A 77-year-old man with chronic venous ulceration presented after yet another failed skin graft. Most venous ulcers will heal within the traditional scope of management: good topical care and compression, followed by venous interruption, and then excision and skin grafts if needed. However, when disease is persistent, other care has failed, and there are essential coverage needs, then excision and skin reconstruction is required. Upon presentation, the right medial ankle ulcer was surrounded by extensive eczematous dermatitis and edema. Necrotic recent skin grafts were still present.

After two weeks of basic hygiene, topical steroids, and compression, acute conditions were controlled. Because of the given history, healing was not expected with topical care and compression alone.

Ulcer excision exposed the posterior tibial neurovascular bundle, posterior compartment muscles, and the Achilles fat space. Integra was opted for wound management for all of the reasons mentioned: chronicity, a history of failed care, and the presence of exposed structures and adverse biomechanics, which would prevent successful skin grafting.