Reconstructive ladder

Method	Description	Use Case
Primary Closure	Direct stitching of the wound edges together.	Small, clean wounds that can be easily brought together without tension.
Closure by Secondary Intention	The wound heals naturally without surgical closure.	Small wounds that can heal from the inside out, though it may result in larger scars and longer healing times.
Negative Pressure Wound Therapy (NPWT)	Uses a vacuum-sealed dressing to create negative pressure, promoting healing.	Wounds that benefit from reduced edema, increased blood flow, and stimulated granulation tissue formation.
Skin Graft	Transplanting skin from a donor site to the wound.	Wounds that cannot be closed directly but have a healthy enough bed to support a graft.
Dermal Matrices	Bioengineered scaffolds to replace or support the dermis.	Replacement or support of damaged or missing dermis, promoting cell regeneration.
Local Flaps	Tissue adjacent to the wound is used to cover the defect, keeping its blood supply.	Larger or more complex wounds where skin grafts might not be successful.
Regional Flaps	Tissue harvested from near the wound site, still connected to its blood supply, to cover defects.	Covering defects that cannot be closed by simpler means, utilizing nearby tissue segments.
Distant Flaps	Tissue from a different part of the body, transferred to the wound area.	Complex wounds not adjacent to usable tissue, requiring microvascular techniques to reattach blood vessels.
Free Flaps	The most complex method, transferring tissue along with its blood supply to the wound, requiring microvascular surgery.	Large or complex defects needing not just skin but possibly muscles, nerves, or bone reconstruction, especially when other methods are not viable.

Reconstructive ladder

Here's an explanation from the bottom to the top of the ladder:

• Primary Closure: This is the simplest and most straightforward method where the edges of the wound are stitched together directly. This approach is typically used for small, clean wounds that can be easily brought together without tension.

• Closure by Secondary Intention: This method allows the wound to heal on its own without surgical closure, usually when the wound is small and can heal from the inside out. It may result in a larger scar and takes longer to heal.

• Negative Pressure Wound Therapy (NPWT): Also known as vacuum-assisted closure, this method uses a sealed wound dressing attached to a pump to create a negative pressure environment in the wound. It helps to promote healing by reducing edema, increasing blood flow, and stimulating the formation of granulation tissue.

• Skin Graft: A skin graft involves taking a piece of skin from one area of the body (donor site) and transplanting it to the wound site. This method is used when primary closure is not possible but the wound bed is healthy enough to support a graft.

• Dermal Matrices: These are bioengineered products that can be used to replace or support damaged or missing dermis (the thick layer of living tissue below the epidermis). They can act as a scaffold for the body's own cells to regenerate the dermal layer of the skin.

• Local Flaps: A local flap uses tissue that is adjacent to the wound to cover the defect. The tissue remains attached to its blood supply and is repositioned over the wound. This is suitable for larger or more complex wounds where skin grafts might not take successfully due to the depth or location of the wound.

• Regional Flaps: Regional flaps are segments of tissue harvested from an area of the body near the wound. The flap is still connected to its blood supply, which may come from a named vessel or a random blood supply. This allows for a robust and reliable option for covering defects that cannot be closed by primary intention or skin grafting.

• Distant Flaps: These flaps are similar to local flaps but use tissue from a different part of the body, which is not immediately adjacent to the wound. The tissue is transferred to the wound area and requires a microvascular surgical technique to reattach blood vessels and ensure the viability of the flap.

• Free Flaps: Free flap surgery is the most complex method on the reconstructive ladder. It involves transferring tissue from one part of the body to another along with the blood supply. The surgeon must reconnect the blood vessels of the flap to vessels at the wound site using microvascular surgery. This method is used for large or complex defects where other methods are not viable, especially when the wound area requires not just skin, but muscles, nerves, or bone to be reconstructed.
  

Each rung on the ladder represents increasingly complex reconstructive options. The decision on which method to use depends on several factors including the size, location, and depth of the wound, the presence of critical structures like bones or tendons, the patient's general health, and the desired functional and aesthetic outcomes.