A survey of antibiotic use by plastic surgeons conducted by Krizek et al.16 and reported in 1985 noted that 64% of the responding practitioners used antibiotics "always" or "often" in free tissue transfer cases. We routinely use perioperative antibiotics in our uninfected free tissue transfer cases to minimize the risk of contamination in transiently ischemic tissue progressing to infection in tissue margins, hematomas, or other compromised areas created by ischemia time, debridement, and areas of wide dissection. First-generation cephalosporins are again our first therapeutic choice. Although this antibiotic use has no clear published experimental or prospective clinical study to justify it, our incidences of infectious flap and donor site complications have been low.17

Free-Tissue Reconstruction of Defects Complicated by Infection

Infected chronic wounds contain subsets of problems that include large structural defects, large soft tissue defects, devitalized sequestrae, poor blood supply, and scarred and inflamed adjacent tissue, as well as contaminative and infectious populations of bacteria. Application of microsurgical tissue transfers to these problems offers an approach that permits extensive debridement and reconstruction with vascular tissue that may significantly augment local immune responses, antibiotic delivery, and nutrition.

Pedicled muscle flaps, pedicled omental flaps, and microvascular transfer reconstructive techniques, all of which use components that introduce new sources of blood supply to the reconstructed site, have provided successful solutions to a wide variety of defects (Table 41-2). As early as the 1920s, surgeons reporting in the English-language medical literature recognized that wide debridement and reconstruction with vascular muscle tissue could successfully treat chronic, infected wounds.18 Pedicled muscle reconstruction of chronic wounds was reported in detail by Stark19 in the 1940s, Campbell20 in the 1950s, and Ger21 in the 1960s. Widespread recognition and application of these techniques in the 1970s led to increasingly higher rates of successful repair of difficult defects.22 This expanding base of clinical experience with pedicled muscle flaps provided a foundation for expecting free tissue transfer to play a major role in these reconstructions once advances in microsurgical technique made these procedures reliable. Free tissue reconstruction of cranial wounds,23 orofacial and neck wounds,17,24 extremity wounds, 17,25-27 and osteomyelitis28-31 now permit the definitive resections and debridements necessary to eradicate extensive disease processes in vital areas when no satisfactory local flap tissue is available.

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