Contraindications to Surgical Wound Closure
David A. Daar, and Maristella S. Evangelista
This is an edited extract from the full chapter ‘Wound Closure’ from Operative Plastic Surgery (2 end) (OUP, 2019).
There are few absolute contraindications to wound closure. However, factors that impair healing should be considered as relative contraindications in order to ensure patient safety and successful wound closure. Possible risks for wound healing can be divided into wound factors as well as intrinsic and extrinsic patient factors. In each case, use of negative pressure wound therapy and/or dressing changes can provide temporary coverage and promote a clean, healthy wound bed until the closure is appropriate.
When the bacterial load within the wound reaches greater than 10 organisms per gram of tissue, there is an increased risk of wound infection. Inadequate debridement is often the cause for persistent infection. Exposed bone or hardware is presumed infected and should be debrided or removed if possible. Antibiotic regimens should initially cover a broad spectrum of organism and be de-escalated as soon as possible based on culture and sensitivity results. Because bacteria will colonize all exposed areas, aim to obtain cultures from deep, nonexposed areas or after superficial debridement has taken place.
Aging has shown to delay wound healing in healthy adults without actually impairing the healing quality. Aging delays each stage of the wound healing process, including inflammatory response, angiogenesis, re-epithelialization, and collagen turnover. Hormonal changes in aging patients also affect rate of wound healing. In particular, estrogen has shown to improve age-related wound healing and may explain the gender discrepancy in which aged males heal more slowly than aged females.
Malnutrition delays wound healing and alters immune system function, thus increasing the risk of infection. Protein malnutrition affects all stages of wound healing. Recommended range of protein intake is between 1.25 and 1.5 g/kg/day in chronic wounds, and adequate intake can be gauged by testing serum prealbumin (PAB) and albumin levels. C-reactive protein (CRP) should be checked alongside prealbumin as elevated levels may indicate unreliable PAB. Arginine and glutamine are two amino acids integral to wound healing, yet their supplementation has shown mixed results.
Corticosteroid use affects wound healing by impairing inflammation and collagen production as well as inhibiting epithelialization. Their use should be discontinued prior to surgery if possible. Patients taking corticosteroids can be offered vitamin A supplementation to mitigate delayed wound healing, although risk of wound contraction and infection still remain.
Nicotine impairs wound healing through its vasoconstrictive effects and increased risk of thrombus formation. Studies show a two- to threefold increased risk of tissue necrosis, delayed healing, dehiscence, and infectious complications with cigarette smoking. Digital blood flow velocity can decrease by roughly 42% after smoking a single cigarette. It is recommended that patients quit smoking for at least 4 weeks prior to surgery, with progressive risk reduction out to 6 weeks.
Nicotine products, such as nicotine gum, nicotine patches, and electronic cigarettes, will also affect the wound healing process and should be addressed similarly.
Diabetes is a well-known risk factor for wound complications due to hyperglycemia and vascular impairment. Poor control, both long-term and perioperatively, is associated with increased risk of infectious and non-infectious wound complications. Plastic surgery literature suggests cutoffs for adequate control as a hemoglobin A1c level of 6.5% and perioperative glucose level of 200 mg/dL for patients undergoing primary wound closure. Delay closure, if possible, in poorly controlled patients.
Cancer patients are at significant risk for impaired wound healing due to both the nature of disease as well as the multimodal treatment they undergo. Approximately 40–80% of patients are malnourished, due to various reasons, and impacts of chemoradiation and corticosteroid use can be additive.
Multiple animal studies have demonstrated decreased wound strength after neoadjuvant or adjuvant chemotherapy, especially in the early postsurgical period. While clinical evidence regarding the risk of postsurgical wound complications in the setting of chemotherapy remains inconclusive, estimates suggest an interval of at least 5–8 weeks between chemotherapy and surgery.
Ionizing radiation causes DNA damage and acute microvascular occlusion and stasis that predisposes tissue to edema, thrombosis, and poor healing. Wounds involving irradiated skin are at increased risk for dehiscence and infection, and, if possible, irradiated skin should be excised and then sutured to a well-vascularized flap. Studies show enhanced equilibrium of tissues at 6 months post-radiation and one should consider delaying reconstruction until that time.