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The Reconstructive LadderMussa MensaCT2 The Welsh Centre for Burns and Plastic Surgery
Aims•By the end of the session, you should be
able to:▫Outline the reconstructive ladder
▫Be able to outline and understand the differences between different rungs of the reconstructive ladder
▫Understand and apply the principles behind the concept
The Reconstructive Ladder
The Reconstructive Ladder•A heirachy of options available for closing
a wound•Systematic, modern and safe approach to
reconstruction▫Choose least aggressive method initially▫Rise-up rungs of the ladder as necessary▫More problematic wounds may require
higher-rungs
Step 1: Dressings•Adjunct applied to a wound to promote
healing and prevent further harm•Allow the wound to heal by secondary
intention•Aim – maintain a moist environment
without excess exudate
Low adherence dressings•Maintain a moist wound bed •Allow exudate to pass through into a
secondary dressing e.g gauze
•Soaked in paraffin:▫Jelonet, Paranet, Urgotul
•Textiles:▫Mepilex, Mepitel, Tegapore
Semi-permeable films•Transparent polyurethane sheet coated
with hypoallergenic adhesive•Permeable to air and water vapour;
impermeable to fluids and microorganisms
•Example - Tegaderm
Foam dressings•Polyurethane or silicon foam sheet•Highly absorbent with a hydrophobic
backing to prevent strikethrough•Example - Allevyn
Hydrocolloids•Hydrocolloids – come as sheets, foams or
paste•Consist of sodium carboxymethylcellulose,
gelatin, pectin and elastomers•Virtually impermeable•Example – Savlon; Duoderm
Hydrogels•Hydrogels - viscous gel•Matrix of insoluble polymers, high water
content•Can come as free-flowing gel/spray,
impregnated in gauze/sponge or sheets•Example - Intrasite
Alginates•Derived from brown seaweed•Very absorbent – used only on wound with
high exudate•Examples – Kaltostat; Sorbisan
Antimicrobial dressings•Reduce microbial load in colonised or
infected wounds•Silver = most common active ingredient;
Iodine also effective•Examples – Aquacel Ag; Mepilex Ag;
Acticoat; Inadine
Vacuum Assisted Closure•VACs create a controlled sub-atmospheric
pressure environment•Draws excess exudate away from the wound•Promotes angiogenesis and granulation•Foam + semi-permeable adhesive +
Vacuum device/tubing •Continuous or intermittent suction
▫50-70mmHg – chronic wounds/skin grafts▫~120mmHg – acute wounds
Step 2: Primary (or delayed) closure•Primary closure – appose + secure incised
wound edges•Traumatic/dirty wounds – may require
debridement + delayed closure
Primary closure•Apply basic surgical principles:
▫Slight eversion to skin edges▫Minimal tension on wound edges
(intradermal)▫Gentle tissue handling▫Right suture material and not too tight▫Excise dog-ears▫Eliminate dead-space (drains/ deep dermal)
Delayed closure•Indicated when wounds are dirty,
contaminated or at high risk of sepsis (e.g. bites)
•The first option following debridement•Wounds can be also left to heal by
secondary intention•More likely to need higher-rung
reconstruction
Step 3: Skin grafting•Block of tissue transferred without blood
supply•Classified according to tissue of origin:
▫Autograft ▫Allograft▫Xenograft
Step 3: Skin grafting•Either split-thickness or full-thickness
•Graft survival dependent on graft quality AND the graft bed▫Muscle/fascia bed Bare cortical
bone/tendon
Stages of graft take1. Adherence (<8hrs):
▫ Fibrin bonds between graft & bed▫ Easily disrupted by shear forces
2. Plasmic imbibition (<day 2):▫ Breakdown of intracellular PGs in graft cells▫ Osmosis and swelling of graft
3. Inosculation (days 2-5):▫ In-growth of blood & lymphatic vessels
4. Remodelling (>1 week):▫ Re-innervated + regeneration of skin appendages▫ Graft may become pigmented
Split-thickness skin graft• Epidermis +/- variable part of dermis• Choice of donor site depends on amount of skin
required, cosmetic outcome + ease of dressings• Common sites thigh, buttock, scalp (but
anywhere possible)• Watson knife OR power assisted dermatome
Split-thickness skin graft•Advantages:
▫versatile, ▫can be meshed to increase coverage▫donor site heals spontaneously + can be re-
harvested•Disadvantages:
▫Lack volume▫Develop patchy pigmentation
Day 0 Wk 3 Mo 3+
Full-thickness graft•Entire epidermis & dermis•Limited in size – leave defect with no
healing potential•Donor site needs direct closure or SSG •Chose donor site for good colour and
texture match
Full-thickness graft•Advantages:
▫retain volume & pigmentation▫less contraction ▫adnexal structures retained
•Disadvantages:▫more donor site morbidity – limits size▫don‘t “take” as well – blood supply from
margins not base ▫adnexal structures (hair) retained
Step 4: Tissue expansion•Increases surface area of locally available
skin•Expander implant into subcutaneous
pocket serial injection with saline via port over weeks/months
•Expander removedskin advanced
Tissue ExpansionAdvantages
• Reconstructed tissue is a similar colour & texture to defect
• Allows reconstruction with sensate skin with appendages
• Limited donor site morbidity
Disadvantages:
• Painful• Prolonged• Multiple procedures and
clinic attendances• No role in acute injury
Contra-indications:
• Immature scars• Presence of infection• Use underneath skin
grafts or irradiated tissues
Step 5: Flaps• Flap = “a unit of tissue which maintains its own
blood vessels whilst being transferred from a donor site to a recipient site”
• 3 broad types – random pattern, pedicled and free• Numerous classification systems• Simplified = The three C’s:
▫Circulation – blood supply named vs unamed/random vessel
▫Contiguity – donor site local vs distant, pedicled vs free
▫Composition – type of tissue single vs composite
Flap classification: Composition•Flaps are composed of single or multiple
tissue types (composite)▫Cutaneous▫Fasciocutaneous▫Fascial▫Muscle▫Musculocutaneous▫Osseous▫Osseocutaneous▫Composite
Flap classification: Composition•Cutaneous•Fasciocutaneous•Fascial•Muscle•Musculocutaneous•Osseous•Osseocutaneous•Composite
Flap classification: Composition•Cutaneous•Fasciocutaneous•Fascial•Muscle•Musculocutaneous•Osseous•Osseocutaneous•Composite
Flap classification: Composition•Cutaneous•Fasciocutaneous•Fascial•Muscle•Musculocutaneous•Osseous•Osseocutaneous•Composite
Flap classification: Composition•Cutaneous•Fasciocutaneous•Fascial•Muscle•Musculocutaneous•Osseous•Osseocutaneous•Composite
Flap classification: Circulation•Random pattern flaps:
▫No directional blood flow, no named vessel▫Rely on dermal/subdermal plexus▫Limited length to breadth ratio (1:1)
Flap classification: Circulation•Axial pattern flaps:
▫Named depending on course of vessel▫Direct, fasciocutaneous, musculocutaneous
Flap classification: Circulation•Perforator flaps:
▫Improved understanding of anatomy/physiology = custom made flap designs based on specific vessels
•Subclassification:▫Direct –
source vessel skin▫Indirect –
source vessel other structure skin
Flap classification: CirculationMusculocutaneous flaps•Can be classified based on blood supply•Mathes and Nahai – Types 1-5 depending on the pattern of blood supply
Flap classification: CirculationMusculocutaneous flaps•Type 1 – single pedicle (gastrocnemius )
Flap classification: CirculationMusculocutaneous flaps•Type 2 – single dominant pedicle enters near insertion or origin (gracillis )
Flap classification: CirculationMusculocutaneous flaps•Type 3 – two dominant pedicles (gluteus maximus )
Flap classification: CirculationMusculocutaneous flaps•Type 4 – multiple segmental perforators (sartorius )
Flap classification: CirculationMusculocutaneous flaps•Type 5 – one dominant pedicle and smaller secondary pedicles (lat. dorsi )
Flap classification: Contiguity•Local –donor site next to recipient site•Regional•Distant – pedicled or free
Flap classification: Contiguity•Local –donor site next to recipient site•Pivotal:
▫Rotation▫Transposition▫Interpolation
Flap classification: Contiguity•Local –donor site next to recipient site•Pivotal:
▫Rotation▫Transposition▫Interpolation
Flap classification: Contiguity•Local –donor site next to recipient site•Pivotal:
▫Rotation▫Transposition▫Interpolation
Flap classification: Contiguity•Local –donor site next to recipient site•Advancement:
▫Single pedicle▫Bi-pedicle▫V-to-Y
Flap classification: Contiguity•Local –donor site next to recipient site•Advancement:
▫Single pedicle▫Bi-pedicle▫V-to-Y
Flap classification: Contiguity•Local –donor site next to recipient site•Advancement:
▫Single pedicle▫Bi-pedicle▫V-to-Y
Flap classification: Contiguity•Distant – pedicled or free•Pedicled flaps - based on a named vessel
(axial flaps)•Flap remains attached to pedicled vessel
(which is not detached from the donor site)•Types:
▫Direct (vessel in subcutaneous tissue)▫Fasciocutaneous (vessel in or near fascia)▫Musculocutaenous (based on muscle
perforators)
Flap classification: Contiguity•Distant – pedicled or free•Types:
▫Direct (vessel in subcutaneous tissue)▫Fasciocutaneous (vessel in or near fascia)▫Musculocutaenous (based on muscle
perforators)
Deltopectoral flap (Int Mamm Art Perfs)
Flap classification: Contiguity•Distant – pedicled or free•Types:
▫Direct (vessel in subcutaneous tissue)▫Fasciocutaneous (vessel in or near fascia)▫Musculocutaenous (based on muscle
perforators)Type A: Sural or saphenous flaps Type B: scapular and parascapular flaps
Type C: radial forearm flaps
Flap classification: Contiguity•Distant – pedicled or free•Types:
▫ Direct (vessel in subcutaneous tissue)▫ Fasciocutaneous (vessel in or near fascia)▫Musculocutaenous (based on muscle
perforators)
Flap classification: Contiguity•Distant – pedicled or free•Free flaps – tissue moved from area of the
body to another with disconnection then re-anastomosis of their blood supply
•Based on known axial flaps•Involves tissue ischaemia, hypoxia and
reperfusion•Highest rung of reconstructive ladder•Riskiest reconstructive option
Flap classification: ContiguityDistant – pedicled or free•Indications:
▫Need for a certain tissue at recipient site▫No local options (foot, distal 1/3 leg, head
and neck)▫Massive defects▫Areas that need reconstruction with
multiple different tissue types (head and neck/ breast)
▫Areas requiring freshly vascularised tissue
Flap classification: ContiguityDistant – pedicled or free•Indications:
▫Need for a certain tissue at recipient site▫No local options (foot, distal 1/3 leg, head
and neck)▫Massive defects▫Areas that need reconstruction with
multiple different tissue types (head and neck/ breast)
▫Areas requiring freshly vascularised tissue
Flap classification: ContiguityDistant – pedicled or free•Advantages:
▫Single-stage procedure▫Choice of donor tissues▫Large volume of tissue can be transferred▫Can optimise vascularity (recipient and
donor)▫Less immobilisation cf. pedicled flaps▫Can choose and hide donor defects (esp.
breast)
Flap classification: ContiguityDistant – pedicled or free•Disadvantages:
▫Long and specialised
▫High-risk (flap-loss can occur)▫Quality of recipient vessel may be poor▫Donor site morbidity (varies according to
flap) Scar, hernia, loss of function
Flap classification: Contiguity•Examples:•DIEP ALT
Conclusion•Basis of plastic surgery•Variety of recon. options•Sometimes no right or wrong choice•Wise to start on bottom rung•Don’t burn bridges unnecessarily
Useful websiteswww.microsurgeon.org
www.dressings.org
Thank you for listening!