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The relative values of the components of these clinical strategies is yet to be determined. Certainly, thorough debridement of involved tissue to eliminate residual foci of infection32 is necessary. Wound management that includes soft tissue contouring33 and careful dressing care is an important adjunct that provides a favorable bed for the resurfacing flap. Topical antibiotic and disinfectant use, advocated by some authors33 but seldom used by us, is not clearly helpful,34 is possibly harmful,35 and is no substitute for debridement. Systemic antibiotics, while unable to penetrate ischemic foci of chronic infection,32 may prophylactically help perfused tissue resist invasive bacterial infection during debridement and reconstruction.34 Postoperatively, systemic antibiotics may be required for varying periods29 to prevent establishment of invasive infection from residual contaminated foci, but the required duration of antibiotic coverage may be far less than in the established clinical antibiotic therapies of such defects as osteomyelitis.36,37 The choice of perioperative antibiotics should be specifically determined by cultures taken during debridements and at the time of reconstruction. Finally, filling the defect with independently vascularized tissue such as pedicled muscle or a free microvascular transfer liberates the reconstruction from dependence on local, ischemic tissue and provides ample tissue for tension-free closure and obliteration of dead space.34
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Further experimental and clinical investigation should clarify the relationships between these components of wound reconstruction. Analysis of complications17 and exploration of the utility of such adjuncts as quantitative wound cultures34,38 may contribute to a more detailed definition of adequate debridement. The timing33 of reconstruction may prove a decisive variable in promoting success and decreasing morbidity. Careful bacteriologic examination of treated wounds and analysis of infectious complications may yield more specific information on optimal perioperative antibiotic therapy and the useful duration of postoperative antibiotic therapy following reconstruction of such defects as osteomyelitis.
Table 41-2 Reconstruction of Defects Complicated by Chronic Scarring and Infection
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