Chronic wounds have traditionally been classified based on their etiology (venous ulcers, diabetic ulcers, pressure ulcers, etc.), reinforcing a reductionist perspective of the problem. However, this fragmented model has undermined understanding of their common pathophysiology and standardizing management approaches. From a medical epistemology standpoint, the evolution of pathological concepts has demonstrated that many syndromes were initially considered heterogeneous disorders until their underlying commonality became evident (e.g., metabolic syndrome, systemic inflammatory response syndrome). This review discusses and supports the proposition that chronic wounds should be conceptualized within a syndromic framework, wherein a shared set of pathophysiological processes underlies their diverse clinical manifestations, prompting a move beyond etiological reductionism. This proposition is supported by three epistemological arguments: biological, clinical, and practical. Through an analysis of fundamental syndromic principles, relevant examples illustrate this novel perspective. Ultimately, this proposition aims to advance a comprehensive and multi-level approach to chronic wound care, emphasizing multidimensional therapies that facilitate optimal, timely, and cost-effective outcomes. Such a conceptual shift would enable the integration of therapeutic strategies, the development of cross-cutting biomarkers, improved prediction of treatment responses, and greater consensus in research.
Pressure sores are frequently observed in chronically bedridden patients. When body position is not changed regularly, a single ulcer may develop in the area subjected to constant pressure, such as the sacral or trochanteric region; one habitual position usually results in one sore. The simultaneous presence of pressure sores on the sacrum and both trochanteric regions in a single patient is uncommon, and their reconstruction is challenging. A 48-year-old male paraplegic patient with three pressure sores on the pelvis was referred. The sores involved the sacral and bilateral trochanteric regions and were complicated by infection, including osteomyelitis. Serial flap coverage was staged according to wound readiness and the resolution of infection. First, the right trochanteric sore was reconstructed using a perforator-based island flap (PBIF). After 9 days, the sacral sore was reconstructed with another PBIF. After an additional 20 days, the left trochanteric sore was covered using a pedicled anterolateral thigh musculocutaneous flap. All flaps were selected based on lesion size and condition and survived without major complications. When reconstructing multiple sores in one patient, establishing a clear strategy is essential. The order of reconstruction, appropriate intervals between procedures, and optimal flap selection are key considerations.
Reconstructing Fournier’s gangrene is particularly challenging because it rapidly leads to soft tissue necrosis that requires extensive debridement. This often results in a large soft tissue defect with dead space due to structural irregularity. We report two cases of Fournier’s gangrene successfully reconstructed using a pedicled anterolateral thigh (ALT) flap with a chimeric pattern. A 61-year-old man with Fournier’s gangrene presented with extensive necrosis in the penoscrotal area. After radical debridement and infection control, the wound was reconstructed using a chimeric pattern pedicled ALT flap. The flap was composed of fasciocutaneous and muscle components supplied by branch vessels from the main pedicle. The fasciocutaneous component adequately resurfaced the defect, and the muscle component filled in the dead space between the two testes. A 58-year-old man with Fournier’s gangrene on the penoscrotal area also underwent reconstruction using the same method. In both cases, the flaps survived without any major complications and the reconstructions were successful with no recurrence of infection. When reconstructing Fournier’s gangrene, a trapezoidal-shaped dead space between the two testes is inevitable. Inadequate obliteration of this space may result in recurrent infection. An ALT flap with a chimeric pattern offers an adequate option for resurfacing and dead space obliteration.
Recurrent wound complications after cardiac surgery are usually associated with deep sternal wound infections. We report a rare case of a patient with persistent wound complications and no clear evidence of deep sternal infection, who was eventually diagnosed with fungal osteitis and successfully treated with free tissue transfer. A 66-year-old man with multiple comorbidities underwent off-pump coronary artery bypass grafting using the left internal thoracic artery as a conduit. Three months after surgery, the patient developed persistent wound complications at the sternotomy site. Despite repeated debridement, the wound failed to heal, and cultures remained negative for several months. Eventually, Aspergillus fumigatus was identified, and invasive fungal osteitis was confirmed histologically. After serial debridement, definitive reconstruction was performed using a free latissimus dorsi musculocutaneous flap. The right internal thoracic artery and vein served as recipient vessels, ensuring dead space obliteration and stable chest wall coverage. The patient recovered without further wound complications, and long-term antifungal therapy was maintained. At follow-up, no evidence of recurrent infection was observed. This case highlights the clinical challenges posed by fungal osteitis, a rare but difficult-to-treat condition.
Background: This study assessed 10-year changes in the proportion and epidemiology of work-related burns among inpatients at a single institution; as an institutional proportion, results reflect within-center surveillance.Methods: Burn inpatients admitted in 2016–2025 (n=5,074), including work-related burns (n=535), were retrospectively reviewed. Annual proportions were calculated. Because proportions dropped during COVID-19 (2020–2022), these years were excluded from the primary trend analysis. Period differences were tested with two-proportion tests and an overall 2×3 chi-square test; trends excluding 2020–2022 were evaluated with linear regression.Results: Work-related burns accounted for 10.5% (535/5,074). The proportion decreased in 2020–2022 versus 2016–2019 (7.7% vs. 10.9%; P=0.002) and increased in 2023–2025 versus 2020–2022 (13.1% vs. 7.7%; P<0.001); overall period differences were significant (chi-square P<0.001). Excluding 2020–2022, the proportion increased by +0.34 percentage points/year (95% confidence interval, 0.05–0.63; P=0.029). Scalds (53.6%) and electrical burns (18.5%) predominated. Mean burn total body surface area (TBSA) was 5.9%±9.2%, with 83.7% <10% TBSA; 78.9% were second-degree burns. Surgery was performed in 292 (54.6%), most commonly split-thickness skin grafting (STSG; n=150) or STSG with acellular dermal matrix (n=92). The highest incidence occurred in summer (33.3%).Conclusion: After excluding 2020–2022, the institutional proportion of work-related burns increased over time despite declining total burn admissions. This reflects a relative shift in case-mix, not population-level incidence; explanations such as changing exposures or improved reporting/compensation are hypothesis-generating.
The reconstruction of bilateral ischial pressure sores presents a formidable challenge in reconstructive plastic surgery. Adequate padding over the ischial tuberosity and proper resurfacing of the defect are critical in preventing recurrence after reconstruction. We present a case of bilateral ischial sores reconstructed using two different approaches. A 62-year-old paraplegic man with bilateral ischial sores and osteomyelitis of both ischial tuberosities presented to the plastic surgery department. After serial debridement, the 6×4 cm ischial sore on the left side was reconstructed using dual-plane flaps—two independent flaps consisting of a biceps femoris muscle flap and a perforator-based fasciocutaneous island flap. The 7×4 cm ischial sore on the right side was reconstructed using a single hamstring flap, a composite flap consisting of a semitendinosus muscle flap with a distally linked skin flap. Both defects were successfully reconstructed, and the patient regained wheelchair ambulation. Both approaches—the dual-plane flaps and the single hamstring flap—are effective options for ischial sore reconstruction, as they provide sufficient volume and adequate resurfacing. Given the hamstring flap’s capacity to significantly reduce operative duration, it may be considered the primary surgical option. However, in the absence of a reliable perforator between the hamstring muscle and the overlying skin, dual-plane flaps should be selected.
Background: Adequate tissue oxygenation is a key determinant of diabetic foot ulcer (DFU) outcomes. Though transcutaneous oxygen pressure (TcPO2) is the gold standard for evaluating tissue oxygenation, its limited availability restricts routine clinical use. Consequently, toe pressure is frequently utilized as a practical surrogate; however, the direct correlation between these two modalities has yet to be rigorously investigated. This study aimed to assess the correlation and agreement between TcPO2 and toe pressure in patients with DFUs.Methods: A retrospective review was conducted on 837 DFU patients who received simultaneous TcPO2 and toe pressure assessments. The correlation between the two tests was analyzed using the Pearson correlation coefficient, and agreement was evaluated using Bland–Altman analysis. To aid interpretation, a scatterplot and Bland–Altman plot were generated.Results: TcPO2 and toe pressure demonstrated a strong correlation (R=0.66; 95% confidence interval, 0.62 to 0.70; P<0.001). Bland–Altman analysis showed a mean bias of 26.9 mmHg (standard deviation of differences, 28.8 mmHg; 95% limits of agreement, −28.9 to 82.6 mmHg) between toe pressure and TcPO2, reflecting limited agreement and increased variability at higher perfusion levels.Conclusion: TcPO2 and toe pressure are strongly correlated. However, they are not interchangeable, particularly in DFU patients with high tissue perfusion.
The anterolateral thigh (ALT) flap serves as a workhorse flap for reconstruction of large extremity defects. However, primary closure of the donor site is often not possible when the flap width exceeds 8–9 cm, and skin grafting is commonly required, resulting in unfavorable scarring and discomfort. Three patients received skin cancer or sarcoma resection surgery which required subsequent resurfacing with an ALT free flap. Instead of directly closing the donor sites, elastic sutures were employed in a zigzag shoelace configuration for gradual approximation of the wound edges. Subsequently, negative pressure wound therapy (NPWT) was applied to manage postoperative edema and stabilize the wounds. Complete donor wound closure was achieved between postoperative days 4 and 10. NPWT was continued in the form of incisional NPWT after definitive closure to stabilize the wound site, reduce edema, and facilitate recovery of skin pliability. Tension-releasing taping was also used together with the wound closure. No complications such as skin edge necrosis were observed. The scars were satisfactory with minimal discomfort. This staged combination of shoelace approximation and NPWT represents a simple, safe, and effective alternative to skin grafting for ALT donor sites that cannot be closed primarily, minimizing morbidity while providing aesthetically favorable outcomes.
Pediatric vulvar hematoma typically results from straddle-type injuries and is usually managed with nonoperative measures. However, rapid progression and the risk of complications in some cases, including tissue necrosis, infection, and urinary retention, necessitate surgical intervention. The highly vascularized anatomy of the vulva allows for rapid hematoma expansion, requiring careful assessment of hematoma size, progression, functional impairment, and hemodynamic stability when determining the treatment strategy. In addition, genital trauma during developmental periods can influence self-perception and psychosexual development, making timely intervention important to prevent aesthetic and functional sequelae. We present two pediatric patients with vulvar hematoma who underwent successful surgical treatment following careful evaluation of both physical and psychological factors. This report emphasizes the importance of a comprehensive, multifaceted approach to the management of pediatric vulvar hematomas.
Background: This study analyzes the mutual interaction between the wound care products provider and the clinician, with the synergistic association of value perception, clinician experience (CEX), and the branding process on clinicians’ continuous usage intention (CUI) for hemostatic wound dressings. The research aims to understand the factors from clinicians’ perspectives when using acute wound products continuously.Methods: The study deploys a cross-sectional survey with Partial Least Squares - Structural Equation Modeling through purposive sampling. Data were collected from 147 clinicians frequently using hemostatic wound care products, including nurses and specialist physicians in private hospitals.Results: The analysis reveals that all proposed pathways are significant (P<0.005; 95% confidence interval), indicating relationships among variables in the model. Among direct relations with CUI, CEX showed a substantial relation, surpassing the role of brand competence and brand benevolence. Both economic and epistemic values strongly relate to CEX and thus are pivotal in shaping practical interactions with wound dressings.Conclusion: This study underscores the importance of clinicians’ hands-on experience continuously using a particular wound dressing. Understanding the experience based on the clinician’s perceived value will create a mutually beneficial relationship between providers and clinicians who represent the interests of patients. These patient interests are crucial to improving the quality of care in hospitals.
Compression therapy is the gold standard for treating stasis dermatitis and venous ulcers resulting from chronic venous insufficiency. It is also an essential component of non-surgical management for lymphedema, together with manual lymphatic drainage, decongestive exercises, and skin care. However, recurrence is common due to poor patient adherence or compliance. Patients with chronic medical conditions often find compression therapy uncomfortable and restrictive in daily life, making it difficult to maintain consistent use. The author introduces a structured educational protocol to improve compression therapy adherence in patients who struggle with consistent application. Key components of this protocol include: enhancing health literacy through tailored bedside education, practical bandage application training based on a demonstration-observation-performance-feedback model adapted from clinical student education, and most importantly, caregiver-centric education and skills training to support patients in coping with physical limitations in self-application. This approach enabled patients and their caregivers to effectively use elastic compression bandaging to improve their symptoms, promoting sustained use after discharge.
Diabetic foot ulcers are a major diabetes complication, particularly in regions with high prevalence and limited access to advanced care. Impaired healing in diabetic foot ulcers results from chronic inflammation, poor angiogenesis, extracellular matrix dysfunction, and metabolic imbalances. This review examines the roles of peroxisome proliferator-activated receptor gamma (PPARγ), interleukin-1 beta (IL-1β) blockers, and transforming growth factor beta 1 (TGF-β1) in diabetic wound healing. PPARγ suppresses inflammation and promotes tissue repair, but its function is often impaired in diabetes. IL-1β sustains inflammation and delays macrophage transition from M1 to M2, while TGF-β1 dysregulation disrupts collagen synthesis and extracellular matrix remodeling, contributing to fibrosis or delayed healing. These pathways are also implicated in diabetic retinopathy, where chronic inflammation and impaired angiogenesis worsen tissue damage. PPARγ agonists (e.g., rosiglitazone), IL-1β blockers (e.g., anakinra, canakinumab), and TGF-β1 modulators offer promising therapeutic strategies. While preclinical studies show potential, further clinical research is needed to refine treatment approaches and improve patient outcomes.
Background: Unlike other small to medium-sized skin and soft tissue defects, facial defects face significant constraints on reconstruction due to the limited availability of nearby skin, the necessity to preserve the integrity of surrounding structures, and the paramount focus on achieving optimal aesthetics and minimal scarring. We present a new modified Limberg flap and analyze the surgical outcomes of patients who underwent reconstruction using this technique.Methods: We conducted a retrospective chart review of patients who underwent wide excision and subsequent reconstruction using the modified Limberg flap between October 2020 and December 2022 at our institution. We analyzed patients’ sex, age, lesion characteristics (location and size), type of lesion, complications, recurrence, and scar satisfaction (visual analog scale score).Results: In total, 28 surgical procedures were performed on 26 patients. A total of 18 patients were followed up for 6 months postoperatively. There were 16 cases of skin cancer and two cases of benign tumors, with the most frequent locations being the cheek, periauricular area and nose. Three postoperative complications were found, including one case of marginal partial necrosis of the flap and two hematomas. Among patients who underwent resection of malignant tumors, residual tumor was detected in one case, necessitating additional excision and flap repositioning. Mean visual analog scale score with respect to scar outcomes after surgery was 3.6.Conclusion: The modified Limberg flap can offer a viable option for covering facial skin defects measuring 2–4 cm. This approach minimizes deformities of surrounding structures and is considered a relatively satisfactory aesthetic choice.
The surgical reconstruction of severe penile contracture complicated by recurrent urethrocutaneous fistula after multiple failed proximal hypospadias repairs poses a significant challenge due to extensive scarring, soft tissue deficiency, and vascular compromise. We report a successful two-stage reconstruction in a 14-year-old patient with this complex presentation. In the first stage, complete contracture release was performed from the normal urethral opening to the glans tip while preserving tunica albuginea continuity. A single wide full-thickness skin graft from the hairless groin provided optimal urethral lining. Meticulous postoperative care including prolonged dorsal extension and compressive dressings ensured graft survival and prevented ventral contracture recurrence. Six months later, the second stage surgery involved neourethral tubularization and bilateral skin flap advancement. A two-layer closure technique approximating Buck’s fascia before skin suturing ensured adequate vascularization and successful healing. One year after the second surgery, the patient reported normal urination and penile function, along with high satisfaction regarding both functional and aesthetic outcomes. This case highlights the importance of complete scar contracture release, optimal soft tissue supply, and meticulous surgical planning in complex penile reconstruction, demonstrating the efficacy of full-thickness skin grafting in achieving successful outcomes.
Chronic wounds represent a significant healthcare challenge, with traditional treatments often proving inadequate for optimal healing. Human umbilical cord mesenchymal stem cells (hUCMSCs) have emerged as a promising therapeutic option due to their unique biological properties and lack of ethical concerns. This review examines the current understanding of hUCMSCs in wound healing, highlighting their characteristics, mechanisms of action, and clinical applications. hUCMSCs, derived from Wharton’s jelly, demonstrate superior immunomodulatory properties compared to other mesenchymal stem cell sources and exhibit high proliferation rates with minimal donor-related variations. These cells facilitate wound healing through multiple mechanisms, including immunomodulation, angiogenesis promotion, and tissue regeneration. They secrete various growth factors and cytokines that orchestrate the complex wound healing process while suppressing excessive inflammation. Preclinical studies have demonstrated accelerated wound closure and improved tissue regeneration in various wound models, particularly in diabetic and burn wounds. Clinical trials have shown promising results in treating chronic diabetic ulcers, skin lesions, and other wound types, with significant improvements in healing rates and minimal adverse effects. Recent developments in delivery methods, including hydrogel-based applications and exosome therapy, have further enhanced their therapeutic potential. Future perspectives include the optimization of cell preparation methods, development of cell-free alternatives using extracellular vesicles, and combination therapies with advanced biomaterials. This review synthesizes current evidence supporting hUCMSCs as a safe and effective treatment option for wound healing and highlights emerging technologies that may enhance their therapeutic efficacy.
Background: Intuitive judgment is critical in diabetic foot nursing, as it aids rapid wound assessment and timely decision-making. The intuitive judgment of nurses improves early detection, facilitates individualized care, and enhances patient outcomes. Despite its importance, research specifically examining intuition in diabetic foot nursing is limited, and empirical studies on how nurses use it in practice are scarce. This gap underscores the need to clarify how intuition functions in diabetic foot care and how it can be integrated into practice. The following study aimed to examine intuitive judgment and decision-making processes in diabetic foot nurses.Methods: Q methodology was chosen for its structured approach to exploring and classifying subjective viewpoints, making it particularly useful for understanding diverse patterns of intuitive judgment in nursing practice. Q sorting was conducted using a forced normal-distribution grid. Data analysis was performed using PQMethod 2.35, integrating interview transcripts, demographic data, and factor arrays.Results: Four factors were identified: Patient-Centered Intuitive, Observation-Driven Experiential, Risk-Aware Adaptive, and Precision-Guided Analytical.Conclusion: Identifying these intuitive types offers valuable insights into the cognitive processes underlying diabetic foot care decisions. The findings may inform simulation-based training and education programs, providing practical guidance for strengthening decision-making skills and making diabetic foot nursing more responsive and effective in real-world settings.
Age and pregnancy-related hormonal changes affect breast tissue, making simultaneous augmentation-mastopexy a popular corrective procedure. However, despite technical advancements, risks including necrosis, hematoma, implant malposition, and sensory alterations still exist. Understanding and addressing these risks is of utmost importance, as demonstrated in the following case. A 35-year-old woman with grade 3 breast ptosis underwent augmentation-mastopexy with 305 cc silicone implants. Hematoma, skin peeling, and hypoesthesia on the right nipple-areola complex (NAC) that led to partial nipple tip necrosis were noted postoperatively. Following debridement and secretome injection, complete epithelization occurred within a week with enhanced sensory function during a 2-month follow-up. Noninvasive approaches such as stem cell therapy and its derivatives are highly sought after for managing surgical complications. Abundant in trophic factors, secretome promotes cell proliferation, differentiation, migration, and tissue repair. It is effective in treating skin necrosis by accelerating the wound healing process, and might have potential neuroprotective effects. Several factors may affect NAC viability and sensory function after augmentation-mastopexy. Early intervention, including the use of stem cell-based therapy, may promote tissue regeneration, accelerate healing, and preserve cutaneous sensory function.
Diabetic foot ulcers (DFUs) are chronic complications of diabetes mellitus that often result in delayed wound healing and in severe cases, even limb amputation. High-voltage pulsed current (HVPC) therapy has shown potential in promoting angiogenesis and cellular repair. This report describes two cases of chronic DFUs treated with adjunctive HVPC therapy. Two male patients with type 2 diabetes and chronic DFUs received HVPC therapy (3,000 V, 100 μs, 80–100 Hz) using a commercial device. Treatment was delivered every other day for 2 weeks (30 minutes per session), followed by every 3–4 days for an additional 2 weeks (20 minutes per session), alongside standard care including topical epidermal growth factor and systemic antibiotics. Wound healing was evaluated by area reduction, epithelialization time, and pain, using a visual analog scale. In Case 1 (Wagner grade 3, hemoglobin A1c [HbA1c] 6.8%), full epithelialization was achieved in 5 weeks. In Case 2 (Wagner grade 4, smoker, HbA1c 9.5%), complete healing was observed within 7 weeks after distal toe disarticulation. Both patients showed more than 75% wound reduction, pain resolution, and no adverse effects. These findings suggest that HVPC may be a useful adjunctive therapy for chronic DFUs, although controlled studies are needed to validate its clinical efficacy.
