Reconstructive surgery

The “reconstructive ladder”

Reconstructive surgeons use the concept of a “reconstructive ladder”—the more problematic the wound, the higher up the ladder the surgeon has to climb. Simple wounds may be closed by primary suturing, sometimes in the primary care setting. But others may require complex reconstruction, including free tissue transfer, in hospital.

The “reconstructive ladder” is used by reconstructive surgeons to assess the complexity of treatment required

All traumatic wounds should undergo debridement and thorough irrigation before primary closure. The aim of debridement is to remove all potentially contaminated and devitalised tissue along with foreign material. Primary suture may not be indicated in heavily contaminated wounds, where the risk of infection is high. In such cases the wound should be debrided, with “delayed closure” carried out later. Occasionally, wounds may be allowed to heal by secondary intention, where areas of skin loss are initially replaced by granulation tissue. The skin defect continues to heal as a result of proliferation or migration of epidermal cells within and around the wound and by contraction of the wound by specialised cells (myofibroblasts) within the granulation tissue. Healing by secondary intention is slow and may lead to contractures, scarring, and restriction of movements.

A finger injury is irrigated with saline before debridement and closure

Where skin defects are too large for skin apposition, and healing by secondary intention is inappropriate, skin grafts may be used. Free skin grafts are …