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8Treatment - bone and soft-tissue reconstruction

The “reconstructive ladder” shown on the left presents in increasing order of complexity the options available for wound closure

Split-thickness skin grafting and secondary wound healing

If an open wound involves loss of skin and subcutaneous tissue, but has a base of healthy muscle, fascia, or tendon sheath, granulation tissue will form on the base and a split-thickness skin graft (STSG) can be applied, or the wound can be allowed to heal in from its sides (second intention).

Bare bone (without periosteum), exposed blood vessels, nerves and tendons (without paratenon) are all harmed by desiccation and do not support granulation tissue and STSG. These tissues should never be left exposed, and should be kept moist with appropriate dressings. Alternative coverage techniques should be used. Definitive coverage should be achieved as soon as possible.

The “reconstructive ladder” shown on the left presents in increasing order of complexity the options available for wound closure, and is helpful for treatment planning.  
Other than STSG and some local rotation flaps, the more complex soft-tissue reconstructions should be undertaken by surgeons experienced in these techniques, e.g., plastic surgeons.