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Chest Wall Recon after sternal dehisence of sternectomy
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Back Recon after spinal infection or dehisence
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Sacral Decub
Following criteria must be met prior to flap reconstruction:
Nutrition: albumin > 2.5 gm/dl Prealbumin: normal >16 mg/dl. In general patients with osteo and inflammatory processes do not have a normal prealbumin. (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction.
The patient must have Source control: Adequate debridement and staged reconstruction after several weeks of IV antibiotics.
Flap reconstruction may be scheduled after the debridement with the patient managed with a wound vac.
Control of any spasms or release of fixed contractures that may impair flap mobilization.
Bowel regimen well established and urinary control. If necessary, diversion prior to surgery.
Plan for postoperative disposition: pressure relieving surface obtained prior to debridement, medical management and rehabilitation plan.
The patient is to follow up with Dr. * in outpatient clinic. OR Surgical closure of pressure sores has a high rate of failure. To maximizing the patient's chance for success, the following criteria must be met prior to consideration of soft tissue closure or reconstruction for chronic pressure ulcers: - Wound: The patient must have source control. Staged reconstruction can be considered for a clean wound after adequate debridement and antibiotic therapy optimization. Debridements should be performed by the patient's primary surgical service or by the general surgery service. If evaluation for osteomyelitis or bone biopsy is desired, the orthopedic service should be consulted. Often an MRI is necessary. The infectious disease service should be involved for antibiotic recommendations. The clean wound should be managed with a wound vac whenever possible until ready for soft tissue closure. There should be evidence of the ability to form healthy granulation tissue in the wound. If wound care recommendations are needed in the interim, please consult the wound care team. - Nutrition: Albumin > 3.0 gm/dl Prealbumin >16 mg/dl. In general, patients with osteomyelitis and inflammatory processes do not have a normal prealbumin (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction. A nutrition consult should be ordered if these goals are not being met. - Medical comorbidities: Medical comorbidities, such as diabetes, must be well controlled. Control of any spasms or release of fixed contractures that may impair flap mobilization should be obtained prior to soft tissue closure. A bowel regimen must be well established and urinary control must be obtained. If necessary, stool diversion must be arranged prior to soft tissue closure. - Postoperative disposition: Pressure relieving surfaces should be used during hospitalization and should be obtained for outpatient use prior to closure (e.g. mattress, wheelchair). Outpatient wound care, if needed, should be arranged. Medical management follow up and rehabilitation plan should be set up. Physical therapy, occupation therapy, and social work should be involved with the disposition process. Once these parameters have been met, the patient can follow up with Dr. * in outpatient plastic surgery clinic for evaluation.