Understanding reconstructive plastic surgery for wounds and burns
Tuesday, November 1st, 2011Individuals may require reconstructive plastic surgery for wounds sustained from any number of reasons such as trauma, prior surgery, tissue infection, burns, and cancers.
A wound bed composed of tissue that has a good blood supply and is durable generally does not require protective coverage using reconstructive surgery. These wound beds may include muscle, dermis and/or subcutaneous tissue.
However, wound beds containing tissue that dessicates (dries up), gets injured or gets infected does need to be covered by means of reconstructive plastic surgery. Tissues that require coverage include tendon, nerve, vessel, bone, and/or prosthesis.
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. This reconstructive ladder begins at the bottom with the least invasive method of reconstruction which is healing by secondary intention.
When healing by secondary intention, 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 wounds, and wounds to large for primary closure (suturing the wound edges together).
The next least invasive wound healing option in reconstructive plastic surgery is primary closure of the wound. Primary closure is done if:
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 wound 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.
The next least invasive plastic surgery option is called 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.
However, 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. A flap of tissue with a blood supply is called a pedicle.
A regional flap uses pieces of tissue from the most appropriate area of the body. The tissue flap is then transferred to the wound with the blood supply (pedicle) still intact. Unfortunately, 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, the most invasive reconstructive plastic surgery option, will be used to reconstruct the wound. A free flap of tissue has been disconnected from its original blood supply and microvascular surgery (sewing the new and old vessels together) is used to reconnect the flap of tissue to its new blood supply within the wound bed.