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Reconstructive Ladder

The document discusses various reconstructive options for wounds in a hierarchical ladder approach from simple to complex. It covers wound dressings, primary closure, secondary healing, skin grafts, tissue expansion, local flaps, regional flaps, and free microvascular flaps.

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Sihle Sibeko
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46 views

Reconstructive Ladder

The document discusses various reconstructive options for wounds in a hierarchical ladder approach from simple to complex. It covers wound dressings, primary closure, secondary healing, skin grafts, tissue expansion, local flaps, regional flaps, and free microvascular flaps.

Uploaded by

Sihle Sibeko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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