Planning skin reconstruction

Key questions:

• Can it be closed primarily? Then do it.
• Is there enough local tissue laxity to allow a local flap? Then plan the best local flap.
• If no to both of the above, consider graft, healing by secondary intention or free flap.

Consider simplest option available (Gilles reconstructive ladder - if you can confidently perform a technique higher on the ladder that will lead to a better result, it should be offered to the patient)

1. • Direct closure
     • If possible - do that
     • Otherwise continue below
   • Healing by secondary intention
   • Graft
     • FTSG
     • STSG
   • Local flap
   • Distant flap
   • Free flap

Consider aims of reconstruction

1. • Aesthetic
     • Contour
       • Difficult to disguise later
       • Matching contour is therefore more important than colour
       • Expect distorted anatomical features to improve slightly with time, once the underlying muscle relaxes, especially with young people
       • Often a larger flap that uses an entire cosmetic unit or subunit of the face will give a better result than a smaller flap that crosses units
     • Colour
       • Local flaps are a good match
       • Grafts have an unpredictable final colour when the blood supply adjusts
     • Texture
     • Symmetry
     • Match features - hair
   • Functional
     • Sometimes harder to achieve than aesthetics
     • Depends on normal contour, but also sensation and movement
     • Scars inhibit function - position it in the place that least inhibits free motion

Consider aims of surgery

1. • Functional vs aesthetic - match procedure and reconstruction to patient's desires
   • Be clear about level of aesthetic change aiming for - to look unremarkable, to not have a scar under makeup, or just not to attract attention in public
   • Don't chase after a goal the patient is not interested in, but at the same time don't believe a patient that says they don't care at all what it looks like

Consider anatomical factors

1. • Where will the skin come from?
     • Is there an adjacent site with redundant skin? (check by pulling skin away from body)
     • If no, then use skin graft or distant flap
     • If yes, perform a local flap
   • How will it be transferred?