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Grafts and Local Flaps in Head and Neck Cancer
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
The reconstructive ladder is an important concept in reconstructive surgery. It begins with the simplest option first, which is to allow the wound to heal by secondary intention. As one advances up the rungs of the ladder, more complex reconstructive techniques are encountered, up to the highest rung, which is microvascular free-tissue transfer. When analyzing a defect to be reconstructed, the reconstructive surgeon would start at the bottom rung and work his way up, deciding which reconstructive method should be undertaken. There are some instances, however, where the ‘reconstructive elevator’ should be taken instead and some of the rungs in the reconstructive ladder can and should be skipped. An example of this would be in the reconstruction of a significant defect in the neck following primary tumour excision with exposure of the great vessels. In this case, although a skin graft could theoretically be used and probably would ‘take’, the risk of exposed vessels would warrant the use of a pedicled or free flap for reconstruction. An example is shown in Figure 91.1.
Local advancement flaps
Published in P Ronan O’Connell, Robert D Madoff, Stanley M Goldberg, Michael J Solomon, Norman S Williams, Operative Surgery of the Colon, Rectum and Anus Operative Surgery of the Colon, Rectum and Anus, 2015
One must first consider ’the reconstructive ladder’ which has as its first rung primary closure and next has skin grafting, with complex microvascular flaps at the highest rung. Between these options lie local, regional, and distant flaps (Figure 7.3.1).
Intraoperative Surgical Techniques and Pearls
Published in Alexander Berlin, Mohs and Cutaneous Surgery, 2014
Layered Closure If surgical reconstruction is determined to be most beneficial, the next step is careful selection of the appropriate repair. The first consideration on the reconstructive ladder is layered closure. Primary closure is the most common type of reconstruction following Mohs surgery, with approximately half of surgical defects repaired in this manner.18 It is worth repeating that the simplest approach often confers significant advantage on both the patient and the reconstructive surgeon.
Strategies for extremity reconstruction with exposed bones and tendons using acellular dermal matrices: concept of sequential vascularization
Published in Case Reports in Plastic Surgery and Hand Surgery, 2022
Successful take of skin grafts requires a well vascularized wound bed and remains a challenge for plastic surgeons particularly when performed over poorly vascularized structures, such as exposed bones and tendons. Using the guiding principles of the reconstructive ladder, trauma and plastic surgeons have different options to choose from when facing wound reconstruction [1]. Local and regional flaps cover bony surfaces and tendons, but are limited by the size of the defect [2]. Pedicled and free flaps allow coverage of large tissue defects, but are associated with substantial donor-site morbidity [3]. Advanced technologies, such as dermal matrices, are now integral part of the reconstruction ladder/elevator, adding new opportunities for vascular ingrowth and subsequent graft take [4].
Free latissimus dorsi flap for upper extremity reconstruction in a 9-month-old
Published in Case Reports in Plastic Surgery and Hand Surgery, 2021
Ryan D. Wagner, Jacqueline S. Yang, Brittany E. Bryant, William C. Pederson, Shayan A. Izaddoost
Free tissue transfer can be one of the most powerful reconstructive procedures and occupies the top rung on the reconstructive ladder. Free tissue transfer in the pediatric population is now routinely performed at many institutions for a wide range of indications. With advances in technology and microsurgical technique, success rates are comparable to the adult population [1–3]. However, there is far less literature on free tissue transfer in infants along with a variety of complicating factors. In addition to greater technical difficulty, lower functional reserve, and a challenging postoperative recovery process, there is the added consideration of operative time and long-term neurological consequences of exposure to general anesthetics in infants. Free flaps can be one of the lengthiest reconstructive surgeries with the potential for additional surgeries for emergent takeback during the initial postoperative period [4].
Surgical management of severe facial trauma after dog bite: A case report
Published in Acta Oto-Laryngologica Case Reports, 2020
Bernhard Prem, David Tianxiang Liu, Bernhard Parschalk, Boban M. Erovic, Christian A. Mueller
The reconstructive ladder indicates the best means of treatment for each individual case [8]. PC of the wound should always be considered first. Previous reports describe PC leading to good outcomes in treating similar injuries [9,10]. Time is an important aspect, with guidelines and evidence indicating that surgery should be performed within 6–8 h after the bite [5,11]. Although prolonging this time limit is widely accepted and commonly leads to satisfactory results [4], a delayed surgical approach reportedly leads to more frequent structural and functional deformities [12], highlighting the individuality and unique treatment of each case. Fortunately, the surgery in this case was performed within 4.5 h after the attack. Regarding infection risk, studies show no significant difference between infection rates after PC or secondary intention [1]. The robust blood supply to the face enables PC without an increased infection rate [9,13]. The wound should be thoroughly cleansed and rinsed with povidone-iodine solution to lower the risk of infection [2,5].