Sir,
Wound management is an integral part of plastic surgery. The aim is to heal it completely
with function and cosmetic restoration. The selection of procedure for management
of the particular wound needs planning. The planning is learned by education which
is not about what to think but how to think. It should be simple, easy to learn and
should give best possible results.
The metaphor reconstructive ladder was introduced by Mathes and Nahai.[[1]] The procedures for wound management become from simple to complex as one climbs
the ladder. The changes have been suggested in the ladder as new technologies have
evolved.[[2]] These advancements have simply expanded the working scope of the existing rungs
of the ladder. The critics of the ladder erroneously believe that it gives only the
idea of the closure of wound without emphasizing any other aspect such as cosmoses
or function. It has been criticized to the extent of saying awful effect of hearing
“Reconstructive ladder” and “tearing down the reconstructive ladder.”[[3]] Its value in teaching, learning, and selecting the most appropriate procedure for
reconstructing the wound has simply been ignored.
The concept of reconstructive elevator has been introduced.[[4]] The concept may look attractive and advanced but as a thought process for wound
healing it has its drawbacks. The elevator takes the surgeon directly to procedures
which are meant for complex reconstructions. It narrows the vision of surgical procedures.
This concept comes when the surgeon is working only on particular type of cases. Each
problem needs to be viewed individually for selecting the technique of reconstruction
for better result. The reconstruction of soft-tissue defect may be done by number
of procedures. The elevator concept will offer a free flap. The ladder may suggest
skin graft, local, or free flap depending on the site, function, cosmetic consideration,
and morbidity involved. The reconstructions by elevator concept happen by overlooking
better but simple procedures.[[5]]
The attitude that only technologically advanced procedures are the best in each situation
needs to desist. The surgeon should know how to climb the ladder by jumping or ignoring
a rung to achieve the desired result. There is a difference between planning by ladder
or elevator concept. The elevator takes directly to the station of what to think.
The ladder takes the course of how to think for optimum reconstruction of wound. The
choice is of the surgeon.
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Nil.
