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The Reconstructive Ladder of Soft Tissue Injury

Elizabeth Erickson, PA-C

Borealis Plastic Surgery AASPA conference October 4, 2013

• PA training in Michigan at Central Michigan University 2006-2009

• Surgical residency at Montefiore Medical Center in New York City 2009-2010

• Trauma Service in Traverse City, MI 2010-present

• Physician Assistant at Plastic Surgery practice in TC 2012-present

Home of Good Morning America’s Most Beautiful Place-Sleeping Bear Dunes

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• Describe the tiers and standardized applicability of the reconstructive ladder

• Discuss the decision tree for surgical wound and excision management

• Present secondary management options when initial options have failed or not

feasible

• Apply plastic surgical principals to wound

closure and suture choice for common procedures

Objectives

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• I have no fiduciary relationships with any

product or company mentioned in the

course of this presentation

Disclosures

The Reconstructive Ladder

• The ladder exists to

guide us in which

direction to move

forward with repair!

The Reconstructive Ladder

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Closure by Secondary Intention

• The second a wound hits the air, it is colonized with microbes

• How quickly the wound progresses from

colonized to infected is dependent on multiple factors

• Debridement removes any necrotic debris or tissue which can harbor microbes thus accelerating the potential for infection • Surgical Debridement

• Chemical/Enzymatic Debridement

• Autolytic Debridement • Mechanical Debridement

Debridement

• To stop the interrupting or offending circumstances that lead to acute or chronic wounding

• For example: The most common difficulty is with pressure ulcers causing chronic wounds. The pressure needs to be relieved AND redistributed.

• Edema, contact with caustic substances, repeated trauma, infection, nutrition status, allergic reactions and malignancy are other common issues

Optimizing Wound Healing

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Know your limitations!

• No dressings

• Moist to dry

• Moist to Moist

• Ointments

• Colloids, silver dressings, Hydrogels

• Wound vac

Dressings

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• The basic premise behind wound care is divided into

three main areas: 1. Removal of infection or potential

infectious source

2. Correction of the offending process

3. Nutrition and energy supply to the

wound

Closure by Secondary Intention Summary

Closure by Primary Intention

Langer’s lines Relaxed skin tension lines

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Methods of Excision

• Type of skin

• Location

• Tension of closure

• Direction of wound

• Systemic issues

• Timeliness & Eversion

• TECHNIQUE!

Closure by Primary Intention

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Suture choice and technique

• Simple interrupted

• Vertical/Horizontal mattress

• Subcuticular

• Running

• Use of other closure products

Delayed Primary Closure

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Closure by Skin Grafting

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• Grafts are classically defined as tissue that is completely removed

from the body and devascularized prior to reimplantation

• They derive their nutrients from recipient bed which they are

implanted in and thus depend on the adequate vascularity of those underlying structures

Skin Grafts

• Skin grafts consist of all of the epidermis and some or all of the dermis

• Classically they are divided into split-

thickness and full-thickness skin grafts

• Split thickness skin grafts can vary in their depth of dermal removal and therefore can be adapted to specialty situations

Skin Grafts

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• Split thickness skin grafts are

harvested leaving a portion of the original dermis at the donor site intact

• The advantages of this method are

that the donor site will regenerate epidermis fairly rapidly depending on

the depth of the graft

• However, the dermis does not completely regenerate and this limits

multiple harvesting of the same site

Split Thickness Skin Graft

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• Full thickness skin grafts require complete removal of the dermis and epidermis and

transplantation to another area of the body

• The donor site must be closed or use STSG over the donor site, as no epidermal

regeneration can occur

• Full thickness grafts contract more primarily

versus split thickness grafts that contract

secondarily

Full Thickness Skin Graft

• FTSG will typically provide better skin match and

concealment than STSG

• Both the donor and the graft site exhibit aesthetic changes when harvesting split grafts

versus direct closure possibility with full thickness grafts

• If the grafts are meshed, there can be a

“cobblestoning” appearance to the healed wound in many cases

Aesthetic Differences

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• Facial FTSG are typically harvested from the upper eyelid, pre- and postauricular regions, and the supraclavicular fossa

• Thick skin may be harvested from the hypothenar eminence, Antecubital fossa and pigmented skin from the genital areas.

• Split-thickness skin grafts may be harvested from any surface of the body, but should be easily concealed in clothing. Common sites include the upper anterior and lateral thigh.

Common Donor Sites

Flap Coverage

Flap Coverage

• When simple skin grafts will not suffice and more tissue is required as in pressure ulcers, local flaps can be employed.

• In some cases a flap may be the only option for coverage, no matter how difficult it may be.

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Tissue Expansion

• Can really run in any shape.

• Most common are round and rectangular

• Size

• Most run 100ml-1000ml

• Can be custom

• Integrated ports versus connected by tubing

Types of Expanders

• When a constant mechanical stress (the

expander) is applied to skin over time, mechanical and biological creep occur

• Growth of the tissue by cell proliferation restores resting tension of the stretched tissue to baseline

• The Epidermis gets thicker with concurrent thinning of the dermis and alignment of

collagen fibril

How does it work?

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• Anyone who would benefit from a

local tissue flap that doesn’t have

enough tissue now to support a flap

• Can cooperate with the regimen

• Doesn’t have a lot of co-morbitities

• Non-smokers (Ideally)

Who is a candidate?

• Most commonly placed:

• Scalp

• Forehead

• Face

• Neck

• Breasts

• Trunk

• Extremities

Where can you put them?

• Site specific

• Infection

• Implant exposure

• Flap Ischemia

• Radiation

• Contracture

Complications

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Local Tissue Flaps

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Doug whipperman

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SCC

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Distant/Tunneled flaps

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Free Tissue Transfer

• Free flaps are physically detached from their native blood supply and then reattached to

vessels at the recipient site.

• This anastomosis typically is performed using a microscope, thus is known as a microsurgical

anastomosis.

• Types can include:

• Functioning free muscle transfer

• Structural transfers

• Specific tissue transfers

Free Tissue Transfer

• Lower third of leg reconstruction

• Massive soft tissue injuries

• Head and neck issues

• Open tendon/bone issues

• Cancer reconstruction

Who is a Candidate?

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Who is a Candidate?

BONE!!!

• Tensor Fascia Lata

• Gracillis

• Gluteus Maximus

• Sartorius

• Latissimus Dorsi

• Transverse Rectus Abdominis

• Radial forearm

• Etc…etc….etc….

Common Donor Sites

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8 months later!!!

Theo rondeau??

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• Partial/full flap ischemia

• Infection

• Certain patient population

• Specific site complications

Complications with flaps

• As complexity of the wounds increases, so

does the method of repair

• Always remember the number one rule of

medicine

• In order for wounds to heal you must

eliminate the offending process, remove infection/necrotic tissue, optimize nutrition and energy to the wound

Conclusions

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• Minas T Chrysopoulo, Jorge I de la Torre, Tissue Flap

Classification. Medscape. Article 1284474

• Cunha MS, Et Al. Rev Hosp Clin Fac Med Sao Paulo. 2002 May-Jun;57(3):93-7. Tissue expander complications in

plastic surgery: a 10-year experience.

• Goodwin SJ, Et Al. Ann Plast Surg. 2005 Jul;55(1):16-19;

discussion 19-20.Complications in smokers after

postmastectomy tissue expander/implant breast reconstruction..

• Huang X. Et Al. Plast Reconstr Surg. 2011 Sep;128(3):787-

97. doi: 10.1097/PRS.0b013e3182221372. Risk factors for

complications of tissue expansion: a 20-year systematic

review and meta-analysis.

• Thorne, C. Grabb & Smith’s Plastic Surgery. 6th ed.

Lippincott williams. 2007. Chapter 1 & 5

• Levin LS. The Reconstructive Ladder, An Orthoplastic

Approach. Orthop Clin North Am. 1993; 24:393

• Chapman, M. Chapman’s Orthopedic Surgery. 3rd ed.

Chapter 35. “Free Tissue Transfer”

References