Lower-extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower-extremity wounds. Seventy-five patients with lower-extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open-cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum-assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours.Vacuum-assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split-thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years.

Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted closure provides a new paradigm that can be used in concert with a wide variety of standard existing plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations. The ease of technique and a high rate of success have encouraged its adaptation by thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discusses multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems. This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.

The use of Mohs micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.

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