The Reconstructive ladder of soft tissues

The reconstructive ladder of soft-tissue coverage begins with consideration of the simplest approach (healing by secondary intention) and culminates with the most complex (free tissue transfer)

1.Healing by secondary intention is the simplest approach but is not always feasible. Absolute contraindications include exposed vessels, nerves, tendons, viscera, or bone. Relative contraindications include a large or poorly vascularized wound with a prolonged (>3 weeks) anticipated period of healing and undesirable aesthetic consequences.

2.Primary Closure may provide the most aesthetically pleasing result, but excessive tension on the skin may cause displacement of neighboring structures (e.g., lower eyelid) or necrosis of the skin flaps.

3.Skin grafting is the most common method of large-wound closure. Skin grafts require a healthy, uninfected bed, protected from shear forces, to survive. Wound surfaces such as bare tendon, dessicated bone or cartilage, or infected tissue beds will not support skin graft survival. In addition, exposed vessels, nerves, or viscera are relative contraindications for skin grafting.

4.Local tissue transfers of skin, fascia, and muscle may be used in regions with healthy adjacent tissue. If the adjacent tissue cannot be adequately mobilized or the wound requires more bulk than is locally available, the sole use of local flaps may not be adequate.

5.Distant tissue transfers were the mainstay of difficult wound closure until the advent of free tissue transfer in the 1970s. This involves transferring healthy tissue into the wound bed while leaving it attached to its native blood supply. The pedicle is divided in a subsequent procedure. Inherent disadvantages of this technique include multiple operations, prolonged wound healing, immobilization for at least 3 weeks, and a limited choice of donor sites.

6.Free tissue transfer is the most technically demanding approach to wound closure but has several potential advantages, including single-stage wound closure, a relatively wide variety of flaps to ensure closure specifically tailored to coverage needs, and, in many cases, an aesthetically pleasing outcome.

7.Vacuum-assisted closure has altered wound management by decreasing bacterial load and accelerating granulation. Wounds may be treated adequately with vacuum-assisted closure that would not traditionally be candidates for healing by secondary intention. Furthermore, it may convert a wound that would otherwise need adjacent or free tissue transfer into a wound that needs only split-thickness skin grafting.

Source:Washington manual of Surgery

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