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Reconstructive Ladder Reconstructive Elevator
Simple
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J. P. Hong and A. Datli
for such conditions has been reported to cost
2–3% of the healthcare budget in developed
countries [2, 5]. From the patient’s perspective,
the most frightening fact may be that these
chronic ulcers when left untreated or mistreated
may lead to amputation [7–9]. Although inevitable amputations do occur, reconstructive options
may lead to limb salvage [7, 8].
Today, the reconstruction for soft tissue
defects aims not only to provide coverage but
also to restore function and acceptable form as
well. Once the wound is evaluated to have good
or restored vascular supply, stable skeletal structures, and a relatively clean wound after wound
preparation, soft tissue reconstruction is then
considered [4]. The concept of a reconstructive
ladder was proposed to achieve wounds with adequate closure using a stepladder approach from
simple to complex procedures. Although still valued and widely taught, the reconstructive ladder
comes from the concept of the wound-closure
ladder that dates back beyond the era of modern
reconstructive surgery [10]. A skin graft after
granulation over the exposed anterior tibial bone
can still provide coverage but may end in
inadequate coverage, which can lead to complications such as additional soft-tissue loss, osteomyelitis, functional loss, increased medical cost,
unstable wounds, and even amputation. Using a
well- vascularized ap whether it is local or free,
with adequate padding will provide superior
results in addition to coverage. In addition, other
techniques including tissue expansion, skin
stretching, and negative pressure wound therapy
have had a new impact in approaching reconstructive options [11]. A simpler reconstructive
option may not necessarily produce optimal
results, especially for lower extremity coverage.
Thus, to provide optimal form and function, we
jump up and down the rungs of the ladder like
getting off the elevator at the ideal oor [10].
Restoring the missing components, such as muscle, bone, and skin using a combined ap with a
microsurgery approach, may provide an ideal
solution to complex defects. The reconstructive
elevator requires creative thoughts and consideration of multiple variables to achieve the best
form and function rather than a sequential climb
up the ladder (Fig. 41.1). This paradigm of
thought does not eliminate the concept of the
reconstructive ladder but replaces it with a ladder
of wound closure that makes its mark in the eld
where a variety of advanced reconstructive procedures and techniques is not readily available.
Taking the lower extremity wound for example,
traditionally upper and middle one-third of the
lower leg can be reconstructed with regional
muscles like gastrocnemius and soleus muscle
aps or by using perforator- based local skin aps
also known as propeller aps. However, due to
Complex
Fig. 41.1 The reconstructive approach is shown by comparing the classical reconstructive ladder to the reconstructive elevator. The reconstructive elevator requires
Free flaps
Distant flaps
Local flaps
Skin grafts
Direct closure
Secondary intension
Complex
Simple
creative thoughts and consideration of multiple variables
to achieve the best form and function rather than a sequential climb up the ladder
Free flaps
Tissue expansion
Distant flaps
Local flaps
Skin grafts
Direct closure
Secondary intension
Negative Pressure Wound Therap
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the scarcity of available tissues, the lower third of
the leg and the foot may require reconstruction
using tissues distant from the defect when the
defects are moderate or large. It involves using
microsurgery. Microsurgery is a surgical discipline that combines magnication with advanced
microscope, specialized precision tools, and various operating techniques. These techniques are
primarily used to anastomose small blood vessels
(arteries and veins) and to coapt nerves. A ap is
a piece of living tissue that carries its own blood
supply and is moved from one area of the body to
another. When the blood supply is cut (pedicle)
and transferred far away from the original site, it
becomes a free ap. By anastomosing the vessels
from the ap (pedicle) to the recipient vessels, it
restores the vascular supply to the ap and allows
the distant ap to survive and provide adequate
coverage. Flap surgery can restore form and
function to areas of the body that have lost skin,
fat, muscle movement, and/or skeletal support.
Microsurgery will not only allow wound coverage but can entail restoration of function and
form.
Thus, whether acute or chronic wounds where
the wound is stalling, complex, and challenging,
using the aps with or without microsurgery in
conjunction with a multidisciplinary approach
can provide adequate and timely coverage. This
chapter will focus on patient selection, the multidisciplinary approach, wound preparation, surgical techniques, and outcomes regarding
reconstruction using local and free aps.
41.2 Patient Selection,
Multidisciplinary Approach,
andtheWound Preparation
The wounds that are considered for reconstructive surgery using aps (ap reconstruction) may
occur from various causes, such as acute trauma,
diabetic foot ulcers with or without ischemia and
infection, pressure sores, radiation wounds,
chronic osteomyelitis, unstable scar, and poorly
managed complex traumatic wounds. Table41.1
presents our experience that needed microsurgical reconstruction for wounds excluding acute
Table 41.1 Wounds that underwent microsurgical
reconstruction
Diagnosis N %
Burger’s disease 5 0.9
COM 140 24.2
Diabetic foot 269 46.7
Exposed femoral artery graft 2 0.3
Exposed hardware 9 1.6
Foreign body 4 0.7
Hidradenitis suppurative 7 1.2
Pressure sore 22 3.8
Post traumatic/burn scar contracture 18 3.1
Pyoderma gangrenosum 2 0.3
Radiation ulcer 13 2.6
Unstable scar 86 14.9
Total 577 100.00
trauma and cancer reconstruction [4]. If the
wound is small enough with good regional vascular supply such as pressure sores for the ankle
region or a small neuropathic diabetic foot ulcer,
local aps may be enough to reconstruct the
defect. However, for large and complex wounds,
a microsurgical approach can provide an efcient
solution. In addition to the wound, the patient has
to be ambulating prior to reconstruction, will
likely be able to ambulate after reconstruction,
have reasonable systemic condition to overcome
the challenges of multiple surgeries, be
psychologically motivated, and have good family
support [12].
When considering these patients for ap
reconstruction, a holistic/multidisciplinary
approach for the patient must commence concurrently with wound management [7, 13, 14].
Without controlling the underlying factors, especially in chronic wounds, it will have a higher
chance of complications. For example, diabetic
patients will need to address the issues to control
their hyperglycemia, renal insufciency, nutrition, and other associated medical comorbidities
that may adversely affect healing requiring close
collaboration with endocrinologists [15, 16].
Vascular interventionists or vascular surgeons
need to be involved to evaluate and improve the
vascular status. One must maximize the circulation of the leg for reconstruction [7, 17, 18]. The
exact roles of endovascular and open bypass procedures are still evolving but are primarily deter-
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Systemic condition and Wound evaluation
Good standard of wounds care
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J. P. Hong and A. Datli
Fig. 41.2 An algorithm for reconstruction is presented
mined by arterial anatomy, wound severity, and
patient comorbidities [18, 19]. Whatever the
method, it is imperative to restore as much blood
ow as possible to the foot so it can be adequately
used as a recipient vessel [9, 20]. It is crucial
when considering ap reconstruction that adequate vascular supply not only to the defect
region but also to the ap is conrmed [21–24].
Orthopedic surgeons or podiatrists need to be
involved to evaluate the skeletal status of the
lower leg or foot when indicated. With multiple
departments involved, the clinical nurse specialist plays a central role in maintaining clear communication and efcient treatment solutions in
the front line of management. An algorithm to
consider wounds for ap reconstruction is shown
in Fig.41.2. Improving vascularity by intervention angioplasty or bypass surgery usually reects
the extremity, but other pharmacological methods can be also considered for other parts of the
body [25–27].
Controlling infection is also an important factor to address. Poorly controlled infection may
cause late-stage ap failures often leading to ap
failure [4, 28–30]. When skin tissue is not clearly
demarcated, the use of hyperbaric oxygen therapy can be helpful to achieve demarcation of the
necrotic and viable tissue. In cases where bone
Conservative care
Small/shallow
Skin graft/local flab
NPWT
Ambulation
Failure
Large/Deep
Surgical (salvage) care
Failure
Free flap
Evaluate vascular status
Reliable
Failure
Amputation
ComplexSimple
Bypass surgery
Angioplasty
No benefit
Unreliable
infection is suspected, complete excision of the
bone at the time of coverage is essential followed
by antibiotic use [31, 32]. Bone gaps can be lled
by temporary cement mixed with antibiotics to
occupy the space and the ap coverage performed. After the eradication of the infected
bone, the cement can be removed during the
second- stage surgery replacing it with bone grafts
or aps. When considered for ap reconstruction,
the wound preparation process may easily be
overlooked. However, preparing the wound adequately addressing vascularity, infection, dead
space, and stability of the skeletal structure will
lead to a better outcome [33, 34].
41.3 Surgical Techniques
The rst surgical step of treatment for any wound
is to evaluate, debride, and treat infection [35].
Optimal management of chronic wounds, especially diabetic foot infections, can potentially
reduce the incidence of major limb amputations
and other related morbidities. All nonviable and
infected soft tissue and bone should be excised
during debridement. In the diabetic foot, milking
along the proximal tendon can help identify and
limit ascending infection, especially for diabetic
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foot wounds. A tissue culture should be sent, and
antibiotics used accordingly. Sufcient irrigation
should follow after debridement to reduce bacterial count [36]. The use of a hydrosurgery system
may allow for to efcient debriding of large
extensive wounds by preserving viable tissues
and irrigating simultaneously [37]. The understanding of the vascular distribution of the foot,
angioma, helps to plan not only reconstruction
but also debridement, especially in legs with limited vascularity [20, 38]. Performing debridement according to the angiosome territory may
enhance ap survival by increasing the chance
for marginal vascularization from healthy surrounding angiosome territory [20]. Repetitive
debridement should be performed as part of
wound preparation for reconstruction while monitoring c-reactive protein for possible hidden
infections and using it as an index for possible
infection after reconstruction. In chronic wounds,
thorough debridement may lead to what seems
like an irreparable wound that may warrant
amputation. Microsurgical procedures, including
soft tissue and bone aps, and vessel and nerve
grafting, can be used to reconsider such problems
as defects with replaceable parts.
Once an adequate debridement and reasonable
vascular perfusion are achieved, for extensive
and complex defects, ap reconstruction is considered. The biggest challenge in ap surgery
especially for diabetic foot is nding an adequate
recipient vessel for free aps and an adequate
pedicle for local aps. No one must consider atherosclerosis can hinder the vascular supply leading to the ap. One should check the perfusion
and the velocity of the ow when local aps are
considered especially in wounds with calcied
vessels. Using a handheld Doppler or especially a
duplex ultrasound can provide you with real-time
ow velocity information increasing the reliability of the local ap [39–42]. When performing
the free ap, when a named artery will be used as
a recipient, one must try to nd a small segment
spared from calcication [7]. One must remember, especially for the ischemic limb, that it was
the initial poor vascular supply that caused the
wound formation, and thus, all efforts should be
made to preserve the distal ow to the foot.
Microsurgical techniques such as end-to-side
anastomosis and T-style ow through or end-toend on a branch of a major artery will minimize
the steal phenomenon where ow may be diverted
to the low-resistance vascular bed of the new ap
[43, 44]. Another challenge for chronic conditions with inammation like chronic osteomyelitis or radiation wounds is the scarring of the
tissues. It can make the dissection of the recipient’s vessels very difcult. Thus, searching the
recipient vessel out of the zone of injury or
inammation may make the search easier and
more reliable.
A ap consists of tissue that is mobilized on
the basis of its vascular anatomy. Flaps can be
composed of skin (including subcutaneous fat),
skin and fascia, skin and muscle, or skin, muscle,
and bone, or various compositions of tissues.
Because the circulation to the tissue to be mobilized is crucial for ap survival, the development
of ap techniques has depended on dening the
vascular anatomy of the skin and underlying soft
tissue [45]. The ap for reconstruction of chronic
wounds has to provide a well-vascularized tissue
to control infection, allow adequate contour for
footwear, be durable, and provide solid anchorage to resist shearing forces, especially on the
plantar surface. In cases with large dead spaces, a
ap should be selected to provide obliteration of
the dead space as well. Common local aps based
on the subdermal plexus or the underlying vascular source without identication include the
bipedicle ap, advancement aps (i.e., V–Y), and
rotation or transposition aps [45]. Today, these
techniques are still widely used for small- or
medium-sized defects that can be reconstructed
with regional skin. A similar concept used for
larger wounds on the trunk and extremities is the
keystone ap. As described by Behan, the keystone ap is a curvilinear-shaped trapezoidaldesign ap, essentially being two V–Y
advancement aps along the long axis of the ap
[46]. One can also identify the pedicle by using a
handheld Doppler or Duplex ultrasound and base
the island ap on a perforator and rotate as a local
ap as shown in the case of Example 1 [24, 47,
48]. One must remember that using local perfora-
tor aps is in a way non-free ap microsurgery.
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Microsurgery techniques are frequently needed
to isolate and to skeletonize the pedicle preventing any unwanted complication related to perfusion delivery to the ap.
A free ap is a piece of tissue that is disconnected from its’ original blood supply and is
moved a signicant distance to be reconnected to
a new blood supply around or within the wound
or a defect. Various tissue can be used as a free
ap as long as it has its own blood supply that can
used to connect. The artery that comes with the
ap is sewn under the surgical microscope to the
artery near the defect to bring the blood in, and
the vein is sutured to a vein near the defect to
reestablish the blood ow. Free aps are more
reserved for larger defects or defects that need
composite tissues for reconstruction. An example
would be a composite ap with muscle, skin, and
bone together. Using a free ap will be technically demanding as it requires microsurgery
skills. However, once this skill is readily applied,
the choices for donor sites to reconstruct defects
become wider, and customization of the aps can
be made to achieve ideal reconstruction for function and aesthetics.
Controversy still remains about which ap,
whether muscle aps with skin grafts, fasciocutanous aps, or recently added perforator aps,
offers the optimal solution to reconstruct the
wound. However, as long as the large defect is
covered with any well-vascularized tissue, it will
provide an independent and well-nourished vascular supply to eradicate infection, increase local
oxygen tension, enhance antibiotics activity, and
neovascularization to the adjacent ischemic tissue [7, 49–52]. One of the basic elements of plastic surgery is to replace like with like. Thus, for
defects with skin defects, we are shifting toward
using perforator aps (skin and subcutaneous fat
composite ap) such as ALT (anterolateral thigh)
perforator ap, TDAP (thoracodarsal artery perforator) ap, and SCIP (supercial circumex
iliac perforator) ap as it provides a thin ap to
minimize shearing, can take only the supercial
fat to imitate the brous septa of the sole to
adhere tightly, enhance neovascularization of the
subdermal plexus with adjacent tissue, and provide adequate blood supply to ght infection [7–
9, 20, 33, 53, 54]. The elevation technique of
each individual ap is described in detail in the
referenced papers.
Vigilant postoperative care is needed after ap
reconstruction as ows to the ap can be suddenly impaired due to multiple reasons including
mechanical compression to the pedicle, faulty
anastomosis, and low systolic blood pressure to
name a few. However, usually after 2 days of
uneventful monitoring, one can expect a relatively good outcome as most thrombosis occurs
within the rst 2days [55, 56].
41.3.1 Case Examples
41.3.1.1 Case 1
An example of a local perforator ap is shown.
The goal of using a well-vascularized local ap
was to eradicate infection and provide adequate
coverage over the defect without compromising
the esthetic outcome. A 56-year-old female
patient visited the clinic with hidradenitis suppurativa Hurley stage 3 on the left axilla (Fig.41.3).
Multiple interconnected sinus tracts, abscesses,
and rope-like elevation of the skin can be noted
(Fig.41.3a). Excision margins, the design of the
ap (5×13cm), and preoperatively traced perforators can be seen (Fig.41.3b). The entire armpit
was completely excised, including hair-bearing
Fig. 41.3 An example of a local ap is shown in this
56-year-old female patient who visited the clinic with
hidradenitis suppurativa hurley stage 3 on the left axilla.
Multiple interconnected sinus tracts, abscesses, and
rope-like elevation of the skin can be noted (a). Excision
margins, the design of the ap (5×13cm), and preoperatively traced perforators can be seen (b). The entire
armpit was completely excised, including hair-bearing
skin and underlying soft tissue (c). The propeller ap
(local ap) was elevated based on a perforator near the
chronic lesion and rotated 180° to cover the defect (d).
The ap was trimmed according to the size of the defect,
and both the axillary wound and donor site were closed
primarily (e). During 26months of follow up, no recurrence was noted in the axilla (f)
ab
ef
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d
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J. P. Hong and A. Datli
skin and underlying soft tissue (Fig.41.3c). The
propeller ap (local ap) was elevated based on a
perforator near the chronic lesion and rotated
closed primarily (Fig.41.3e). During 26months
of follow up, no recurrence was noted in the
axilla (Fig.41.3f).
180° to cover the defect (Fig.41.3d). During the
elevation, microsurgery was used to skeletonize
the pedicle and to ensure safe perfusion. The ap
was trimmed according to the size of the defect,
and both the axillary wound and donor site were
c
41.3.1.2 Case 2
An example of a free ap using microsurgery is
shown in Fig. 41.4. The goal of using a wellvascularized free ap was to achieve the eradica-
d
e
Fig. 41.4 A 56-year-old-male patient is shown with an
exposed tibial bone with chronic infection and necrotic
bone xed by an external apparatus (a). The wound started
to develop after few months after the initial injury and surgery ending in skin necrosis and exposed bone. After
debridement of the soft tissue, and bone and cleaning the
wound, a tibial defect was seen with a wide skin defect as
well (b). In order to provide efcient coverage, one-stage
elevator approach was made using an anterolateral thigh
(ALT) ap combined with a bular bone ap (c). The
combined ap was anastomosed to the anterior tibial
artery in an end-to-side manner (d). The immediate postoperative result is shown (e). The nal result is shown
with the bular bone completely integrated with the tibial
bone and good overall appearance of the leg with functional and aesthetic outcomes at 16months (f, g)
gf
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Fig. 41.4 (continued)
tion of infection, obliteration of dead space,
reconstitute the tibial bone, provide skin coverage, and adequate wound healing. A 56-year-oldmale patient is shown with an exposed tibial bone
with chronic infection and necrotic bone xed by
an external apparatus (Fig. 41.4a). The wound
started to develop after few months after the initial injury and surgery ending in skin necrosis
and exposed bone. After debridement of the soft
tissue and bone and cleaning the wound, a tibial
defect was seen with a wide skin defect as well
(Fig.41.4b). In order to provide efcient coverage, a one-stage elevator approach was made
using an anterolateral thigh (ALT) ap combined
with a bular bone ap (Fig.41.4c). The combined ap was made by anastomosing the bular
pedicle on the branch of the ALT pedicle, which
is the lateral circumex femoral artery. Ultimately,
the combined ap was anastomosed to the anterior tibial artery in an end-to-side manner
(Fig.41.4d). The immediate postoperative result
is shown in Fig.41.4e, achieving functional cov-
erage and with adequate appearance. The nal
result is shown with the bular bone completely
integrated with the tibial bone and good overall
appearance of the leg with functional and aesthetic outcomes at 16months (Fig.41.4f, g).
41.3.1.3 Case 3
An example of a free ap using the supercial
circumex iliac artery perforator (SCIP) ap is
shown in Fig.41.5. The goal of using a free ap
was to provide adequate coverage using wellvascularized tissue and to prevent high-level
amputation. A 65-year-old patient with wounds
from a diabetic ulcer is noted after transmetatarsal open amputation (Fig.41.5a, b). After multiple debridements and using NPWT, the wound
was ready for ap coverage, the SCIP ap was
used as a free ap, and the pedicle was connected
to the dorsalis pedis artery and vein (Fig.41.5c).
The ap after 18months of surgery shows good
contour with no further ulceration, and the patient
exhibits good functional gait (Fig.41.5d, e).
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b
d
e
Fig. 41.5 A 65-year-old patient with wounds from a diabetic ulcer is noted after transmetatarsal open amputation
(a, b). After multiple debridements and using NPWT, the
wound was ready for ap coverage, SCIP ap was used as
a free ap, and the pedicle was connected to the dorsalis
pedis artery and vein [5] (c). The ap after 18months of
surgery shows good contour with no further ulceration,
and the patient exhibits good functional gait (d, e)
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41.4 Outcomes
The spectrum of treatment for chronic wounds
can be wide: Addressing systemic issues like
blood sugar control and nutrition, family support,
good standard of care, providing advanced care
such as NPWT, hyperbaric oxygen, cell therapy,
to surgical options. Without the ability to have
reconstruction in the treatment options, the spectrum of care is not optimal. Conversely, without a
team with multidisciplinary offerings, the care
would not be complete. No one service can provide the care that is needed, which is all interconnected. With the introduction of the
multidisciplinary approach, the goal and trend of
management have shifted away from major
amputation toward limb salvage for complex
chronic wounds [14]. Addressing the issues of
perfusion, infection, wound treatment, skeletal
stability, and biomechanics, now we are able to
increase the salvage rate. Examples of such multidisciplinary approaches have been shown to
reduce major amputation by 3–4% in diabetic
feet as we have seen at our center [57, 58]. We
must have good clinical judgment on whether to
amputate or not weighing against clinical situations with systemic sepsis, major tissue loss, signicant comorbid factors, poor patient
compliance, and nonreconstructable peripheral
vascular disease. A non-healing ulcer itself
should not be considered an indication for amputation but be systemically approached by various
disciplines of medicine [59, 60]. The majority of
reconstruction that needs microsurgical reconstruction are complex defects from diabetic foot,
unstable scars, radiation ulcers, and chronic
osteomyelitis as presented in Table41.1.
The biggest advantage of using a ap to cover
the wound is providing well-vascularized tissue
over the defect. This provides the most resembling tissue after healing and allows it to have
better function and esthetic outcomes. Most of
all, the tissue provides an adequate surface reducing the risk for recurrence, especially for the foot
region or wounds over the hard bone. In addition,
compared to other modalities for healing such as
NPWT or other conservative care, using aps for
reconstruction allows a faster healing process
minimizing the time needed for care. One must
be prudent in deciding which approach is adequate for each wound. Most likely, wounds that
are deep, complex, and large can be considered
for ap reconstruction as mentioned before in
this chapter.
The general success rate for these patients was
the same for other chronic wounds, whereas the
diabetic foot had a slightly lower success rate.
However, limb salvage from diabetic foot using a
microsurgical approach showed success comparable to non-diabetic patients [12, 53, 61–64].
Meta-analysis of a systematic review of free tissue transfer in 528 diabetes patients in 18 studies
showed that ap survival was 92% and limb
salvage rate of 83.4% over a 28-month average
follow- up period. This study indicates that free
tissue transfer in the management of nontraumatic lower extremity wounds in patients
with diabetes may avoid amputations [12]. In our
previous study, we showed similar ndings using
microsurgery. Which achieved an overall ap
survival rate of 91.7%, limb salvage rate of
84.9%, and 5-year survival of 86.8% [8]. Now
with the introduction of supermicrosurgery, we
are able to use small vessels to perform reconstruction even on patients with poor vascular status. In our recent publication of 95 cases that
used the super microsurgery approach, we noted
9 total losses and 12 cases of minor complications [20]. Thirty-four patients had one or less
major arteries after the intervention, but only had
four cases of total failure. The lack of major vessels was not a signicant risk for failure, thus
supporting our approach of using collateral vessels for recipients. Overall, in this series, the ap
survival rate was 90.5% and the overall limb salvage rate was 93.7% [20]. This approach extends
the possibility for reconstruction in patients with
severe ischemic diabetic foot.
In chronic osteomyelitis, our experience of
microsurgical reconstruction using perforator
aps showed a ap survival of 95.8% [33]. The
treatment has similar principles that require
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