A variety of operative procedures are available, the selection of which depends upon patient characteristics, ulcer site, and available surgical expertise [ 1 ]. Direct wound closure is usually not possible; thus, wound coverage entails using a skin graft, skin flap, or myocutaneous flap, often as a staged procedure. Prior to graft or flap placement, the wound should be free of devitalized tissue and infection, and patient factors predisposing to development of pressure-induced injuries should be corrected, where possible. Nutrition should be optimized, and smokers should be encouraged to stop since continued smoking impairs wound healing and may result in higher rates of recurrence [ 71 ]. (See "Skin grafting and skin substitutes" .)
Laws and Penalties: Concerns over growing illegal AAS abuse by teenagers, and many of the just discussed long-term effects, led Congress in 1991 to place the whole AAS class of drugs into Schedule III of the Controlled Substances Act (CSA). Under this legislation, AAS are defined as any drug or hormonal substance, chemically and pharmacologically related to T (other than estrogens, progestins, and corticosteroids) that promotes muscle growth. The possession or sale of AAS without a valid prescription is illegal. Since 1991, simple possession of illegally obtained AAS carry a maximum penalty of one year in prison and a minimum $1,000 fine if this is an individual’s first drug offense. The maximum penalty for trafficking (selling or possessing enough to be suspected of selling) is five years in prison and a fine of $250,000 if this is the individual’s first felony drug offense. If this is the second felony drug offense, the maximum period of imprisonment and the maximum fine both double. While the above listed penalties are for federal offenses, individual states have also implemented fines and penalties for illegal use of AAS. State executive offices have also recognized the seriousness of AAS abuse and other drugs of abuse in schools. For example, the State of Virginia enacted a law that will allow student drug testing as a legitimate school drug prevention program (48, 49).