There are three main goals of reconstructive plastic surgery. These goals are to promote healing, restore form and restore function.
Individuals may require reconstructive surgery for wounds sustained from any number of reasons such as trauma, prior surgery, tissue infection, burns, and cancers. For those requiring reconstructive surgery of a wound, a thorough wound assessment will assist in obtaining the ideal reconstruction.
A wound assessment considers the following characteristics of the wound:
-Location
-Size
-Depth
-Tissue components
-Etiology
Evaluation of the tissue components of the wound allows the surgeon to determine whether or not the wound will require coverage. Tissue that is vascular and durable generally does not require coverage. This may include muscle, dermis and subcutaneous tissue.
Tissue that dessicates (dries up), gets injured or gets infected requires coverage. Tissues requiring coverage include tendon, nerve, vessel, bone, and prosthesis.
Understanding the etiology of the wound may be important for preoperative, operative and postoperative intervention. Possible wound etiologies include:
-sharp
-crush
-tear
-chemical
-pressure
-temperature
-infection
-radiation
Once an assessment of the wound has been completed the method of reconstruction can be decided. Knowing that the overriding goals are to promote wound healing, restore form and restore function, a surgeon will consider the reconstructive options that best meet these goals while providing the best cosmetic result possible.
The available methods of reconstructive plastic surgery may be thought of as a hierarchy of options that range from least invasive to most invasive including:
-Healing by secondary intention
-Primary closure
-Skin grafts
-Local flaps
-Regional flaps
-Free flaps
This reconstructive ladder begins at the bottom with the least invasive method of reconstruction which is healing by secondary intention. This means that basic wound care is provided but the wound is left to heal on its own. It is not even sutured closed.
Wounds that require healing by secondary intention are:
-Infected wounds
-Superficial defects
-Wounds to large for primary closure (suturing the wound edges together)
A wound may be closed by primary closure if three end objectives will be met:
1. The sutures will bring the wound edges together without tension
2. Primary closure of the wound will not distort adjacent structures
3. Primary closure of the wound will not alter function
If a defect is too large for primary closure and closing the wound by secondary intention will leave to large of a scar then a skin graft is the next least invasive method of reconstruction. However, a skin graft is only a viable option if the wound bed is clean and vascular and located at an area that is immobile.
If a skin graft is not a viable option because it would not survive or would result in an unacceptable appearance, then the next least invasive option is a local flap. A local flap covers the wound with the tissue immediately adjacent to the wound. There are several techniques used in local flap closure. The technique used is the one that will create the best cosmetic results.
A local flap is not possible in some situations. The defect may be too large for a local flap, or the local skin is injured or infected and cannot be used. Perhaps the defect requires bulk, muscle, fascia or bone. In some cases the flap reconstruction needs a specific blood supply (called a pedicle).
If a local flap is not possible then a regional flap will be used. A regional flap uses pieces of tissue from the most appropriate area of the body and the tissue flap is then transferred to the wound with the blood supply (pedicle) still intact.
There are cases in which the regional flap vessels will not reach the wound or the regional flap tissue has already been used at a previous surgery or is itself injured. If a regional flap is not possible then a free flap will be used to reconstruct the wound. A free flap has been disconnected from its original blood supply and microvascular surgery is used to reconnect the flap of tissue to its new blood supply within the wound bed.
