The Reconstructive Ladder

Reconstructive plastic surgeons are frequently faced with complicated wounds in many areas of the body. These can range from small lacerations to wounds that involve missing structures, such as that seen following a mastectomy for breast cancer. The goal of the plastic surgeon is to restore function and form as well as possible using a variety of surgical approaches. The surgical options are best visualized as a hierarchy of possibilities arranged in a “reconstructive ladder.”

Approaching the reconstructive ladder involves asking several important questions. First of all, what types of structures are missing? What are the options for replacing these missing tissues? Which option is the best for restoring normal form? Which functions are missing? Which options are best for restoring function? What are the risks involved with the types of surgery available? Will there be scarring or a loss of function at the “donor site?”

The first option on the reconstructive ladder is direct wound closure. This option is available for the majority of minor injuries, in which the wound is not overly contaminated and is encountered within a short amount of time. Chronic wounds or those with missing skin require other methods, however. Allowing the wound to gradually heal itself is sometimes an option. Skin grafts are often used to cover a clean wound lacking skin that does not have raw tendon, bone, or nerve exposed. Wounds too extensive for skin grafting require additional tissue for coverage.

Repositioned tissues that maintain some form of blood supply are referred to as “flaps,” and are named for the types of tissues that are involved. “Skin flaps” consist of the skin and subcutaneous fat, and are often preferable to skin grafts when better skin match can be achieved without excess additional scarring. “Fasciocutaneous flaps” include the dense, supportive tissue called fascia, as well as the subcutaneous tissues and skin. “Myocutaneous flaps” include the muscle, overlying subcutaneous tissues, and skin. The TRAM flap and several others used for breast reconstruction are examples of myocutaneous flaps.

Flaps are further classified according to their type of blood supply. “Random flaps” receive their blood supply through a random array of blood vessels at their attached base, rather than through a defined blood supply. “Pedicle flaps” remain attached through their pedicle of vessels that continue to provide their normal blood supply. Free flaps are disconnected from their normal blood supply, placed in new location, and then reattached to blood vessels in the new area through microscopic surgery.

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