Skin Ulcers: Surgical Management

Surgical debridement refers to the use of sharp instruments to remove devitalized tissue from wounds. Skin grafting is an adjunctive therapy that uses human (autograft or allograft), nonhuman (xenograft), or artificial (synthetic graft) skin to cover nonhealing ulcers. Bilayer artificial skin plus compression is more effective for venous leg ulcers (VLUs) than standard dressings plus compression. Reconstructive surgery provides options for coverage of deep, refractory pressure ulcers; however, no randomized trials have compared these techniques with standard care. For patients with VLUs with superficial venous reflux, early endovenous ablation plus compression heals VLUs more quickly than compression with deferred ablation. Revascularization restores in-line arterial flow to ischemic extremities, facilitating wound healing and pain resolution. Bypass surgery has been shown to result in better luminal patency at 1 year than percutaneous transluminal angioplasty (PTA), but PTA is associated with fewer perioperative complications and shorter hospitalizations. PTA with and without stenting are comparable in terms of rates of perioperative complications and major amputation and mortality in patients with infrapopliteal arterio-occlusive disease. Amputation is the last option for patients with critical limb ischemia who are not candidates for or have not benefited from revascularization attempts.