Complex Wound Closure: Surgical Principles, Adjunctive Technologies, And Emerging Strategies

Complex wound closure remains a major challenge in reconstructive surgery because wound healing depends on coordinated cellular, molecular, vascular, infectious, and mechanical factors. Large traumatic defects, chronic wounds, postoperative dehiscence, irradiated wounds, diabetic ulcers, spinal wounds, chest wall defects, and wounds in medically compromised patients frequently fail to heal through standard closure methods. Successful management requires careful assessment of wound etiology, vascularity, contamination, tissue loss, tension, patient comorbidities, and reconstructive goals. Traditional strategies include primary closure, delayed primary closure, secondary intention healing, skin grafting, local tissue rearrangement, and flap reconstruction. Adjunctive modalities such as negative pressure wound therapy, incisional negative pressure therapy, skin stretching systems, dermal matrices, bioengineered scaffolds, and smart dressings have expanded the reconstructive armamentarium. Among these, negative pressure wound therapy has become one of the most widely adopted tools for complex wound management because it stabilizes the wound environment, reduces edema, promotes granulation tissue, and may decrease surgical site complications. However, no single technique is universally appropriate. Complex wound closure should be individualized according to wound biology, patient risk factors, anatomical location, functional demands, and available reconstructive resources. This review summarizes current principles, surgical options, adjunctive technologies, and future directions in complex wound closure.