediate referral and attention by a hand surgery specialist. In addition, flexor tendon laceration is a complex injury that also needs immediate referral to a specialist to provide adequate repair that maintains hand function. Cheung et al¹⁵ also reported that wounds over the knuckles and any wound that is presumed to be the result of a human bite should be referred to a specialist because of the risk of septic arthritis. The possibility of replantation should always be considered in the patient with amputated digits or an amputated hand. Woo¹⁶ noted that, for single digit amputations in which the amputation stump is correctly preserved, delayed or suspended replantation may be appropriate because prolonged cold ischemia time does not negatively affect the viability or functionality of the replanted digit. Proximal hand replantation in which the stump contains intrinsic hand muscles is more urgent, however, and should not be delayed. Woo¹⁶ also noted that, although the literature indicates that survival and function of replanted digits is not significantly affected by immediate versus delayed replantation, the effects of ischemia are minimized when replantation is performed within 12 to 24 hours of amputation.

Replacing like by like is an important principle in reconstructive surgery. Wounds on the plantar and palmar surfaces of the foot and hand, respectively, can present a particular challenge owing to the unique thickness and composition of these skin surfaces.¹⁷ These are also very important surfaces for ambulation and weight-bearing in the case of the plantar surface of the foot and general use of the hand in the case of the palm. Pinch grafts of the medial plantar arch and hypothenar area have proven highly effective in closing these wounds in a timely manner and producing optimal functional outcomes.¹⁷ Consultation with a plastic surgery specialist is recommended in cases requiring wound closure in complex areas such as the plantar and palmar surfaces that have substantial functional and/or aesthetic ramifications for the patient.

Wounds for which SOC was unsuccessful

Wound management may be complicated by intrinsic factors (eg, general patient health) and extrinsic factors (eg, facility resources, provider experience). A wound can transition from acute to chronic; the latter requires more dedicated nursing staff and clinical expertise for management.^18-20 Management of chronic wounds such as pressure ulcers and diabetic ulcers can be challenging (Figure 5), because typically, such wounds have phased out of the typical window of healing.²¹ Health care providers may be less experienced in the basics of wound care than they realize, which can contribute to the prolongation of wounds such as venous ulcers.²² In addition to typical wound treatment, atypical wounds should prompt consultation from an interdisciplinary team, which should include plastic surgery, at a wound center with providers of various specialties who have an in-depth understanding of wound healing.²³ It is also important that the treating providers have a well-rounded understanding of the deficient components involved in chronic wounds and how they can best be addressed with developing technologies.²⁴

Significant advancements have been made in the use of biologics for wound care. Their use for wound bed preparation prior to the plastic surgeon’s intervention may be indicated.

Most surgeons—including general, vascular, plastic, and others—perform STSGs. For wounds located on the face after Mohs procedure, for example, a plastic surgeon should be consulted for full-thickness skin graft or flap closure. Radiated, non-healing wounds may require a free flap for coverage, which plastic surgery can provide.

In addition to the management and referral principles presented above, it is important to stress the basic, critical practices that are prerequisites to optimal wound healing, including optimizing nutritional status, adequate wound debridement, and managing comorbidities. Optimizing nutritional status is paramount; malnutrition is prevalent in hospitals and can contribute to immune dysfunction, loss of skin and tissue integrity, and impaired wound healing.²⁵ Additionally, wound debridement is required for chronic wounds in order to remove nonviable tissue, deny potential pathogens a growth medium, promote the formation of granulation tissue, and prepare the wound bed for reepithelialization.²⁶ Finally, comorbidities such as neuropathy, vasculopathy, and metabolic dysfunction can obstruct tissue regeneration and wound healing.²⁷ Thus, it is critical that wound care providers collaborate with an interdisciplinary team to rapidly identify and manage disease states that can affect the healing process or preclude a patient from effective surgical wound closure.

An important limitation of this work is the variability in protocol and management of the wounds discussed herein. Different hospital systems, practices, and wound care centers may have different methods of managing such wounds and may have unique criteria for wound referral. This review is not meant to supersede these methods and criteria; rather, it is intended to serve as a general guideline for primary care teams to consider when presented with the wound types discussed herein. Another limitation is that this work is not completely inclusive of all wound presentations that will be encountered by a primary care team. However, the aim of this review is to provide preliminary recommendations rather than attempt to review every possible wound presentation.

The timely, accurate referral of wounds to specialists in plastic and reconstructive surgery is an integral aspect of primary and emergency department care. Many of the wounds discussed in this review may be time-sensitive and require prompt action by the primary care provider to minimize pain, infection, and costs and to maximize the speed of closure and the potential for a full or improved functional and aesthetic recovery. This review describes strong support for wound referral that can be useful for primary care teams presented with large, complex wounds, wounds in sensitive areas, wounds with exposed bone or neurovascular structures, and wounds that have proven resistant to standard treatment. Through strong and efficient communication, health care providers and plastic surgeons can collaborate to make wound closure a rapid and routine process for patients, with improved clinical, medical, and financial outcomes. More work is needed to conduct a meta-analysis of the literature to develop a definitive, all-inclusive algorithm for interdisciplinary wound management and referral.