THE RECONSTRUCTIVE LADDER BY DR BINOD CHAUDHARY

reconstructive ladder, reconstructive elevator, reconstructive grid, version 2.0
wound closure, skin grafts, tissue expansion, tissue transfer, flap, recent advances in plastic surgery reconstruction, orthopaedics/orthopedic surgery. trauma surgery, soft tissue injury, most advanced.
wound healing and repair,
factors affecting it,
stages,
dressing, suture techniques,

1. THE RECONSTRUCTIVE LADDER PRESENTER: Dr. Binod Chaudhary Department of Orthopaedics WRH, PoAHS Nepal

2. Aims 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.

3. Introduction Wound a break in epithelium with structural and functional disruption Healing ability of the body to replace destroyed tissue with viable tissue Repair replacement of destroyed tissue with granulation tissue and later scar tissue

4. Wound healing process Stage Cellular events Clinical features Hemostasis Vasoconstriction Platelet aggregation and thrombus formation Blood clot to stanch bleeding Inflammation Neutrophil infiltration Monocyte infiltration then differentiation to macrophages Lymphocyte infiltration Surrounding tissue exhibit cardinal feature of acute inflammation Removal and neutralization of infective and foreign agents Proliferation Re- epitheliasation Angiogenesis Collagen synthesis Granulation tissue scaffolding initially (within 48 hours), then converted to scar tissue Remodelling Collagen remodeling Vascular regression and maturation Wound contraction Scar relatively avascular Maximal tensile strength only 80% of normal skin, plateaus after 30 months

5. Factors affecting wound healing Patient Surgeon Systemic Local Non modifiable Age gender Modifiable Hypoxaemia Nutrition Anaemia Jaundice Uremia Obesity Alcoholism Smoking Immunocompromised Medications (steroids, chemotherapy) Oxygenation Infection Foreign body Arterial and venous sufficiency Radiotherapy Malignancy Repeat surgery Experience Suture technique Suture material Knotting Optimal tension Anatomical continuity

6. Reconstructive ladder A hierarchy of options available for closing a wound Systematic, modern and safe approach to reconstruction Decision making guided by wound characteristics and patient factors Choose least aggressive method initially Rise up rungs of the ladder as necessary More problematic wounds may require higher rungs

7. Dressing Adjunct applied to a wound to promote healing and prevent further harm Allow wound to heal by secondary intention Aim Maintain a moist environment without excess exudate Protect the wound from infection Enhance the process of slough removal Maintain the optimal pH of wound Maintain the optimum local temperature, so that wound can heal as soon as possible

8. Layers of dressing Contact layer Absorptive layer Compressive layer Types Adhesive dressing Non adhesive dressing

9. Primary(or delayed) closure Primary closure = appose + secure incised wound edges Traumatic/ dirty wounds- may require debridement = delayed closure

10. Primary closure Surgical principles Slight eversion to skin edges Minimal tension on wound edges Gentle tissue handling Right suture material and not too tight Excise dog-ears Eliminate dead-space (drains/deep dermal)

11. 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 reconstructions

12. Skin grafting Portion of epidermis along with some or all of the dermis Block of tissue transferred without blood supply. Grafts of any kind require vascularization from the bed into which they are placed for survival. Classified according to tissue of origin: Autograft Isograft Allograft Xenograft

13. Indications for grafts Extensive wounds Burns Specific surgeries that may require skin grafts for healing to occur Areas of prior infection with extensive skin loss Cosmetic reasons in reconstructive surgeries

14. Skin graft: Either split-thickness or full-thickness Split- thickness skin graft= epidermis + varying amounts of dermis Full-thickness skin graft = epidermis + entire dermis

15. Skin grafting process

16. Stages of graft take Adherence (<8 hours) Plasmic imbibition (<2 days) Inosculation (day 2-5) Remodelling (>1 week)

17. Contraction Primary contraction Secondary contraction Graft survival depend on graft quality and the graft bed

18. Split- thickness skin graft Epidermis +/- variable part of dermis Choice of donor site depends on amount of skin required, cosmetic outcome + ease of dressing Common sites thigh, buttock, scalp (but anywhere possible) Watson knife or power assisted dermatome

19. 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

20. Full-thickness graft Entire epidermis and dermis Limited in size- leave defect with no healing potential Donor site needs direct closure or SSG Choose donor site for good colour and texture match Donor site: post auricular area, upper eyelid skin, groin area

21. Full-thickness graft Advantages Retain volume and pigmentation Less contraction Adnexal structures retained Disadvantages More donor site morbidity- limits size Don’t “take” as well- blood supply from margins not base

22. Tissue expansion Increases surface area of locally available skin Expander implant into subcutaneous pocket  serial injection with saline via port over weeks/ months Expander removed  skin advanced

23. Tissue expansion Advantages Reconstructed tissue is a similar colour and 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 Contraindications Immature scars Presence of infections Use underneath skin grafts or irradiated tissues

24. Flaps Flap= a unit of tissue which maintains its own blood vessels whilst being transferred from a donor site to a recipient site Vascularized block of tissue Indcations : Bare bone and tendon Cover vessels or vital nerve Avascular recipient site or poor perfusion of wound Require thickness or strength of wound Wound at pressure site Cosmetic better than skin graft (color, elasticity) Require a plenty of layer (from huge excision )

25. Classifications 3 broad types: Random Pedicled free Simplified (The three “C”s) Circulation – blood supply named vs unnamed/axial vs random Contiguity – donor site local vs distant, pedicled vs free Composition – type of tissue single vs composite

26. Flap classification: Composition Composed of single or multiple tissue types (composite) Cutaneous Fasciocutaneous Fascial Muscle Musculocutaneous Osseous Osseocutaneous composite

27. Due to blood supply Random pattern flaps No directional blood flow, no named vessel Based on dermal and subdermal plexus Length: width of 2:1

28. 2. Axial pattern flaps Named depending on course of vessel Direct, fasciocutaneous , musculocutaneous Peninsular flaps Island flaps Free flaps

29. Due to site of flap Local flap Flap rotating about a pivot point Rotation Transposition(Z- plasty , Rhomboid flap, interpolation, bilobed ) Advancement skin flap Single pedicle flap B ipedicle flap V-Y advancement flap Y -V advancement flap 2. Distant flaps a. Pedicled b. Free

30. Rotation flap Semicircular flap, rotated about a pivot point into the defect to be closed. Donor site subsequently closed by sutures or with skin graft. Commonly used for coverage of sacral pressure sores Can cover wounds of various sizes Dog ear, back cut, burrow’s triangle

31. Transposition: Z plasty Transposition flap: square or rectangular pieces of skin and subcutaneous tissue, rotated about a pivot point into an immediately adjacent defect. Z- plasty : transposition and reversion of two triangular skin flaps Angles vary from 30 to 90 degrees(classic 60 )

32. Benefits and uses Increases the length of the skin, such as skin contracture or congenital finger web Changing the direction of the scar Change the direction of skin

33. Rhomboid ( Limberg Flap) Transposition flap designed for parallelogram shaped defects Two angles of 60 and two angles at 120 Good cosmetic results(tissue of same colour and thickness with good vascular supply)

34. Transposition: Interpolation flap Rotate around a pivot to fill a defect that is near to but not adjacent to the donor site. The pedicle of flap pass above or beneath the tissue to reach the recipient Donor site: Primary closure, skin graft

35. Advancement flaps Formed by sliding donor skin longitudinally over defects. Can be achieved simply by stretching along the long axis Equalizes the length of the flap and the adjacent wound edges. Types Single pedicle advancement flap Bipedicle advancement flap V-Y advancement flap Y-V advancement flap

36. Single pedicle advancement flap

37. Bipedicle advancement flap

38. V-Y and Y-V advancement flap

39. Distant flap: Pedicled flap Axial flaps Flaps remain attached to pedicled vessel until inosculation and neovascularization from recipient site occurs Types (Cormack and Lamberty ; 1984) Direct (vessel in subcutaneous tissue) Fasciocutaneous (vessel in or near fascia) Musculocutaneous (based on muscle perforators)

40. Direct flap

41. Fasciocutaneous

42. Musculocutaneous flap

43. Distant flap: free flap 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 , hyoxia and reperfusion Highest rung of reconstructive ladder Riskiest reconstructive option

44. Free flap Indications Need for a certain tissue at recipient site No local options (foot, distal 1/3 rd leg, head and neck) Massive defects Areas that need reconstruction with multiple different tissue types (head and neck/ breast) Areas requiring freshly vascularized tissue

45. Advantages: Single staged procedure Choice of donor tissue Large volume of tissue can be transferred Can optimize vascularity (recipient and donor) Less immobilization compared to pedicled flaps Can choose and hide donor defects( eg , breasts)

46. Disadvantages: Long and specialized 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

47. Revised reconstructive ladder

48. From Reconstructive Ladder to Reconstructive Elevator The reconstructive ladder: improper extension of the well known and appropriate concept of wound closure ladder. Mandates starting with the simplest, least complex closure possibility and progressing up the ladder only when required

49. Reconstructive elevator allows one to ascend directly to the chosen level of reconstructive complexity Implies that in the era of form and function, simplest is not necessarily always the best E.g. a paraplegic with clean, granulating pressure sore ladder: split skin graft elevator: flap Why climb a ladder, when you can take the elevator?

50. Take home message Reconstructive ladder – basis of plastic surgery Variety of reconstructive options Sometimes no right or wrong choice Wise to start on bottom rung Don’t burn bridges unnecessarily

51. References Rockwood and Green’s Fracture in Adults, 9 th edition Campbell’s Operative Orthopaedics , 14 th edition Miller’s Review of Orthopaedics , 8 th edition Michael R. Zenn , Reconstructive surgery: anatomy, techniques and clinical applications, 2012 Textbook of Plastic and reconstructive surgery, 2022

52. Thank you