The Reconstructive Ladder

Plastic surgery originates from the Greek word ‘plastikos’ meaning to mould. Modern day plastic surgery functions on the following stepwise surgical management, with the severity of the patient’s defect and overall health determining which step is taken initially:

The reconstructive ladder

The reconstructive ladder

Grafts and Flaps

Definition- A completely or partially isolated section of tissue, supplied by blood.

When considering grafts, skin is the tissue we are referring to, whereas bone and muscle can also be transplanted with flaps. Grafts also depend on the recipient site for nutrition, contrasting with flaps. When comparing the two, flaps are more adaptable to weight bearing and do not usually require pressure dressings.

Local Where the flap is immediately adjacent to the defect.

Regional Where the flap is moved from an adjacent region.

Distant Where the flap is moved from a remote anatomical area.

Pedicled Where the flap is moved with the vessels remaining in place & act as a bridge of support.

Islanded No intact skin but moved under the skin for non-contiguous defects.

Non-pedicled These are any flaps where the vessels are incised.

Free flaps These are flaps where the vessels and other structures have been cut, and the skin is transplanted to another part of the body.


Langer’s lines are the lines across which there is the minimum amount of tension if incisions are made. It is an important surgical principle when making incisions in any part of the body, but with facial surgery it is particularly important for aesthetics.

Langer's lines

Langer’s lines

Different flap configurations

Propeller flap

This flap has this name, as the skin is twisted on its pedicle to cover a nearby region requiring the graft. The twisting of the vessels may cause clots and occlusion, but freeing of the vessels from the skin reduces this risk.

Advancement flap

This involved a simple incision of the defect, followed by the advancement of a rectangular section of skin to cover the underlying tissue. Sufficient skin laxity is paramount.

V-y advancement

This flap is where a v-shaped incision is made, with a further incision extending from the point of the V. The cuts are made, and the v shaped area of skin is advanced into the straight incision.

Island flap

This flap is where a circular shaped incision is made to remove the defect. A triangular shaped island of skin is raised and sutured to the edges of the circular incision. The skin must have sufficient laxity to stretch over and cover the defect.

plastics advancement flap drawing- GM

Island flap


A z shaped incision is made. The best angles between the lines of the z is said to be 60 degrees.

plastics z plasty- GM

Z-plasty flap


Double z-plasty with v-y advancement/Jumping man

This is essentially two z-plasties either side of a v-y advancement flap. When the incisions are made, it resembles a jumping man. This flap is commonly used in the finger web spaces and the naso-malar fold.

plastics jumping man- GM

Double z-plasty with v-y advancement/Jumping man

O to Z flap

The defect is excised a circle and the wound is extended in a curved fashion a both edges. The edges are now brought together to close the defect.

plastics drawing o-z- GM

O to Z flap

There are of course a range of more complex flaps that can correct severe defects, e.g. a cleft lip

plastics drawing Cleft lip repair- GM

Cleft lip repair


The basic management of burns are discussed below.

Superficial burn


  • Lukewarm water under the tap for 5-10 minutes (not ice or cold water)
  • Do not apply lotions or balms.
  • Keep burn clean and cover with bandage.


Partial thickness

Hospital admission


Full thickness

Hospital admission


Rule of 9s (Adults)

Arm – 9%

Leg – 18%

Back – 18%

Front – 18%

Head and neck- 9%

Perineum- 1%

Palm – 1%


Fluid requirements

Parkland formula:

  • 4ml x burns surface area % x body weight (kg).
  • Give half over the first 8 hours and half over the next 16 hours.

Hospital management

  • The key is to debride thoroughly.
  • All the dead tissue must be removed to avoid life threatening sepsis.
  • Keeping the patient warm is essential, as loss of cutaneous surface area means more fluid is lost through evaporation and hypothermia can quickly result. Burns units are kept very warm for this reason.


  • The key is to provide a high calorie diet post-burns and long after discharge from hospital. This is to prevent weight loss and promote recovery, as the body is in a hypermetabolic state for a long time following the burn injury.
  • Burn contractures must be prevented by regular physiotherapy and scar massage.


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