Intended for healthcare professionals

Student Education

Basic plastic surgery techniques and principles: Wound healing

BMJ 2003; 327 doi: (Published 01 August 2003) Cite this as: BMJ 2003;327:0308271
  1. Ben Taylor, third year medical student1,
  2. Ardeshir Bayat, honorary lecturer and specialist registrar in plastic and reconstructive surgery1
  1. 1University of Manchester

In the fourth part of our series, Ben Taylor and Ardeshir Bayat explain the first few steps on the reconstructive ladder -- primary closure and skin grafts

Previous articles in this series have covered

  • Choosing the right suture material

  • How to suture

  • Local anaesthetics

Closing wounds and defects is a basic surgical skill. Plastic surgeons manage large, infected, or complex defects with a range of techniques; the idea of the “reconstructive ladder” is useful (fig 1). On the lower rungs are simple techniques; if these are not adequate, you can climb the ladder. As with real ladders, however, climbing too high too soon may be dangerous for your patient. Start at the bottom and consider each step carefully as you move up, until you have sufficient experience to know which rungs to jump.

Fig 1

The reconstructive ladder for plastic surgery

Ground floor: do nothing

The simplest way to treat a wound is to leave it to heal by secondary intention. This is not as uncaring as it sounds--our bodies evolved over millions of years to do this. Secondary intention allows the wound to drain and heal from the base up and is particularly appropriate for:

  • insignificant and small wounds--for example, a small paper cut

  • infected wounds--closing an infected wound will trap the infection, until it breaks down the wound

  • when blood supply is compromised--closing the wound would further imperil blood supply

Even though you do not take measures to close the wound, you can do a lot with judicious application of dressings. The main disadvantage to this simple method is the look of the healed wound--you rely on scar contraction to close the wound. The wound edges may not have aligned well, and the end result may be a large scar that distorts the normal contours of the body.

First step: primary closure

The next step up from secondary closure is primary closure. You can use …

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