Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 41:
Antibiotics and the Management of Infected Wounds
  Are different kinds of flaps more or less suitable for the management of specific defects? For example, is a muscle flap reconstruction of a chronically infected wound intrinsically superior to a well vascularized fasciocutaneous flap39 or a structurally flimsy but richly perfused omental flap?40 Chang, Mathes, and co-workers41-45 have attempted to address this question in a series of experiments. Although their models may be marred by questionable relationship to clinical situations38 and failure to consider body region differences in inflammatory response,46 they have identified some investigational areas that are important for the experimental definition of the antibacterial function of a flap in a wound: the effect of size and location of bacterial population, quantitative blood flow in different kinds of flaps, regional neutrophil function, and effects of different kinds of flaps on regional oxygen tensions.47 Robson,38 in his discussion of a paper by Calderon, Chang, and Mathes, alludes to some of this group's work in progress, in which they have developed an experimental chronic wound model with a controlled, variable quantitative bacterial population. Flap experiments using this model may produce findings more easily related to clinical problems.

An Approach to Complex Defects

We have used microvascular transfers for the reconstruction of acute and chronic wounds of the head, neck, trunk, and extremities.17,28,40 From this experience, we can describe a general approach to complex defects. This approach has evolved from clinical cases dating from 1970,40 and refinements can be expected as we continue to analyze our results.17


The initial examination of the patient includes a detailed physical, radiologic, and, in many cases, arteriographic definition of the defect and adjacent areas. Evaluation is made of the patient's ability to physically tolerate a microvascular transfer, and every effort is made to define a clear reconstructive goal acceptable to the patient and the operating team.

We perform our initial operative exploration and debridement of the defect as soon as possible after admission. All obviously devitalized tissue is removed. Areas of bony infection are resected widely and saucerized. Complex cranial or skeletal debridements may require advice from and participation of a neurosurgeon or orthopaedist. Quantitative culture biopsies are taken from the remaining soft tissue and bone. Antibiotics are not given systemically for prolonged periods unless there is local or systemic evidence of invasive infection.

Following the initial debridement, the wound is usually managed by saline and gauze wet to dry dressings to further remove nonviable surface tissue. Operative debridements and irrigation are repeated at 24- to 48-hour intervals until the wound ceases to yield devitalized material. Usually, within 2 to 5 days of admission, the wound is ready for definitive closure.

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