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Page 4 of 10 Othman et al. Plast Aesthet Res 2022;9:29 https://dx.doi.org/10.20517/2347-9264.2021.135

variety of methods, including traditional wet-to-dry with appropriate antibiotic-impregnated dressings,
antibiotic beads, and/or selective coverage. However, the authors reiterate that early debridement is the
most adequate and important first step to optimal wound bed preparation.

Though the authors outline their principles in delayed coverage, the authors advocate for immediate
reconstruction when possible. This helps reduce patient morbidity and hospital course, improves cost-
analysis and health care savings, and may be associated with improved outcomes. Furthermore, even in
wounds with adequate debridement and tissue temporization, the bacterial burden is prone to increase over
time, and unnecessary delays to definitive coverage should be avoided.

DEFINITIVE COVERAGE
Once adequate debridement and tissue temporization have taken place, the plastic surgeon must evaluate
the existing wound bed for reconstructive options. Though several options may be feasible, the role of the
plastic surgeon is to take the clinical scenario into context to select the most appropriate modality.

Local tissue and dermal matrices
Several options exist for local tissue rearrangement as well as dermal matrices, skin grafts, or multiple
combinations therein, often correlated with the famed “reconstructive ladder” . More defects are often
[22]
amenable to skin grafting and dermal wound matrices. This has been enhanced in the setting of NPWT;
when temporizing tissue, and allowing increased granulation, an appropriate wound bed can be
[21]
established .

The authors utilize dermal wound matrices whence possible to avoid free tissue transfer, particularly in the
lower extremity where oftentimes adjacent soft-tissue is scarce, and to avoid a more invasive procedure, and
we have found good success in a variety of settings [23-26] . Indeed, we prefer local tissue, though when this is
not possible, or when there is scarcity of tissue, or in cases with a well-vascularized and clean wound bed,
the authors will utilize skin grafts and dermal wound matrices. Other times, local tissue rearrangement for
lower extremity salvage may lack the aesthetic match that patients seek in comparison to full-thickness skin
[27]
grafting and dermal wound matrices . Further, the utilization of local tissue requires smaller wounds of
healthy patients with lower comorbid risk factors for delayed wound healing (i.e., non-smoker, non-
diabetic) in order to succeed . For these reasons, the authors again pivot to dermal wound matrices as a
[28]
powerful adjunct option. However, several cases preclude its use. Wounds with active infection or
questionable need for secondary re-operation are not strong candidates for these reconstructive modalities.
Our institution has found good outcomes in this setting, indicating that dermal wound matrices can often
show equivalent or better outcomes to their local- and free-flap counterparts [25,26] . However, in situations
with extensive vessel, nerve, and/or bony exposure, skin-grafting and dermal wound matrices are likely
lesser options, with many surgeons opting to avoid these altogether in this context.

Several freestyle, random pattern local flap options, as well as named vessel local flap options, are available
for reconstruction dependent upon the location of the defect as well as the adjacent zone of injury. The
authors prefer these pedicled flaps, particularly the fasciocutaneous variety, for defects requiring likely
future re-operation and those without filling defects or extensive dead space . In the setting of trauma,
[29]
where local tissue may be lost or unusable, delayed elevation techniques may be necessary to ensure flap
survival and maximize the area of coverage. When harvesting random pattern flaps, the authors utilize
hand-held Doppler probes to ensure adequate vascularity in the harvesting of the flap. These include
rotational, transposition, and advancement flaps. The advantage of these local flaps is they can be used
anywhere along the extremity where the anatomy and injury permits, as well as saves tissue except in some