the reconstructive ladder - mussa mensa

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: 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•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:


perforators)

Deltopectoral flap (Int Mamm Art Perfs)



perforators)Type A: Sural or saphenous flaps Type B: scapular and parascapular flaps

Type C: radial forearm flaps


▫ 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•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

http://www.microsurgeon.org/signup.php

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!

the reconstructive ladder - mussa mensa

Healthcare