RECONSTRUCTIVE TECHNIQUES

RECONSTRUCTIVE TECHNIQUES

• These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external fixators and tissue expanders. Improved understand - ing of the blood supply to di ff erent tissue types including skin has vastly expanded the number of flap options (see below) available to reconstruct di ff erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a flap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods first, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local flap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local flap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus significantly reducing the risk of limb-threatening deep infection or osteomyelitis.

Figure 47.6 Negative-pressure wound therapy to promote wound healing in an open abdomen. The system consists of a non-adherent dressing overlaid by a sponge that is sealed with an airtight membrane and connected to a suction device. (primary venous skin graft plexus) Subpapillary Hair Deeper split-thickness plexus skin graft Papillary loops Thick split-thickness skin graft Epidermis Full thickness (Wolfe) skin graft Local /f_l aps Deep Subcutaneous Subcutaneous subdermal vessels tissue plexus Reticular dermis Papillary dermis Figure 47.7 Schematic anatomy of the skin and its relationship to harvesting skin grafts (of varying thicknesses) and raising local /f_l aps.

RECONSTRUCTIVE TECHNIQUES

• These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external fixators and tissue expanders. Improved understand - ing of the blood supply to di ff erent tissue types including skin has vastly expanded the number of flap options (see below) available to reconstruct di ff erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a flap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods first, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local flap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local flap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus significantly reducing the risk of limb-threatening deep infection or osteomyelitis.

Figure 47.6 Negative-pressure wound therapy to promote wound healing in an open abdomen. The system consists of a non-adherent dressing overlaid by a sponge that is sealed with an airtight membrane and connected to a suction device. (primary venous skin graft plexus) Subpapillary Hair Deeper split-thickness plexus skin graft Papillary loops Thick split-thickness skin graft Epidermis Full thickness (Wolfe) skin graft Local /f_l aps Deep Subcutaneous Subcutaneous subdermal vessels tissue plexus Reticular dermis Papillary dermis Figure 47.7 Schematic anatomy of the skin and its relationship to harvesting skin grafts (of varying thicknesses) and raising local /f_l aps.

RECONSTRUCTIVE TECHNIQUES

• These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external fixators and tissue expanders. Improved understand - ing of the blood supply to di ff erent tissue types including skin has vastly expanded the number of flap options (see below) available to reconstruct di ff erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a flap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods first, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local flap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local flap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus significantly reducing the risk of limb-threatening deep infection or osteomyelitis.

Figure 47.6 Negative-pressure wound therapy to promote wound healing in an open abdomen. The system consists of a non-adherent dressing overlaid by a sponge that is sealed with an airtight membrane and connected to a suction device. (primary venous skin graft plexus) Subpapillary Hair Deeper split-thickness plexus skin graft Papillary loops Thick split-thickness skin graft Epidermis Full thickness (Wolfe) skin graft Local /f_l aps Deep Subcutaneous Subcutaneous subdermal vessels tissue plexus Reticular dermis Papillary dermis Figure 47.7 Schematic anatomy of the skin and its relationship to harvesting skin grafts (of varying thicknesses) and raising local /f_l aps.