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Holes.

 

They can occur anywhere on the face or body, and can be composed of missing skin, cartilage, muscle, bone, or any other form of hard or soft tissue.  Holes on the body can result from a myriad of reasons, with the two most common causes been trauma and tumour removal.

A hole on the human body, whatever the cause, will heal on it’s own accord, but may take variable time to achieve final wound healing. If the defect is significant in size however, or the location quite tricky, then the resultant scar may be unstable, not ideal aesthetically, functionally debilitating (such as in burn contractures), or have vital underlying structures that may be placed at risk of exposure or injury.

For centuries, and especially during the first and second world wars, the specialty of Plastic and Reconstructive Surgery has evolved through the development of innovative and anatomically based concepts of “filling in holes”.

The Plastic Surgery Reconstructive Ladder is a phrase used to describe the thinking approach one should take when faced with a physical defect on the body that requires tissue coverage. Let’s take a look at each step of the reconstructive ladder.

 

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The Plastic Surgery Reconstructive Ladder

 

The first step (or perhapsbetter termed ground level) is healing by secondary intention. This means allowing the wound to heal up naturally on it’s own without any surgical intervention. There are certain areas of the body where a wound defect will heal up nicely as long as it is within a certain size limit and is given optimal conditions for healing (such as been kept moist and clean). A small skin defect, for example, on the inner canthus region of the eyelid or the very tip of the finger will heal up nicely, both aesthetically and functionally, simply with regular dressings.

The next step up the ladder is direct closure. If there is sufficient laxity around the wound to allow the wound to be repaired directly without causing untoward distortion to surrounding structures, then this should always be attempted. The ends of the wound may need to be converted in a tapered fashion into an ellipse in order to prevent “dog ears” at the ends of the wound. Remember, it is better to have a longer smooth-contoured scar (which will fade) than a shorter but irregularly contoured scar. When planning the direction and configuration of direct closures, thought should be given to placing the eventual scar along or parallel to natural skin creases.

Then next step up the reconstructive ladder lands us upon the skin graft step. Skin grafts can be either split or full-thickness, depending on the reconstructive needs and size of the defect. An important point to remember with skin grafts is that the graft is technically a non-viable (dead!) piece of skin, and will depend solely on the vascularity of the recipient defect site to “bring it back to life” by nourishing it with nutrients and re-establishing its circulation. Importantly, during this period of skin graft “take”, it is important to optimise conditions for skin graft survival. These include cessation of smoking, immobilisation of the graft, and keeping the graft moist.

 

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Skin graft to the lower eyelid after skin cancer removal.

 

If the recipient site is not well vascularized, such as exposure of bare bone, then a skin graft will fail, and the defect will require soft tissue repair that carries with it an intrinsic blood supply – flaps, the next step up our ladder.

Skin flaps by definition have an intact blood supply and do not rely on the re-establishment of circulation through the blood supply of the recipient site. On certain occasions, even on well-vascularized wounds, a flap may be chosen as a preferred form of repair instead of a skin graft if it can give a more superior functional and aesthetic outcome.

Flaps can be further classified according to their geometry (advancement, rotation, transposition), their content (skin, muscle, bone), and their location (local, regional, distant). A local flap comes from an area directly adjacent to the wound; a regional flap is raised from tissue in the near vicinity, whilst a distant flap is taken from a site far from the defect.

 

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A rhomboid transposition flap after removal of skin cancer on cheek.

 

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Finger tip amputation with exposed bone repaired with advancement flap.

 

Since the advent of microsurgery, we have developed an increasingly better understanding of vascular anatomy. Almost every part of the skin, fascia, muscle, and bony vasculature has been thoroughly mapped out, allowing us to be more liberal and “free-style” in the way we can customise a flap according to the needs of the reconstruction.

As long as there is an artery coupled with a vein that supplies a piece of tissue, we can harvest this “donor” and use it in application to reconstructing a tissue defect. A good example of how advances in microsurgery have improved the quality of reconstruction and outcome has been in the arena of breast reconstruction, where we can elevate a lower abdominal flap, based on one group perforating vessels, join these vessels up to vessels under the rib, and utilize this skin/fat abdominal flap to make a new breast. The bonus is that the woman gets a tummy tuck out of the operation! This is an example of a “free flap” – free in the sense that the flap is completely detached and we can we can apply it anywhere in the body as long as vascular supply can be re-established.

Another example of the versatility of  “free flaps” in customizing and optimizing soft tissue reconstruction is shown in the example below, where the case entails a leg with exposure of metal fixation plates after a wound breakdown post trauma related fracture fixation. In this example, well-vascularized tissue was needed to cover the exposed plates. A piece of Gracilis muscle from the thigh was “harvested” together with its intrinsic supplying artery and vein, and this was then connected to the leg vessels using microsurgical techniques. A skin graft was then applied to the now vascularized and living muscle flap.

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Hole in the leg: exposed metal plate after wound breakdown.

 

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Muscle flap with overlying skin graft used to “fill the hole” in the leg.

 

The reconstructive ladder certainly still forms the basis of thought process in figuring out the reconstructive options a surgeon can employ when faced with a hole that needs to be filled. However, based on more recent evidence and with the better understandings we have these days in flap anatomy and vasculature, we are increasingly becoming more daring in jumping up a step or two on the ladder and heading straight for a reconstructive measure which may be more technically demanding, but which may lead to a more optimal aesthetic and functional outcome!