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Series 1: The Skin · Episode 11, not yet released

Skin Grafts Part Two

The Reconstructive Ladder

20 minutes. 14 references, each checked at source.

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The reconstructive ladder is not a ladder you are obliged to climb, and the two surgeons usually credited with saying so did not say quite what people think they said. Gottlieb and Krieger's 1994 "reconstructive elevator" editorial kept the hierarchy of increasing complexity. What they rejected was the obligation to ascend through it.

Episode 11 of The Anatomy Purist, Series One: The Skin. Dev covers the ladder, where it came from, why it has no single founding paper, and how Janis, Kwon and Attinger modernised it in 2011. The two frameworks nobody teaches: Mathes and Nahai's reconstructive triangle, and Erba's 2010 reconstructive matrix, which is the only one of the four that puts the patient's physiological reserve on an axis of its own. Where grafts fit and where they do not, and why the recipient bed, not the difficulty of the operation, is the true transition point from graft to flap. Local, regional and free flap principles, with the Mathes and Nahai five muscle types and the Cormack and Lamberty four fasciocutaneous types. And the irradiated field: Marx's three H's, why Delanian and Lefaix's fibroatrophic model now competes with it, and why hyperbaric oxygen keeps faili

Themes from this episode

Practice what you just heard

Two questions on the themes of this episode, free, marked as you go. Then one from the Vault on the same ground.

Question 1 · Applied

A surgeon reconstructs a facial defect with skin from the supraclavicular fossa rather than the groin. Which principle is being applied?

Answer to see the explanation and the source.

Question 2 · Foundation

Which of the following lists the rungs of the reconstructive ladder in the correct order, from simplest to most complex?

Answer to see the explanation and the source.

From the Vault, on the same theme

Synoptic: The Operating Theatre Across Regions · Purist Locked

Of the bones offered for free-flap reconstruction of the mandible, the fibula alone is routinely cut on the table into three or four pieces and folded into the arc of a new jaw, with every piece surviving on the one pedicle. What property of the fibula permits this?

  • AIts nutrient artery enters midshaft and runs the length of the medullary canal in both directions
  • BIts cortex is dense enough for the segments to survive as free grafts until union revascularises them
  • CThe peroneal artery reconstitutes across each osteotomy through the interosseous membrane
  • DEach segment carries a musculocutaneous perforator that keeps its own skin island alive
  • EIts shaft draws a segmental periosteal supply from the peroneal artery along its whole length

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References

  1. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator [editorial]. Plast Reconstr Surg. 1994;93(7):1503-4. PMID: 7661898.
  2. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011;127 Suppl 1:205S-212S. PMID: 21200292.
  3. Erba P, Ogawa R, Vyas R, Orgill DP. The reconstructive matrix: a new paradigm in reconstructive plastic surgery. Plast Reconstr Surg. 2010;126(2):492-8. PMID: 20375761.
  4. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-87. PMID: 7465666.
  5. Cormack GC, Lamberty BGH. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg. 1984;37(1):80-7. PMID: 6692066.
  6. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-41. PMID: 3567445.
  7. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41(5):283-8. PMID: 6572704.
  8. Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol. 2004;73(2):119-31. PMID: 15542158.
  9. Dormand EL, Banwell PE, Goodacre TEE. Radiotherapy and wound healing. Int Wound J. 2005;2(2):112-27. PMID: 16722862.
  10. Brown JS, Magennis P, Rogers SN, Cawood JI, Howell R, Vaughan ED. Trends in head and neck microvascular reconstructive surgery in Liverpool (1992-2001). Br J Oral Maxillofac Surg. 2006 Oct;44(5):364-70. Epub 2005 Sep 19. PMID: 16169640.
  11. Mathes SJ, Nahai F. Clinical Applications for Muscle and Musculocutaneous Flaps. St Louis: Mosby; 1982.
  12. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy and Technique. New York: Churchill Livingstone; 1997. (The Reconstructive Triangle, pp. 9, 36.)
  13. McCarthy JG, ed. Plastic Surgery. Vol. 1. Philadelphia: WB Saunders; 1990.
  14. Standring S, ed. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. Elsevier; 2020.
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