82 Reconstructive Surgery

Reconstructive surgery is the technique to replace tissue loss caused by trauma, tumours or congenital deformity. The advent of antibiotics, refined anaesthesia and microsurgery have allowed more major head and neck resection procedures to be developed. Manchot in 1889 studied the blood supply of the skin and introduced the concept of vascular territories, while in 1936 Salmon confirmed the distribution of the perforating branches from marginal arteries. Although skin cover could be achieved by staged transposition of tubed pedicled fasciocutaneous flaps from distant sites, cosmesis, retention of function and quality of life were usually poor. In addition, some procedures took over a year to complete. Such techniques are now essentially of historical interest. The development of one-stage pedicled myocutaneous flaps and microvascular free tissue transfer over the last 25 years has conferred enormous improvement in outcomes including morbidity, rehabilitation and the quality of life.

When considering reconstructive surgery, it is pertinent to reflect on the surgical ladder. We have classified reconstruction into four levels.

82.1 Level 1-Direct Closure

It may be desirable to close small defects directly. Excision of a lesion should be planned, so skin incisions are in the line of least tension as mapped out by Langer’s lines. These lines are usually at right angles to the underlying muscle fibres. Following the excision, some limited undermining between tissue planes is usually necessary to reduce tension. The depth of plane varies according to site; for example, on the face, the level of undermining is very superficial, but on the scalp, it is deep to the galeoaponeurotica. On the trunk and limbs, it lies between the superficial and deep fascia. The skin is able to be stretched, but its tolerance varies according to site and age. Skin suturing should be without undue tension.

82.2 Level 2-Skin Grafts

Skin grafts are considered when the deflect is too large for primary closure, or where the aesthetic result is better than from other methods of closure such as rotation flaps as on the nasal tip. A skin graft is a segment of epidermis and dermis that has been completely separated from the donor site and thus has no blood supply. They may be classified into split-skin grafts (also called partial-thickness skin grafts) or full-thickness skin grafts (also called Wolfe’s grafts). The graft has no blood supply and so needs a vascular bed. It will not take on bone without periosteum, cartilage without perichondrium or tendon without paratenon. A skin graft is less likely to take at sites of poor vascularity, for example, over fat, heavily irradiated tissue or on infected tissue. The contact between the graft and recipient site is maintained by a pressure dressing or by the exposed method. The pressure dressing could be a pressure bandage or dressing with foam or cotton wool sutured or stapled, in position. In exposed wounds, one needs to observe for a seroma, haematoma or a collection of pus between the graft and recipient site. If a haematoma or seroma develops, it can be promptly dispersed by making a small incision in the graft or drawing out the collection using a large-bore needle and syringe.

82.2.1 Split-Skin Grafts

Split-skin grafts (SSG) consist of epidermis and a thin layer of dermis, but the troughs of the rete pegs and epithelium lining the hair follicles are left in situ to allow reepithelialisation of the donor site. They are a very versatile and usually reliable graft and should be harvested using an electric dermatome set at 3 or 4 on the circular scale corresponding to a thickness of 0.3 to 0.4 mm. In the oral cavity, a thicker graft of 0.5 mm is often recommended. However, the take is liable to be poor in the presence of saliva and exposed intraoral defects can be allowed to heal by secondary intention such as following excision of a tumour using a CO₂ laser. It should be noted that the dermatome scale acts as a guide only: other factors such as angle of the dermatome to the skin and skin tension will alter the graft thickness. Immediate grafting with quilt suturing and cross-hatching of the graft is recommended so that blood and serum can escape and do not lift the graft from its bed. The donor site should be hairless and inconspicuous. The inner aspect of the upper arm or thigh is therefore recommended. With large surface areas, it is reasonable to harvest the split skin and place the graft keratin side down on tulle gras, which is rolled, placed in a sterile pot, and refrigerated at 4°C. After 3 to 5 days when all bleeding and serous ooze from the raw bed has stopped and vascular granulated tissue has started to form, the SSG can be unrolled and sutured to the donor site.

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