Key points
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Most soft tissue wound closures may be performed in a delayed fashion with predictable results as long as wounds are decontaminated and kept clean and moist.
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Delayed closure may prove beneficial when the degree of injury is ill defined with blunt or penetrating trauma.
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Given proper wound management, secondary epithelialization with wound contraction may occur with subsequent treatment for closure or grafting of the defect.
Skin surgery may embrace a large portion of any practice. Wounds occur, tissues avulse, and defects remain after ablative surgery.
Traditional hard-wired surgeons are motivated to act or to react to do something when considering the open wound before them. What if an easier closure or even a better outcome might be plausible if the surgeon just waited or delayed the repair?
As experience often trumps the logic of immediate repair, there are several credible reasons to delay repair of soft tissue defects that might produce more predictable results.
Routine wound repair
For decades, a golden time was suggested during which some soft tissue injuries could safely be closed. On the face, a wait of 6 to 24 hours was deemed suitable because of the prodigious blood supply. Experience, however, has never proved that the blood supply alone was the sole reason for a positive or negative outcome based on an anecdotal time interval.
It is now known that most head and neck wound repair may be delayed indefinitely after injury as long as routine concepts are followed.
These concepts might include decontamination, moisture control, scraping the wound bed, and debridement of wound margins. In essence, almost any routine wound can be led toward a path of secondary epithelialization without closure. At almost any stage during that path, wounds may be reopened to the size of the original defect, debrided for secondary closure, grafted, or allowed to heal without surgical intervention.
Likewise, wound contraction after wounds are dressed open follows a predictable course, which may be modified to the benefit of the surgeon. In patients with tissue avulsion, delay offers major advantages: reduction of surgery, limitation of additional scars, revascularization of complex wound edges, and most importantly, time to muse or research the ideal optional approach. Examples are provided followed by discussion.
Delay: reduction of surgery
Case 1: this healthy 50-year-old man arrived in the emergency room (ER) after a motor vehicle accident with an avulsion defect of scalp with complex torn borders measuring 5 × 7 cm. His occupation allowed him to wear a hat.
Treatment: routine washout was done in the ER. The patient was dressed with an occlusive dressing of Bacitracin (over-the-counter), Telfa, and tape. After 3 days, he was switched to routine showers and wound covering with a double layer of Adaptic nonadherent gauze changed every 3 to 4 days plus cover dressing.
Progression of secondary epithelialization was completed at 3.5 months, leaving a residual non–hair-bearing defect half of the original size. The non–hair-bearing scalp was eliminated with a scalp rotation flap and advancement flap ( Fig. 1 ).
Delay: contamination
Case 2: contaminated wound, noninfected
This 30-year-old man had a close-range gunshot wound to face with significant debris. After initial lavage, open moisturized wound care and oral antibiotics were continued for 5 days. Delayed closure included repair of the mandible, scraping the wound bed, sharp debridement of devascularized edges in resting skin lines, and routine closure. Healing was uneventful and antibiotics were not continued after surgery ( Fig. 2 ).
Case 3: infected wound
This 30-year-old man had an infected wound reopened. After oral antibiotics for 7 days and moist wound care, the wound was acceptable for closure at 10 days. Oral antibiotics were given only preoperatively. Because of induration, no attempt was made to square rounded edges, which would increase tension of wound closure. After 6 months when the tissue softened, the rounded edges were removed and a Z-plasty was performed ( Fig. 3 ).
Case 4: infected lesion
This 30-year-old had a grossly infected acne keloidalis nuchae resistant to conservative dermatologic intervention. After total excision, the defect was dressed open with Avitene to control initial bleeding and with nonadherent dressings (Xeroform). After 2 weeks of routine daily showers, ointment, nonadherent dressing, and tape, the surgeon scraped the granulation wound base and applied a meshed split-thickness graft. Four months after excision, the patient complained of neck contracture.
Rectangular 8 × 10 cm skin expanders with buried ports were inserted above and below the nuchal defect. Half the replaced skin (4 cm) would be hair bearing and half (4 cm) would be skin only. After 2.5 months of weekly expansion, easy closure was accomplished with rotational flaps from below and above ( Fig. 4 ).
Delay: clearing skin cancer
Case 5: this 60-year-old woman with a Mohs defect had a complex wound, which required musing for the ideal closure that would not elevate her eyebrows. After 3 days of open moist wound care, the wound was presutured to gain mechanical creep (the tensile force necessary to hold skin decreases with time) with 3-0 nylon the day before surgery as described previously in the literature. One day later, advancement flap closed the defect after scraping the wound debridement (squaring) of wound edges. Only antibiotics prescribed were preoperative prophylaxis ( Fig. 5 ).
