Reconstructive surgeryBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7543.710 (Published 23 March 2006) Cite this as: BMJ 2006;332:710
- Dean E Boyce, consultant hand and plastic surgeon,
- Kayvan Shokrollahi, specialist registrar in plastic surgery
- Welsh Centre for Plastic Surgery, Morriston Hospital, Swansea
Many surgical options are available to a reconstructive surgeon when faced with a difficult wound. However, any decision about management should be holistic and take into account factors such as the occupational circumstances of the patient and likely period of time off work, comorbidity, likelihood of success, donor morbidity, functional outcome, and the risks of surgery and anaesthesia. The basic principles of wound management apply to all wounds.
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.
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.
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 …