Plastic
Surgery in the Management of the Peripheral Vascular Ulcer Sten J acobsson, M.D.
MALMÖ,
SWEDEN
Introduction Wound closure in the peripheral vascular ulcer should primarily be attempted by conservative means. In experienced hands, this gives excellent results, when the underlying vascular defect is amenable to surgically treated. There remain, however, some patients where conservative wound management fails. In such instances, surgical procedures to close the wound should be considered. The principles for excising and grafting therapy-resistant leg ulcers are not new. They were actually laid down long ago by American plastic surgeonsHomans in 1917,1 Brown, Byars and Blair’ and others in the 30’s. The basic principle is to make a wide and deep excision of the ulcer and all the surrounding diseased skin, thus also dividing incompetent perforator veins in the area. Skin grafting is then performed. It has been repeatedly shown, and also forgotten, that grafting without this wide excision in such long-standing therapyresistant ulcers often gives only temporary healing, with recurrences the role. The number of cases that need this type of treatment are not many. At the Department of Plastic Surgery in Malmo, which is the sole unit serving a population of 1.5 million, we have for the last 15 to 20 years seen 8 to 10 such cases a year. These patients are referred to us from surgeons and dermatologists, and have been treated by various conservative means for years. They have also often been operated on for incompetent perforator veins and sometimes sub’
jected
to
prior grafting procedures.
Materials and Methods Patients we handle these cases and some of the results and have chosen to present the patients treated during the years 1974 problems, through 1976. During these years we treated 29 patients: 19 women, 10 men.
To show the way we
Presented at the Twenty-Fifth Annual Meeting of the American College of Angiology: A Scientific Advances in the Management of Peripheral Vascular Diseases: The Peripheral Vascular Ulcer May 29, 1978. Colorado Springs, Colorado
Colloquium:
661
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
662 The mean age for the women was 63 years compared to 56 years for the men. Most patients had a history of previous thrombosis, and the ulcer had been present for 10 years or more in 6 cases and for 3 years or more in another 13 cases. The remaining patients had had ulcerations on and off for years. The size of the ulcer at admission varied (Fig. 1 ). The wound area was 25 square centimeters or less in 6 patients, between 25 and 100 square centimeters in I 1 patients, and above 100 square centimeters in 12 patients. The mean age was lowest in the patients with the smaller wounds and highest in those with the
larger
ones.
Materials and Methods
Procedures Our treatment starts with cleansing the ulcers. We always use inert materials and no local antibiotics. In the wet, draining wound we use Debrisan. Debrisan is a preparation consisting of dry, spherical beads of cross-linked dextran with a high absorptive capacity, which continuously removes cellular debris, enzymes, inflammatory mediators, fibrinogen and other components ol~ wound exudate as well as bacteria from the wound surface. This method is effective in producing clean wounds within a short period of time, usually about 8 days. During this period, we also routinely measure the peripheral arterial blood pressure at various levels in the leg using a strain gauge.’ This reveals the occasional patient who has insufficient arterial circulation besides having a venous leg ulcer-a finding which will influence the surgical procedure. In the post-thrombotic cases, the excision is made wide and deep, removing surrounding atrophic areas. In our opinion, it is not enough to excise the ulcer down to the fascia, but this must also be removed and excision carried down to muscle, periosteum and peritenon. Within 24 hours following excision, we apply meshed split-skin grafts of medium thickness. The advantages of the mesh graft are obvious. Since the supply of skin is abundant, and since a large take site heals just as quickly as a smaller one, grafts should be taken in excess so that they can overlap each other within the wound and also overlap at the wound
edges.
Fig.
1.
Ulcer size related
to sex, mean age
and
mean
hospital stay.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
663 The first change of dressing is done at 4 to 5 days and then at 2 to 5 day intervals. If a defect should remain at 14 days, skin grafts are again applied as soon as the wound bed is clean. At this time there is of course no re-excision. If enough skin was taken at the first operation and stored, it can now be used; otherwise, new grafts have to be taken. We performed such secondary grafting in more than 50 percent of our patients to cover remaining defects. In those patients where there is a concurrent insufficiency of the arterial circulation, a wide and deep excision of the wound is not advisable. After cleansing the wound, we simply scrape off the superficial layer of granulation tissue and cover with a mesh graft. Granulation tissue in a healing wound is very active metabolically, demanding a reasonably good blood supply. In patients with poor arterial circulation, increasing the wound by a wide excision may demand more blood supply than is available, and healing will be absent or seriously retarded. During the whole healing period after grafting, the patients stay in bed and are not allowed to lower the leg. The fine anastomoses between vessels in the graft and in the wound have poor resistance to a raised hydrostatic pressure and are in the early stages easily damaged and severed. Twelve to 14 days of bedrest are necessary, and there seems to be no way to get around this. Should regrafting be necessary, bedrest must be even longer. During this period, exercising of the leg muscles is encouraged and supervised by a physiotherapist. The patients are usually allowed to use a bed cycle after the first dressing. When allowed out of bed with the legs bandaged, the patients may walk for increasing periods of time. The prolonged period of immobilization in elderly patients with venous problems increases the risk of postoperative thromboembolic complications. We therefore give prophylactic treatment using Dextran 70 in all cases and continue as long as the patient is confined to bed. Before we started with this procedure, we saw a few cases of thrombosis and pulmonary embolism; since this treatment became routine, we have had no such complications.
Results The mean hospital stay for all patients was 37 days. Hospital stay was 25 days for patients with small wounds and 44 days for those with the largest wounds (Fig. 1). Of our 29 patients, 20 remained healed after the first operation. Nine patients were again hospitalized for a second operation and 2 of them also for a third. Most of the recurrences occurred within 6 months and all except 1 within 12 months (Fig. 2). This last patient had a recurrence more than 2 years after the operation, probably as a result of her physician telling her that she no longer needed the compression bandages. Both small and large ulcers recurred (Fig. 3). Four of the patients with
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
664
Fig.
2.
Interval between
previous grafting operation
and
recurrence.
recurrences, 3 women and 1 man, had arteriosclerosis and I had
a severe
psychiatric disorder. Both patients with 2 recurrences had psychiatric problems, 1 being feeble-minded and the other senile. After further operations, 4 of our patients stayed healed, making a total of 24 healed out of 29 (Fig. 4). Of the remaining 5 unhealed patients, 1 died of a pulmonary embolus; 1 patient had such severe arteriosclerosis that a thigh amputation had to be made; and 3 patients had ulcers that we could not heal. -
Discussion
Surgical treatment of long-standing leg ulcers requires a long and expensive hospital stay. It requires patience both on the part of the patient and the surgeon. Following grafting, the patient must continue bandaging and it is often necessary to surgically treat the incompetent perforator veins, either before treating the ulcer, at the same time, or after. We also feel that these patients should remain in touch with the physician for extended periods of time and encouraged to come for 6 monthly check-ups, even if the leg remains healed. Of course they should return immediately should an ulcer reappear. The surgical procedure requires a careful preoperative wound cleansing. A wide and deep excision precedes grafting with meshed split-skin grafts. All wounds should be healed before the patient leaves the hospital-even small ones. In venous leg ulcers with marked arterial insufficiency, a more cautious approach is advised, with grafting to the wound bed without the wide and deep excision. The patients presenting healing problems are those who also have arteriosclerosis and those who do not cooperate.
Fig.
3.
Recurrences related
to
size of ulcer and
sex.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
665
Fig. 4.
Results.
In
conclusion, surgical treatment of longstanding leg ulcers is a tedious and expensive procedure, requiring patience and cooperation on the part of the patient; but it can be successfully performed in most cases by appropriate grafting procedures. Sten Jacobsson, M. D. Department of Plastic
Surgery
University Hospital S-214 01 Malmö, Sweden
References 1. Homans, J., The etiology and treatment of varicose ulcers of the leg." Surg Gynec Obstet 24: 300, 1917. 2. Brown, J. B., Byars, L. T. and Blair, V. P., "A study of ulcerations of the lower extremity and their repair with thick split skin grafts." Surg. Gynec. Obstet. 63: 331, 1936. 3. Jacobsson, S., Rothman, U., Artursen, G., Ganrot, K., Haeger, K., Juhlin, I., "A new principle for the cleansing of infected wounds." Scand. J. Plast. Recon. Surg. 10: 65, 1976.
4. Jacobsson, S., Jonsson, L., Rank, F. and Rothman, U., "Studies on healing of DEBRISANtreated wounds." Scand. J. Plast. Reconstr. Surg. 10: 97, 1976. 5. Aberg, M., Hedner, U., Jacobsson, S. and Rothman, U., "Fibrinolytic Activity in Wound Secretions." Scand. J. Plast. Recon. 10: 103, 1976. Surg. 6. Gundersen, J., "Segmental Measurements of Systolic Blood Pressure in the Extremities Including the Thumb and the Great Toe." Acta Chir Scand Suppl 426, 1972.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
Surgery in the Management of the Peripheral Vascular Ulcer Sten J acobsson, M.D.
MALMÖ,
SWEDEN
Introduction Wound closure in the peripheral vascular ulcer should primarily be attempted by conservative means. In experienced hands, this gives excellent results, when the underlying vascular defect is amenable to surgically treated. There remain, however, some patients where conservative wound management fails. In such instances, surgical procedures to close the wound should be considered. The principles for excising and grafting therapy-resistant leg ulcers are not new. They were actually laid down long ago by American plastic surgeonsHomans in 1917,1 Brown, Byars and Blair’ and others in the 30’s. The basic principle is to make a wide and deep excision of the ulcer and all the surrounding diseased skin, thus also dividing incompetent perforator veins in the area. Skin grafting is then performed. It has been repeatedly shown, and also forgotten, that grafting without this wide excision in such long-standing therapyresistant ulcers often gives only temporary healing, with recurrences the role. The number of cases that need this type of treatment are not many. At the Department of Plastic Surgery in Malmo, which is the sole unit serving a population of 1.5 million, we have for the last 15 to 20 years seen 8 to 10 such cases a year. These patients are referred to us from surgeons and dermatologists, and have been treated by various conservative means for years. They have also often been operated on for incompetent perforator veins and sometimes sub’
jected
to
prior grafting procedures.
Materials and Methods Patients we handle these cases and some of the results and have chosen to present the patients treated during the years 1974 problems, through 1976. During these years we treated 29 patients: 19 women, 10 men.
To show the way we
Presented at the Twenty-Fifth Annual Meeting of the American College of Angiology: A Scientific Advances in the Management of Peripheral Vascular Diseases: The Peripheral Vascular Ulcer May 29, 1978. Colorado Springs, Colorado
Colloquium:
661
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
662 The mean age for the women was 63 years compared to 56 years for the men. Most patients had a history of previous thrombosis, and the ulcer had been present for 10 years or more in 6 cases and for 3 years or more in another 13 cases. The remaining patients had had ulcerations on and off for years. The size of the ulcer at admission varied (Fig. 1 ). The wound area was 25 square centimeters or less in 6 patients, between 25 and 100 square centimeters in I 1 patients, and above 100 square centimeters in 12 patients. The mean age was lowest in the patients with the smaller wounds and highest in those with the
larger
ones.
Materials and Methods
Procedures Our treatment starts with cleansing the ulcers. We always use inert materials and no local antibiotics. In the wet, draining wound we use Debrisan. Debrisan is a preparation consisting of dry, spherical beads of cross-linked dextran with a high absorptive capacity, which continuously removes cellular debris, enzymes, inflammatory mediators, fibrinogen and other components ol~ wound exudate as well as bacteria from the wound surface. This method is effective in producing clean wounds within a short period of time, usually about 8 days. During this period, we also routinely measure the peripheral arterial blood pressure at various levels in the leg using a strain gauge.’ This reveals the occasional patient who has insufficient arterial circulation besides having a venous leg ulcer-a finding which will influence the surgical procedure. In the post-thrombotic cases, the excision is made wide and deep, removing surrounding atrophic areas. In our opinion, it is not enough to excise the ulcer down to the fascia, but this must also be removed and excision carried down to muscle, periosteum and peritenon. Within 24 hours following excision, we apply meshed split-skin grafts of medium thickness. The advantages of the mesh graft are obvious. Since the supply of skin is abundant, and since a large take site heals just as quickly as a smaller one, grafts should be taken in excess so that they can overlap each other within the wound and also overlap at the wound
edges.
Fig.
1.
Ulcer size related
to sex, mean age
and
mean
hospital stay.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
663 The first change of dressing is done at 4 to 5 days and then at 2 to 5 day intervals. If a defect should remain at 14 days, skin grafts are again applied as soon as the wound bed is clean. At this time there is of course no re-excision. If enough skin was taken at the first operation and stored, it can now be used; otherwise, new grafts have to be taken. We performed such secondary grafting in more than 50 percent of our patients to cover remaining defects. In those patients where there is a concurrent insufficiency of the arterial circulation, a wide and deep excision of the wound is not advisable. After cleansing the wound, we simply scrape off the superficial layer of granulation tissue and cover with a mesh graft. Granulation tissue in a healing wound is very active metabolically, demanding a reasonably good blood supply. In patients with poor arterial circulation, increasing the wound by a wide excision may demand more blood supply than is available, and healing will be absent or seriously retarded. During the whole healing period after grafting, the patients stay in bed and are not allowed to lower the leg. The fine anastomoses between vessels in the graft and in the wound have poor resistance to a raised hydrostatic pressure and are in the early stages easily damaged and severed. Twelve to 14 days of bedrest are necessary, and there seems to be no way to get around this. Should regrafting be necessary, bedrest must be even longer. During this period, exercising of the leg muscles is encouraged and supervised by a physiotherapist. The patients are usually allowed to use a bed cycle after the first dressing. When allowed out of bed with the legs bandaged, the patients may walk for increasing periods of time. The prolonged period of immobilization in elderly patients with venous problems increases the risk of postoperative thromboembolic complications. We therefore give prophylactic treatment using Dextran 70 in all cases and continue as long as the patient is confined to bed. Before we started with this procedure, we saw a few cases of thrombosis and pulmonary embolism; since this treatment became routine, we have had no such complications.
Results The mean hospital stay for all patients was 37 days. Hospital stay was 25 days for patients with small wounds and 44 days for those with the largest wounds (Fig. 1). Of our 29 patients, 20 remained healed after the first operation. Nine patients were again hospitalized for a second operation and 2 of them also for a third. Most of the recurrences occurred within 6 months and all except 1 within 12 months (Fig. 2). This last patient had a recurrence more than 2 years after the operation, probably as a result of her physician telling her that she no longer needed the compression bandages. Both small and large ulcers recurred (Fig. 3). Four of the patients with
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
664
Fig.
2.
Interval between
previous grafting operation
and
recurrence.
recurrences, 3 women and 1 man, had arteriosclerosis and I had
a severe
psychiatric disorder. Both patients with 2 recurrences had psychiatric problems, 1 being feeble-minded and the other senile. After further operations, 4 of our patients stayed healed, making a total of 24 healed out of 29 (Fig. 4). Of the remaining 5 unhealed patients, 1 died of a pulmonary embolus; 1 patient had such severe arteriosclerosis that a thigh amputation had to be made; and 3 patients had ulcers that we could not heal. -
Discussion
Surgical treatment of long-standing leg ulcers requires a long and expensive hospital stay. It requires patience both on the part of the patient and the surgeon. Following grafting, the patient must continue bandaging and it is often necessary to surgically treat the incompetent perforator veins, either before treating the ulcer, at the same time, or after. We also feel that these patients should remain in touch with the physician for extended periods of time and encouraged to come for 6 monthly check-ups, even if the leg remains healed. Of course they should return immediately should an ulcer reappear. The surgical procedure requires a careful preoperative wound cleansing. A wide and deep excision precedes grafting with meshed split-skin grafts. All wounds should be healed before the patient leaves the hospital-even small ones. In venous leg ulcers with marked arterial insufficiency, a more cautious approach is advised, with grafting to the wound bed without the wide and deep excision. The patients presenting healing problems are those who also have arteriosclerosis and those who do not cooperate.
Fig.
3.
Recurrences related
to
size of ulcer and
sex.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
665
Fig. 4.
Results.
In
conclusion, surgical treatment of longstanding leg ulcers is a tedious and expensive procedure, requiring patience and cooperation on the part of the patient; but it can be successfully performed in most cases by appropriate grafting procedures. Sten Jacobsson, M. D. Department of Plastic
Surgery
University Hospital S-214 01 Malmö, Sweden
References 1. Homans, J., The etiology and treatment of varicose ulcers of the leg." Surg Gynec Obstet 24: 300, 1917. 2. Brown, J. B., Byars, L. T. and Blair, V. P., "A study of ulcerations of the lower extremity and their repair with thick split skin grafts." Surg. Gynec. Obstet. 63: 331, 1936. 3. Jacobsson, S., Rothman, U., Artursen, G., Ganrot, K., Haeger, K., Juhlin, I., "A new principle for the cleansing of infected wounds." Scand. J. Plast. Recon. Surg. 10: 65, 1976.
4. Jacobsson, S., Jonsson, L., Rank, F. and Rothman, U., "Studies on healing of DEBRISANtreated wounds." Scand. J. Plast. Reconstr. Surg. 10: 97, 1976. 5. Aberg, M., Hedner, U., Jacobsson, S. and Rothman, U., "Fibrinolytic Activity in Wound Secretions." Scand. J. Plast. Recon. 10: 103, 1976. Surg. 6. Gundersen, J., "Segmental Measurements of Systolic Blood Pressure in the Extremities Including the Thumb and the Great Toe." Acta Chir Scand Suppl 426, 1972.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 5, 2015
