**Author details**

high‐dose ultrasound in the treatment of skin wounds [117]. Thus, noncontact ultrasound therapy is among the newer modalities. Use of lower frequency (40 kHz) ultrasound in wound management was approved by the FDA in 2004 [118]. Low‐frequency ultrasound therapy provides wound healing via the production, vibration, and movement of micron‐sized bubbles in the coupling medium and tissue. The healing process improves by the reduced bioburden, increased angiogenesis, stimulated cellular activity, and the removal of necrotic tissues [119]. Additional studies are necessary to determine standardized protocols of therapeutic ultra‐ sound in venous ulcers treatment. Routine use of ultrasound therapy in venous ulcer man‐

Surgical procedures are often applied when dressings and compression therapies fail in the venous ulcer treatment [76]. There are two approaches in surgical treatment of venous ulcers: ameliorating the cause of the ulcer and treating the ulcer itself by surgical procedures [4].

Superficial venous insufficiency is present in about forty to fifty percent of patients with venous ulcer [2]. Superficial vein surgery, simply comprised of ligation or sclerosis of the long and short saphenous systems, with or without communicating vein ligation or sclerosis, may be useful in patients with superficial venous insufficiency but only when deep veins are compe‐ tent [120]. Although superficial vein surgery does not affect the success of improvement in venous ulcers, ulcer recurrence has shown to be reduced by the procedure [120]. Subfascial endoscopic perforating vein surgery, a new surgical technique, has proven to be effective in patients with perforator vein insufficiency [8]. In this technique, perforator veins are ligated by an endoscopic camera system through a small incision. This procedure has low complica‐ tion rates and morbidity [121]. As mentioned above, it has been shown that venous surgery

Radical excision of the diseased area including the whole ulcer bed, the fibrotic suprafascial tissues, and the abnormal superficial and perforating veins, and flapping this large soft tissue defect have been shown to be successful in a few cases. However, highly invasive character of

Skin grafting has proven beneficial to heal large‐size recalcitrant ulcers [120]. Contamination with microorganisms and risk of trauma are the main factors that should be kept in mind when grafting for ulcer [123]. Split‐thickness skin grafts, punch grafting, and meshed grafts are some of the grafting methods used in venous leg ulcers. While pinched grafts are suitable for small

In the period that patient has no venous ulcers, it is important to keep in cooperation with and offer some simple lifestyle changes to the patient. Leg elevation is thought to provide venous return, reduce edema, and improve cutaneous circulation [98]. Elevation of the legs above heart level for 30 minutes three or four times a day is a simple and effective method in reducing edema and improving the cutaneous microcirculation in patients with chronic venous

does not seem to improve the healing but delays or reduces the recurrences [76].

ulcers, meshed grafts are useful for large highly exudative ulcers [4].

agement is not suggested [31].

298 Wound Healing - New insights into Ancient Challenges

this procedure limits its application [122].

**6.9. Prevention**

**6.8. Surgical management**

Aslı Aksu Çerman\* , İlknur Kıvanç Altunay and Ezgi Aktaş Karabay

\*Address all correspondence to: aksuasli@hotmail.com

Dermatology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
