Abstract and Introduction
Wound healing is multifactorial and requires careful management. Plastic surgeons have an important role in optimizing healing of various wound types, including large wounds; wounds in sensitive areas (eg, face, hands, feet); wounds with exposed vessels, nerves, and bone; and wounds for which SOC is unsuccessful; as well as in the use of advanced biologics. It is important for the primary care physician and ancillary health care team to understand timing and basic wound healing principles to know when to consult a plastic surgeon to optimize wound healing for possible flap or skin graft closure. This literature review discusses principles of wound management as they relate to referral from primary care providers to specialists in plastic surgery and transitions of care, along with indications that warrant plastic surgery consultation and underscore the importance of interdisciplinary communication, understanding, and cooperation in wound management. Careful attention to fundamentals, including nutritional status, wound debridement, and comorbidities, combined with a strong understanding of the aforementioned indications that warrant the involvement of a plastic and reconstructive surgeon, can result in efficient, rapid wound healing at relatively minimal cost.
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. 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. 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.
Wounds. 2023;35(3):E102-E106. © 2023 HMP Communications, LLC