Basics Of Tissue Reconstruction

Tissue reconstruction is a broadly discussed topic under Reconstructive Surgery / Plastic Surgery.

These reconstructive techniques are widely used to achieve the normal architecture of a human following acute trauma.

Wounds come in various severities. Therefore the management of a simple wound is not the same as a complex wound. 

To correctly choose the technique of reconstruction for each wound is best described in the “Reconstructive Ladder“.

The reconstructive ladder is the visual representation of the hierarchy of options available for closing a wound to ensure the reconstruction process is systematic and safe for the patient.
By clear understanding of the reconstructive ladder, we will be able to learn the basics of tissue reconstruction.


The Reconstruction Ladder

Reconstructive techniques should be applied from bottom to top, as the same way we climb a ladder.
Simple methods at the bottom and the complexity of the procedure increases as you climb up the rungs.


  1. Secondary intention
    • Lies at the ground level
    • Most simplest method of wound closure
    • Wounds heal by secondary intention by covering wound with an appropriate dressing
    • Aim is to promote wound healing and prevent further damage to the tissues
    • Several types of dressings are available
      • Gauze soaked in paraffin
      • Semi permeable films
      • Hydrocolloid dressing
      • Any more… 

  2. Primary intention
    • Surgical incisions are allowed to heal with primary intention 
    • Surgical wounds are clean wounds with sharp edges which can be apposed together by suturing 

  3. Delayed primary healing
    • Dirty wounds, contaminated wounds are allowed to heal with this method
    • Wound debridement is done to clean the wound and left open for sometime for granulation tissue to appear, after that the wound is closed 

  4. Skin grafting 
    • When primary wound closure cannot be achieved by above methods, skin grafts are used to avoid significant cosmetic defect or functional disturbance as a result of wound contracture
    • Skin grafting is the process of surgical removal of skin from one area of the body and transplanting it to another site of the body 
    • Skin graft is a patch of skin that is removed surgically either by a silver knife or an electric dermatome 
    • Skin grafts are devoid of a blood supply 
    • Graft survival depends on the graft quality and graft bed 
    • Grafts do not contain bones and tendons, but can contain muscles and fasica
       
    • Stages Of Graft Take
      1. Adherence (Less than 8hrs)
        • Fibrin bonds between graft and bed 
      2. Plasmic imbibition (Less than 2 days)
        • Intracellular prostaglandin breaks down in graft cells
        • Results in graft swelling 
      3. Inosculation (Day 2 – 3)
        • Formation of blood vessels and lymphatics between the graph and bed
      4. Remodelling (More than1week)
        • Re innervation takes place
        • Regeneration of skin appendages
           
    • Types Of Skin Grafting
      • Split thickness
        • Contains epidermis and variable part of dermis, therefore available in various thicknesses 
        • Thigh is the commonest site
        • Size can be increased by meshing the graft
        • Donor site can be re-harvested after healing 
        • Graft survival is higher
        • Poor cosmetic appearance 
        • Does not prevent contracture
      • Full thickness
        • Contains epidermis and dermis 
        • Used in facial reconstruction 
        • Better cosmetic appearance ; Colour should be matched with the recipient site  
        • Prevents contracture formation
        • Graft survival is lower 
        • Adnexal structure (Hair) is preserved
      • Composite grafts
        • Grafts that contain more than one tissue type 
        • Ex : Skin, fat
        • Used to cover small defects in cosmetically important areas 

  5. Tissue Expansion

    • It is the placement of a tissue expander to increase the amount of tissue at donor site
    • Tissue expander is implanted into a subcutaneous pocket followed by serial injection of saline into the pocket over weeks
    • Not used in acute conditions
    • This is prolonged, painful process
    • Can obtain reconstruction tissue which has similar colour and texture  

  6. Flaps  
    • A flap is a unit of skin which has its’ own blood supply whilst being transplanted from donor site to the recipient site 
    • May contain multiple components – Skin, fat, muscle
    • Have the ability to take, regardless of the underlying tissue bed 
    • Having an intrinsic blood supply increases the rate of success
       
    • According to the contiguity, it is further divided into….
      • Local – donor site lies next to the recipient site
        • Transposition
        • Pivot
        • Alphabetplasty (Z-Y, V-Y)
      • Regional
        • Myocutaneous 
        • Fasiocutaneous 
        • Neurocutaneous
      • Distant
        • Free tissue transfer 
          • Tissue is moved from an area of the body to another area with complete disconnection of the blood vessels and reanastomosed at the recipient site
        • Pedicled 



Difference Between Skin Grafts And Flaps

Traits
Skin Grafts
Flaps
1. Graft size No size limit Size limited by the territory of blood supply
2. Blood supply Reply on the wound bed for the blood supply Has its’ own blood supply
3. Graft take Graft take is better on clean well vascularized wound bed Does not depend on the wound bed
4. Healing of donor site Split skin graft donor site typically heals in 12 days Direct closure of wound site or heal by second intention
5. Re-usability of donor site Can be reused Cannot be reused




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