LECZENIE RAN 2024; 21 (2)

Chronic wound care has improved tremendously through the years due to technological advancements and medical innovations. However, wound care does not only mean the application of a wound dresssing merely. The wound should be evaluated aetiologically, and care should be planned according to the disruption in which stage of the healing has occurred [1]. The patient must be evaluated as a whole, and all systemic disturbances should be determined such as blood sugar irregularity in a diabetic foot patient and venous hypertension in a venous ulcer patient.

Reconstructive surgery means the reconstitution of missing tissue. It does not always need to be a huge defect to be reconstructed. A long-lasting 0.5-mm-wide fistula due to a hypoaesthetic heeling may necessitate a muscle flap to overcome osteomyelitis. When various disruptions in healing are involved, the wound usually needs reconstructive surgery. Reconstructive surgery uses the reconstructive ladder, which the young surgeons usually want to start from the top. The ladder defines that the surgery choice should start from the basic (the first step) to the most complicative one (the uppermost step) [2]. This means that it is sometimes left to wound dressings and simple skin grafts, and to free flaps when no other choice is successful.

Diabetic patients usually suffer from neurological, and vascular comorbidities together [3]. These parameters prevent regular wound healing despite the correct dressings being used. The pressure on the plantar ulcer or the fistula due to a necrotic bone should be relieved and avoided. This means at least performing tenoplasties or debridements (Fig. 1). Dorsal foot ulcers with tendon or bony exposure may get enough granulation tissue after negative pressure wound therapies. However a split thickness skin graft would immediately turn this wound to a closed one in one week above this good granulation tissue. Calcaneus bones usually suffer exposure due to neglected heel ulcers and neuropathies in diabetic patients. The three-dimensional structure of the heel and its function means a skin graft does not need to be the choice of reconstruction. The defect needs a flap tissue to overcome the shear forces and if possible a neurologic input as well. The neurocutaneous flaps give an excellent option for these kinds of defects. They both provide fasciocutaneous flap tissue as well as neurological input through the sural nerve. The most sophisticated procedure of reconstruction is microsurgery and transfer of free flaps, which has shown very good results lately, even in diabetic patients [4].

Overall, reconstruction of chronic wounds gives the best results when following issues are considered:

The required tissue composition is determined exactly (a skin graft or a flap).

The exact time for reconstruction is established (take all measurements for a good wound bed).

Be successful! The reconstruction should decrease recovery time.

Avoid unnecessary donor site wound creation (prefer reconstruction when it is going to heal faster than doing nothing).