A multidisciplinary team approach is necessary for comprehensive management of patients with DFUs who often present with several comorbidities that can potentially impair wound healing.3
The reconstructive surgeon should be the “superintendent” when considering the type, extent and timing of the surgical closure. Important contributing factors include but are not limited to: the patient’s age, presence of comorbidities, level of adherence, presence of infection, vascular status, associated foot or ankle deformities, and the level of medical stabilization. One needs to heavily weigh all of these factors prior to selecting wound closure procedure(s).4
Physicians should not underestimate the assessment of the patient’s psychosocial status and home support system as these can dramatically influence surgical expectations and the postoperative course.
Treating physicians should pursue appropriate diagnostic testing in order to ensure appropriate medical optimization prior to surgery. Hemodynamic instability may require further cardiology and nephrology consultation for medical clearance and anesthesia considerations. One should address any infectious process through extensive surgical debridement and tailored antibiotic therapy before contemplating soft tissue reconstruction. The presence of greater than 105 organisms per gram of tissue cannot sustain a skin graft or flap, and will require further debridement before definitive coverage.5
The patient must also undergo a full evaluation for peripheral vascular disease in order to ensure viable perfusion, which can support the vascular demand required for healing.6 Staging of surgical procedures is often warranted to provide the clinical setting most suitable for plastic surgery techniques.