The Reconstructive Ladder

Mussa Mensa
CT2
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 take
1. Adherence (<8hrs):
▫ Fibrin bonds between graft & bed
▫ Easily disrupted by shear forces
1. Plasmic imbibition (<day 2):
▫ Breakdown of intracellular PGs in graft cells
▫ Osmosis and swelling of graft

1. Inosculation (days 2-5):

▫ In-growth of blood & lymphatic vessels
1. 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 Day 0 Wk 3 Mo 3+

▫ Develop patchy pigmentation

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 removedskin advanced
Tissue Expansion
Advantages Disadvantages:

• Reconstructed tissue is a • Painful

similar colour & texture to • Prolonged
defect • Multiple procedures and
• Allows reconstruction with clinic attendances
sensate skin with • No role in acute injury
appendages
• Limited donor site Contra-indications:
morbidity
• 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: Circulation
Musculocutaneous flaps
•Can be classified based on blood supply
•Mathes and Nahai – Types 1-5 depending on the
pattern of blood supply
Flap classification: Circulation
Musculocutaneous flaps
•Type 1 – single pedicle (gastrocnemius )
Flap classification: Circulation
Musculocutaneous flaps
•Type 2 – single dominant pedicle enters near
insertion or origin (gracillis )
Flap classification: Circulation
Musculocutaneous flaps
•Type 3 – two dominant pedicles (gluteus
maximus )
Flap classification: Circulation
Musculocutaneous flaps
•Type 4 – multiple segmental perforators
(sartorius )
Flap classification: Circulation
Musculocutaneous 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: Contiguity
Distant – 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: Contiguity
Distant – 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: Contiguity
Distant – 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: Contiguity
Distant – 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 websites
[Link]

[Link]
Thank you for listening!