Reconstructive Ladder

PLASTIC, BURNS AND
RECONSTRUCTIVE
SURGERY
RECONSTRUCTIVE LADDER
Dr R Lekalakala
Wounds…
Analysing the wound (defect)
 Location
 Size
 Depth (Partial/ full thickness)
 State of the wound (scarring,

irradiation, infection, well/poor
vascularity)
 Impaired functionality?
 Aesthetic consideration
 Sensation
APPROACH:
RECONSTRUCTIVE
LADDER
 A spectrum (toolbox) of options available for
wound closure
 Hierarchy (ascending simple to complex)
 A number of techniques are available to the

plastic surgeon
 Choose the most appropriate method necessitated
by the defect
 Surgeon must prepare a sequence of plans in case
of reconstructive failure/ disease recurrence
Dressings
• Topical – ointments/creams (Betadine, Bactroban, Silver based –
flamazine)
• Contact dressing (Primapore, Paraffin gauze)
• Polyurethane Films (Tegaderm, Opsite)
• Hydrogels (Intrasite gel)
• Hydrocolloids (Comfeel, Granuflex)
• Alginates (Kaltostat)
• Foams (Allevyn, Biatin)
• Vacuum Assisted closure (“vac dressing”)
 Superficial wound: contact
dressing
 Infected wound: topical/ contact
 Sloughy wound: hydrogels/topical
 Granulating wound: contact
Dressings  Exudating wound: alginates/
foam/VAC
 Necrotic wound:
Debdridment/topical/contact
 Cavity: foam
Primary closure
 Use of suture material
 Absorbable/Non-absorbable
 Tension free
 Approximate wound edges (everted)
 Haemostasis
 Obliterate dead space
 Complications – infection,
dehiscence, abnormal scar (keloid)
Primary closure
 Apply basic surgical
principles:
 Local Anaesthesia
 Wound irrigation
 Debridement
 Closure: suture material,
tension free
 Removal of sutures (5-7 days
majority)
Secondary healing
(delayed closure)
Ideally for small wounds

Edges not approximated, by granulation
from bottom upwards
Heals over a longer period of time
Adjunct: VAC dressing
• Skin transferred WITHOUT its blood
supply
• from a healthy DONOR SITE to a wound
bed (RECIPIENT SITE)
• USES:
SKIN GRAFT - REPLACE SKIN LOSS (BURNS, TATTOO
REMOVAL, LARGE NAEVI)
- CLOSURE OF EXPOSED VITAL
STRUCTURES (DURA,PERITONEUM,
PERICRANIUM, PLEURA)
- CLOSING DONOR SITES OF FLAPS
Skin graft
 Thickness: Split thickness skin graft

 Donor sites = any skin, except face/ flexor surfaces/
joints/ creases
 Harvested with a dermatome
 Sheet size enlarged with a mesher
 Secured with skin clips/ suture
 Exposure: 5-7 days recipient site; 7-10 days donor

site
Skin graft
 Thickness: Full thickness skin graft
 Donor sites = pre/post-auicular, supraclavicular, upper eyelid, antecubital fossa, inguinal, scalp,
prepuce, labia majora, areolar,
 Harvested with a scalpel
 Includes all layers of the skin
 Secured with suture; bolster
 Exposure: 5-7 days

Tissue
Expansion
Tissue expansion is accomplished by placing a
balloon like expander underneath the skin
near the damaged region.
Over time, the expander is filled with a saline
solution causing the skin around it to stretch
Adv = well vascularized tissue, good colour
match & consistency
Disadv = multiple expansion session
(discomfort), extrusion & infection
Flaps
 A unit of tissue transferred with its own
blood supply to the defect/wound
 Classified according to
1) composition (fasciocutateous flap,
muscle flap, bone flap,
musculocutaneous flap etc
FLAPS 2) contiguity/ donor site i.e local flap,
regional flap, free flap
3) circulation i.e random vs a named
vessel
4) Contour (movement) i.e advancement,
transposition, rotation, interpolation
5) conditioning
Local flap
Use of tissue adjacent to the wound to
reconstruct the defect
Indications
 Small wounds where primary closure,
skin graft is not applicable
 Facial wounds
Advantages
 Use tissue that has colour,
composition similar to the defect
 Donor wound is closed primarily
Local flaps
 Advancement flaps
 Rhomboid flaps Circular flap

 Rotational flaps
 Z , W,M plasty
 etc
Rhomboid flap
Z plasty
Regional/ pedicled flaps
Indications
 Large defects
 Inadequate local tissue
Disadvantages
 Donor site can not be closed primarily
 Donor site morbidity

Delto-pectoral flap
Pectoralis major flap
Gastrocnemious flap
Lattismus dorsi flap (breast)
Free flaps (microvascular
surgery)
 The term free flap used to describe
the transplantation of tissue from one
site of the body to another.
 Tissue is transferred with its blood
vessels and are anastomosed to the
recipient blood vessels
 Disadvantages : donor site
morbidities, duration of procedure,
need for recipient vessels, microscopy
Free
radial
flap
(tongue)
Free transverse
abdominis flap for
breast
reconstruction
Thank you !!!
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PLASTIC, BURNS AND

 Depth (Partial/ full thickness)

 State of the wound (scarring,

 A number of techniques are available to the

 Approximate wound edges (everted)

 Obliterate dead space

Ideally for small wounds

 Thickness: Split thickness skin graft

 Sheet size enlarged with a mesher

 Secured with skin clips/ suture

 Exposure: 5-7 days recipient site; 7-10 days donor

 Includes all layers of the skin

 Secured with suture; bolster

 Exposure: 5-7 days

 Rhomboid flaps Circular flap

 Inadequate local tissue

 Donor site morbidity

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