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Page 2 of 11 Matiasek et al. Plast Aesthet Res 2018;5:36 I http://dx.doi.org/10.20517/2347-9264.2018.50

direction of developing an enhanced protocol for the treatment of chronic wounds.

Keywords: Negative pressure wound therapy with instillation, octenilin® wound irrigation solution, chronic wounds,
pressure ulcer, wound bed preparation

INTRODUCTION
Wound healing is a highly complex process which is critical in maintaining the barrier function of the skin.
Chronic, non-healing wounds subject a patient to significant discomfort and distress while also using a
[1]
considerable amount of costly healthcare resources .

A pressure ulcer (PU) is a localised area of tissue destruction which occurs when soft tissue is compressed over
bony prominences for a prolonged length of time. The tissue destruction occurs when the compressed tissue is
deprived of oxygen.

PUs are estimated to affect 18% of patients in hospitals and care facilities in Europe. This prevalence is
[2]
projected to rise due to an increasingly aging population . Patients at particular risk of developing PUs
[3]
include older patients and those with paraplegia . Around 21% of paraplegic patients develop a PU, usually
caused by continual skin pressure inhibiting the adequate circulation of blood to the skin and underlying
[4]
tissue . This frequently leads to chronic complications meaning that on average a patient with paraplegia will
[5]
be hospitalised every three years as a direct result of a PU .
The European Pressure Ulcer Advisory Panel (EPUAP) has categorised PUs into four categories based on
severity of the lesions. These are defined below and provide a useful starting point for the management of
category 4 PUs. Category 1: intact skin with non-blanchable redness of a localized area usually over a bony
prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category 2:
partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum filled blister. Category 3: full thickness tissue loss.
Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. May include undermining and
tunnelling. The depth of a category/stage III PU varies by anatomical location. Category 4: full thickness tissue
loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.
[6]
Often includes undermining and tunneling .
There are many forms of management depending on the category and severity of the PU. A conservative, non-
surgical approach may be appropriate for categories 1 and 2. However, categories 3 and 4 PUs usually require
surgical management. Optimum pre- and post-operative care plays a key role in avoiding recurrences. Surgery
may be undertaken to perform skin grafts and flap coverage, which can provide efficient and rapid methods to
close wounds with good functional and aesthetic results.

There are various wound closure techniques available to the reconstructive surgeon and the reconstructive
ladder is a spectrum of closure options from simple primary wound closure to more sophisticated flap
reconstructive techniques. Where possible closure should be achieved by the simplest effective technique.
In terms of increasing complexity, the ladder goes from healing by secondary intention, healing by primary
intention, delayed primary closure, split thickness skin grafts, full thickness skin grafts, tissue expansion,
random flaps, axial flaps and free flaps.

Unlike skin grafts, flaps have their own blood supply and good results have been demonstrated in the