Reconstructive Stages as an Alternative to the Reconstructive Ladder

Abstract

Sir: Various paradigms have been offered to describe the increasingly sophisticated methods of wound closure. The most established is, of course, the reconstructive ladder. From the bottom rung, the simplest way to deal with a wound is direct closure, next is skin grafting, then local flaps, followed by regional flaps, and, at the top, free flaps. The reconstructive ladder is believed to have originated from the ancient Egyptians. The Healing Hand mentions a crude wound closure ladder in the Smith papyrus, humanity’s oldest medical text.1 It advises that simple wounds should be closed with suture, other wounds repaired using gum adhesive strips, while infected wounds should be first treated with topicals (honey and grease usually). The reconstructive ladder implies that the simplest technique should be explored before progressing up the rungs, and that should be done only when required. It has been dismissed by the champions of the second paradigm, the reconstructive elevator. The “floors” are equivalent to the rungs of the ladder, but with an elevator we can jump several floors and go straight to the floor/technique desired. The best option is adopted immediately to optimize form and function.2 For example, a defect over the ankle joint may require a flap as opposed to skin grafting, as this provides better coverage. The third paradigm, proposed by Mathes and Nahai, is the reconstructive triangle, the corners of which represent flaps, microsurgery, and tissue expansion.3 Although it gave the latter two techniques the deserved recognition, this concept feels rather “flat,” as it does not convey the idea of increasing complexity as that suggested by the ladder and the elevator. We propose a new paradigm, the reconstructive stages (Fig. 1). Instead of rungs or floors, we equate surgical techniques to stages. A baby crawls first, and then stands. As the baby’s confidence increases, he or she walks and then, ultimately, runs. This is akin to the training of the plastic surgeon. He or she first learns direct closure (crawl), and then skin grafting (stand), and then local flaps (walk), and then regional and distant flaps (run), and finally free flaps (sprint). The next stage can only be attempted after the preceding one has been completed often enough so that one does not wobble and fall.Fig. 1.: The reconstructive stages.Unlike the ladder or elevator, the reconstructive stages reflect the skill and effort required as the more difficult technique is adopted. It conveys the dynamicism of surgical training and the sense of “maturing” as each stage is mastered. As a baby needs support and encouragement to walk, a junior plastic surgeon, too, needs the teaching and support by his or her seniors to progress. Once we can run, we learn precisely when we have to or when walking or standing will suffice, as each situation calls for a different action (we know this from everyday life). Admittedly, there will be the occasional stumble or fall, but as long as we get up and brush ourselves off, we learn caution. These metaphors may seem simplistic, but they reflect plastic surgical training. Hence, the reconstructive stages should be considered as an alternative to the other three reconstructive paradigms. Corrine J. Wong, M.R.C.S. Colchester General Hospital Colchester, Essex, United Kingdom Niri Niranjan, F.R.C.S.(Plast.) St. Andrew’s Center for Burns and Plastics Broomfield Hospital Chelmsford, Essex, United Kingdom