The Reconstructive Clockwork of the Twenty-First Century: An Extension of the Concept of the Reconstructive Ladder and Reconstructive Elevator

Abstract

Sir: The conventional reconstructive ladder addressing tissue defects begins with primary and secondary closure of wounds followed by autologous skin grafting, regional and local pedicled flaps, tissue expansion, and free tissue transfer.1 Conceptionally different, the reconstructive elevator allows one to ascend directly to the chosen level of reconstructive complexity.2 Another Plastic and Reconstructive Surgery commentary is entitled, “Why Climb a Ladder When You Can Take the Elevator?”3 Despite enormous achievements and refinements in the aforementioned reconstructive techniques, clinical situations and problems occur beyond the scope of these conventional reconstructive measures. As such, composite tissue allotransplantation of partial faces (unilateral or bilateral) has been introduced as a juvenile part of transplantation medicine with encouraging early and midterm clinical results.4 However, short- and long-term problems such as potential tumor induction by immunosuppression and chronic rejection are to be considered. Given the fact that patients undergoing composite tissue allotransplantation have undergone various reconstructive procedures before, the patients often gain tremendous improvement in quality of life. A further evolving field is robotics, such as the da Vinci Surgical System for surgeons and the Penelope assistant robot, which found their way into the clinical operating room. Although even microsurgical anastomosis has been performed using the da Vinci system, the total amount of time and resources spent is beyond being practical today. Regeneration and tissue engineering are of distinct and genuine interest in reconstructive surgery. Adipose-derived stem cell transfer is able not only to improve contour but also to improve overlying skin,5 with potential widespread future application in reconstructive surgery. Comprehensive care is usually achieved best using a team approach. A given reconstructive problem is reasonably addressed by a combination of various reconstructive techniques if one alone is not able to do so. Having said that the combination of reconstructive procedures is feasible and clinically relevant, the aforementioned evolving fields of composite tissue allotransplantation, robotics, and regeneration/tissue engineering will be and sometimes are already integral parts of daily reconstructive procedures. Although the above-mentioned metaphors of the reconstructive ladder and the reconstructive elevator do not allow one to intuitively combine various reconstructive measures from different echelons, we would like to propose a novel thought on this issue. We consider these novel techniques—composite tissue allotransplantation, robotics, and regeneration/tissue engineering—as potential future integral parts of a reconstructive sequence that is not necessarily consecutive but simultaneous (Fig. 1). Given the integral nature of the procedures, we would propose the term “reconstructive clockwork” for reconstructive surgery of the twenty-first century. The idea of the reconstructive clockwork is to mirror the integral parts of various reconstructive echelons serving the one goal of addressing the defect, the function, the deformity, or all of them in combination. The reconstructive clockwork metaphor bears the precision of microsurgical procedures and complexity of reconstructive approaches in a natural fashion.Fig. 1.: A reconstructive clockwork as a refinement of the conventional reconstructive ladder. CTA, composite tissue allotransplantation.DISCLOSURE The authors have no financial interest to disclose. Karsten Knobloch, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Hannover Medical School Hannover, Germany