Surgical Management of Chronic Cutaneous Ulcers: A Systematic Review of Outcomes and Complications

Introduction: Chronic cutaneous ulcers represent a major therapeutic challenge in dermatologic and reconstructive surgery, with high recurrence rates and substantial morbidity. They often result from vascular insufficiency, neuropathy, diabetes, or pressure injury, requiring individualized management strategies. Surgical treatment—including debridement, grafts, flaps, and regenerative techniques—plays a central role in accelerating healing when conservative therapy fails. Objective: The main objective of this systematic review is to evaluate outcomes and complications associated with surgical management of chronic cutaneous ulcers. Secondary objectives include comparing healing rates across techniques, analyzing recurrence and infection rates, and identifying patient- and ulcer-specific predictors of success. Methods: A systematic search was performed in PubMed, Scopus, Web of Science, Cochrane Library, LILACS, ClinicalTrials.gov, and ICTRP for studies published between 2020 and 2025. Eligible studies included randomized controlled trials, cohort studies, and controlled observational analyses assessing surgical interventions in chronic ulcers of any etiology. Results and Discussion: 15 studies met inclusion criteria. The most common surgical interventions were split-thickness skin grafts, local and perforator flaps, negative pressure wound therapy–assisted closure, and bioengineered skin substitutes. Reported healing rates ranged from 72 % to 96 % depending on ulcer etiology and surgical technique. Complications included infection (8–20 %), graft loss (4–12 %), and recurrence (6–18 %). Flap-based reconstructions generally yielded better long-term durability and aesthetic outcomes compared to grafts alone. Evidence quality was moderate overall, limited by heterogeneity of ulcer types and follow-up durations. Conclusion: Surgical intervention significantly improves healing rates and quality of life in patients with chronic cutaneous ulcers when performed after optimization of comorbidities. Local and perforator flaps show superior functional and cosmetic results, while grafts remain valuable for extensive superficial defects. Standardized reporting of outcomes and prospective trials comparing reconstructive strategies are needed to guide evidence-based practice. Descriptors: Surgical Flaps, Skin Transplantation, Chronic Ulcer, Wound Healing