Reconstructive Ladder Research Articles

English

INTRODUCTION: Reconstruction of lower 3rd of extremity poses great challenge to reconstructive surgeon. Free flap coverage brings a striking difference in lower limb salvage. Lower extremity defects can be managed by direct closure, skin grafting, local flaps, cross leg flap and free flap. The versatility of free flaps in covering a defect of any size irrespective of their locality keeps them in the top rung of the reconstructive ladder. MATERIALS AND METHODS: We present a retrospective study of 12 patients who underwent free flap reconstruction for lower extremity defects between august 2012 to June 2014. Different flaps were chosen based on the size and location of the defect. Radial forearm flap was done in 6 patients, anterolateral thigh flap in 4, latissimus dorsi flap in 1 and free fibula flap in 1 patient with a success rate of 91.6%. CONCLUSION: Free flap is the most cost effective and stable solution for lower extremity reconstruction. It is the best solution to manage large defects. They play a major role in limb salvage. In spite of the steep learning curve, practicing micro surgical principles can save a limb and influence the life of the person in a positive way.

Free tissue transfer for head and neck reconstruction: a contemporary review.

Microvascular free tissue transfer is used for complex composite tissue defects in previously treated fields, in particular after treatment of malignant disease. The increasing incidence of skin cancer in the general population has increased the number of patients with massive tumors that require the expertise of the free flap reconstructive surgeon. We herein examine a number of the recent advances in the field that use free tissue transfer for orbitomaxillary and scalp reconstruction, including maxillary reconstruction, virtual surgical planning in head and neck reconstruction, and scalp reconstruction. Advanced computer algorithms allow planning of these procedures at a savings of time and cost. Free tissue transfer is a reconstructive modality that is often at the top of the reconstructive ladder and, in some instances, is the reconstructive method of choice. The ability to harvest composite tissue that matches the tissue defect in composition, surface area, and volume makes free tissue transfer a versatile modality.

Application of the Orthoplastic Reconstructive Ladder to Preserve Lower Extremity Amputation Length

A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

Basic flap design.

Basic flap design utilization for reconstruction of head and neck defects requires creativity from the surgeon. Ultimately, the surgeon must closely restore the basic functions and properties of the surgical flap and adjacent tissue. All options within the reconstructive ladder should be considered. When possible, like should be replaced with like (similar tissue) within an esthetic zone. When considering a flap design, the surgeon must remember that the donor site must be closed in an esthetic and functional manner. Finally, knowledge of normal anatomy, the extent of the defect, and the patient is vital for successful outcomes.

Achievements in scalp reconstruction

Reconstruction of scalp defects remains a challenge. This article reviews the reconstructive options and provides recommendations for scalp restoration based on current literature. It is difficult to apply the standard reconstructive ladder to scalp defects due to the scalp's unique properties and paucity of adjacent tissue. Because of the frequency of large resections and the limited local tissue options microvascular free tissue transfer is a mainstay in scalp reconstruction and has been shown to be well tolerated and reliable with acceptable cosmetic and functional results. With advances in both surgery and anesthesia, increasing numbers of patients are candidates for free tissue transfer. The latissimus dorsi flap is a fundamental flap in scalp reconstruction. Recently, use of the anterolateral thigh (ALT) flap has risen. The radial forearm (RFF) free flap is also an extremely reliable, thin flap with great pedicle length well suited for the restoration of scalp contouring. Microvascular free tissue transfer provides well tolerated, reliable, functional and cosmetically pleasing scalp restoration in a single surgery. The latissimus dorsi flap, ALT flap and RFF are the three most utilized free tissue options.

Unilateral one stage nasolabial flap for reconstruction of the lips.

Nasolabial flap (NLF) is one of the oldest described soft tissue flaps. Despite the great advances in maxillofacial reconstruction it still has a stable location in the reconstructive ladder of the face and oral cavity. Reconstruction of the lips, which are important structures that connect the oral cavity to the facial skin, with this flap is the interest of the surgeons. Experience of the authors for reconstruction of the upper lip philtrum, correction of lower lip contracture and subtotal reconstruction of the lower lip with emphasis on simultaneous correction of the red lip (volume and color) is explained in five cases. Satisfactory functional and aesthetic results were obtained. Iatrogenic epidermoid cyst occurred in one patient. One stage reconstruction of lateral lower lip defects with/without commissural involvement in full or partial thickness defects is possible by NLF. Supplementary flaps are needed when the vermilion needs simultaneous reconstruction.

A Local Flap That Never Disappoints

There are lots of ways to close a defect according to the reconstruction ladder. In this article, we would like to share our experience with V-Y rotation advancement flap on different parts of the body. Between 2006 and 2009, we performed V-Y rotation advancement flap on 68 patients (average age, 50 years). We performed this flap for decubitus and neuropathic ulcer on 33 patients, for defect reconstruction after tumor removal on 29 patients, and for trauma on 6 patients. The sizes of the defects ranged between 2 × 2 and 26 × 16 cm. All flaps survived without any major complications. Patients were satisfied with their scar appearance, and no sensory impairment was seen. V-Y rotation advancement flap restores the defect with a perfect color match and leaves an aesthetically acceptable scar. With its surgical flexibility and durability, this flap disappoints neither the surgeon nor the patient.

Evaluation of a Facial Transplant Candidate with a Facegram

Sir: Facial transplantation has emerged as the next step on the reconstructive ladder for severe facial disfigurement, but functional recovery and return of facial sensation and motion will vary, be difficult to predict, and may take months or years.1,2 Motor recovery following composite tissue allotransplantation has been reported to be slower and often less optimal when compared with the sensory recovery outcomes.3–5 The facial appearance of the recipient improves gradually along with nerve regrowth, with changes in expression and the appearance of nasolabial folds. A kinematic preoperative evaluation may be important for further analysis of the results. A 22-year-old man with severe sequelae of thermal burns (55 percent total burn surface area), a candidate for facial transplantation, was analyzed with a novel quantitative method: facegram (Fig. 1).Fig 1: Male patient, 22 years old, with severe sequelae of thermal burns (55 percent total burn surface area).In order to reliably capture the dynamics of the smile movements, we developed specialized software capable of simultaneously tracking the position over time of a number of anatomical points (commissures, midpoints, and Cupid’s bow), using video recordings of the subject. The programing environment MATLAB (R2011a; MathWorks, Natick, Mass.) was used for computing the facegrams. The software provides a graphic user interface (GUI) to assist the user in different tasks, such as drawing a line setting the face’s vertical axis of symmetry or pointing and clicking on the colored dots marking the anatomical landmarks. The main element is the plot, in scale, of the paths followed by each anatomical landmark, as shown in Figure, Supplemental Digital Content 1,https://links.lww.com/PRS/A823. In every pathway, six points mark important times: T1, start of recording; T2, start of contraction; T3, end of contraction; T4, start of relaxation; T5, end of relaxation; and T6, end of recording; as shown in Figure, Supplemental Digital Content 2, https://links.lww.com/PRS/A824. The complete facegram includes four additional elements: the absolute horizontal (and vertical) displacements and the differential horizontal (and vertical) displacements of each landmark as a function of time. Facegram analysis in this patient revealed symmetry/balance and temporal consistency, despite the reduction in range of motion over time (Fig. 2). The hold period is not properly maintained (there is a progressive loss of extension). Vertical movement appears to be superior in relation to horizontal movement. The extension of the commissures is clearly superior to that of the midpoints or Cupid’s bow, which may be explained by cicatricial retraction of the central part of the patient’s lips.Fig 2: Facegram analysis shows symmetry/balance and temporal consistency. The hold period is not properly maintained (there is a progressive loss of extension). The extension of the commissures is clearly superior to that of the midpoints or Cupid’s bow.Muscles would regain motion through the facial nerve, and if this nerve was being dissected proximally to include all branches, regeneration would take a long time to enable muscular activity within the graft. Mobile facial expression also depends on the depth of scarring before the operation. There are then two possibilities: (1) the patient has a deformity so obvious that any degree of functional recovery after transplantation means a significant gain on facial expression, or (2) as in this patient, despite scarring caused by burns, it will be difficult to recover motor function that will achieve the same degree of muscle contraction. In this case, the facegram can provide a baseline pattern, which will be important to accompany functional recovery. PATIENT CONSENT The patient provided written consent for the use of his image. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Keynote Address VI: The evolution and limitations of current approaches to autologous reconstruction of the head and neck: A personal perspective and a look forward

The goal of all reconstruction is the restoration to normal form and function. Nowhere is this more difficult than in the head and neck especially after major extirpative procedures. There is a lack of ‘like tissues’ available locally, and usually autologous tissue needs to be transported from a distance to achieve wound closure. However the initial outcome often falls well short of the stated goal of ‘restoration to normal form and function’. The reconstructive process commences with an accurate diagnosis of the deformity and appraisal of the missing part(s). The surgeon then needs to be familiar with the full spectrum of reconstructive options and select the method of reconstruction that will give the best outcome. This takes meticulous technique and planning, and the optimal strategy may involve multiple modalities of treatment and/or multiple staged procedures. One must take special care not to burn bridges and compromise the final result. The options available to the reconstructive surgeon have increased greatly over the last 30 years. With the larger number of flaps available, there is now an expansive choice, and the emphasis has shifted to better flap selection and refinements. The focus of the presentation will be to describe the current techniques available to reconstruct facial contour deformities, facial resurfacing after burn injury and tumor extirpation, and in complex defects, the use of folded flaps, multifaceted and laminated flaps, prelaminated and prefabricated flaps. However we still a need to distinguish between “Restoration” (which can only be achieved with reattachment of severed parts) and “Reconstruction”, which unfortunately will always be well short of the restorative result if the lost part could have been replanted – this is despite the utilization of every rung of the reconstructive ladder and multiple stages to obtain a maximum aesthetic result. Furthermore, as we are about to enter a new era of composite tissue transplantation, this presentation will also critique and contrast the aesthetic and functional results that are achievable in the head and neck utilizing the full spectrum of reconstructive options and compare these with what has been achieved in the few partial and full facial transplantation cases that have been performed to date.

Scrotal reconstruction: a review and a proposed algorithm

Scrotal reconstruction is a difficult problem following infection, trauma or tumour resection. The focus of classic reconstructive options remains occlusive and aesthetic with little regard for testicular function. The important factors in choosing the right reconstructive option for our patients are age, testicular functional requirements and best aesthetic outcome. We reviewed contemporary options available for reconstruction of the scrotum and their effects on testicular function in an effort to provide an algorithm for scrotal reconstruction. We performed an extensive online search using OVID SP, OVID, Medline, PubMed, CINAHL Plus and Cochrane Library database using keywords “scrotal, scrotum and reconstruction”. The introduction of axial pattern analysis of flaps has led to a flourish of innovative and novel coverage techniques to achieve aesthetic and gross reproductive function. With the emergence of new technology, however, spermatogenesis has moved to the forefront of the field, and a new paradigm shift in reconstruction needs to follow. New studies have re-orientated best practice to include this in the reconstructive ladder, and here, we provide a useful algorithm for scrotal reconstitution that will help reconstructive surgeons in choosing the right option for their patients.

Microsurgery : From Basic Skill of Plastic Surgery to The Top of Reconstruction Ladder


 
 
 
 For more than 5 decades, microvascular surgery has been growing and found its place in reconstructive surgery. In Indonesia, microsurgery became popular since 30 years ago. In the past, this subspecialty was developed for soft tissue transfer and replantation of amputated extremities.
 
 
 

Facial reconstruction after resection for cutaneous malignancies

The reconstruction of facial defects after the resection of cutaneous malignant lesions is challenging. Knowledge of several key principles, such as that of facial subunits and of the reconstructive ladder, is paramount to achieving functionally and aesthetically pleasing surgical outcomes. Various reconstructive modalities, from local flap closure to free tissue transfer, are available to the practicing surgeon depending on the defect requiring reconstruction. In this article we describe several of the most commonly used local and regional flaps in facial reconstruction as well as some of the special challenges faced when reconstructing areas such as the eyelid, the lips, the nose, and the ear.

A Clinical Study Comparing Helicoll with Scarlet Red and OpSite in the Treatment of Split Thickness Skin Graft Donor Sites-A Randomized Controlled Trial.

Split thickness skin graft (STSG) is a key method in the reconstructive ladder for covering skin defects used widely by surgeons from all specialties. The donor site is often a source of delayed healing, associated with considerable pain and discomfort even more than the recipient wound. The aim of this prospective randomized controlled study was to compare Helicoll® (EnColl Corp., Fremont, CA, USA), a type I pure collagen dressing, to OpSite® (Smith & Nephew, USA) dressing and to Scarlet Red® (Kendall HealthCare, USA) dressing in the treatment of standardized STSG donor sites. Thirty patients, over a 3-month period, underwent various reconstructive procedures, necessitating the use of STSGs. Following a simple randomized clinical protocol, the analysis of data included donor site pain, healing time of the donor site, initial absorption of the applied dressing and rate of infection with the three different dressings to form the basis of this paper. Patients in the Helicoll group reported significantly less pain, less infection rate and required no dressing change when compared with the OpSite (Johnson & Johnson, Langhorne, PA, USA) or the Scarlet Red groups. Healing time of the donor site in the Helicoll group was shorter than that in the Scarlet Red group; however, it was comparable to the OpSite group. This study indicates that Helicoll, as a donor site dressing, is successful in providing pain-free mobility with a measurable healing rate.

(iii) Soft-tissue reconstruction in open tibial fractures

Abstract Open long bone fractures are surgically challenging limb-threatening injuries. There are a variety of techniques to close a soft-tissue defect ranging from the occasionally used primary closure, through local skin and muscle flaps based on perforating vessels from axial named arteries to micro-vascular free-tissue transfer. While now an historical concept, the ‘Reconstructive Ladder’ is still relevant today. Angiography is of paramount importance and should be undertaken as a matter of routine when free-tissue transfer is considered.

The reconstructive microsurgery ladder in orthopaedics

Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.

Limb salvage surgery

The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.

Evolution and Limitations of Conventional Autologous Reconstruction of the Head and Neck

Conventional reconstruction in the head and neck has undergone a revolution as microsurgery has evolved and expanded our ability to reconstruct the most difficult defects. Vascularized composite allotransplantation (VCA) has provided a new paradigm of options to restore in 1 stage what in the past has been performed in multiple stages with multiple combinations of free flaps and local flap options. This review demonstrates an evolving perspective of head and neck reconstructive surgery incorporating the indications and advantages gained over a career that has developed in parallel with microsurgery, prefabrication, prelamination, and face transplant. All current conventional reconstructions for the most severe defects often involve multistage procedures, using every rung of the reconstructive ladder, and the end results can still be lacking despite our best efforts. Despite all the tailoring and planning of these multiple flap and multiple-stage reconstructions, in our experience, these interventions never quite exactly recapitulate the face and fall short of full restoration. The early experience with VCA has been very promising and yields results that are superior to those achieved using conventional methods of reconstruction. However, it will be synergistic efforts in both VCA and conventional reconstruction to take us to the next level of full face restoration.

Anterior urethral stricture review.

Male anterior urethral stricture disease is a commonly encountered condition that presents to many urologists. According to a National Practice Survey of Board Certified Urologist in the United States most urologists treat on average 6-20 urethral strictures yearly. Many of those same urologists surveyed treat with repeated dilation or internal urethrotomy, despite continual recurrence of the urethral stricture. In point of fact, the urethroplasty despite its high success rate, is underutilized by many practicing urologists. Roughly half of practicing urologist do not perform urethroplasty in the United States. Clearly, the reconstructive ladder for urethral stricture management that was previously described in the literature may no longer apply in the modern era. The following article reviews the etiology, diagnosis, management and comparisons of treatment options for anterior urethral strictures.

The role of dermal regeneration template “Integra®” in reconstructive skin cancer surgery

Dermal regeneration templates (DRT) use, like “Integra®”, has spread over the past years since its introduction a few decades ago beyond its initial role in burn reconstruction. There is now evidence that it can be used as a biological template in post-cancer excision surgery as a method of reconstructing challenging defects We identified the patients that have undergone reconstruction following cutaneous cancer surgery within our institute by reviewing our records. The case notes of the patients were retrieved and the information extracted from the case notes. This is a retrospective analysis of the case studies. Over the time period of the study, we performed reconstruction using DRT on five individual cases. All the patients did not have any significant post operative complications and the reconstruction seemed durable and reliable. We discuss its benefits as part of the reconstructive ladder post cancer resection reconstructive surgery. DRT can now play a role in post cancer excision reconstruction in selected patient groups, especially the elderly or in those in which flap reconstruction options have been exhausted or deemed unsuitable. Level of Evidence: Level V, therapeutic study.

Closure of tracheoesophageal fistula with two‐layer tracheal‐esophagoplasty and tracheal advancement

Closure of tracheoesophageal fistula with two‐layer tracheal‐esophagoplasty and tracheal advancement