EDITORIAL
MICROSURGERY 25:185 186 2005
MICROSURGERY AND THE RECONSTRUCTIVE LADDER
I was recently invited to contribute a chapter to a
textbook. The proposed title of my assignment is ‘‘The
Reconstructive Ladder.’’
To the best of my knowledge, Mathes and Nahai
introduced the metaphor of the reconstructive ladder in
the second of their now-classic books describing muscle
and myocutaneous flaps for general reconstructive sur-
gery practice.1 The point of the image was to give the
reconstructive surgeon a framework for organizing
operative options to address a given problem. The rungs
of the ladder went from low to high, and the sequence
was based on increasing complexity of the surgical plan.
To address a given problem, the surgeon arranged po-
tential solutions ranging from the simplest to the most
complex on the ladder, and then chose the simplest
option that satisfied the elements of the problem.
For example, a surgeon analyzing a soft tissue injury
to the dorsum of the hand could initially consider pri-
mary closure. If that solution was not feasible, local
flaps from adjacent tissue might be proposed. If local
flap issue proved inadequate, debridement, wound care,
and split or full-thickness skin grafting would be possi-
bilities. If a skin graft did not satisfactorily address the
extent of the injury, a so-called distant flap such as a
2-staged pedicled groin flap or a reverse radial forearm
flap, might be a candidate for the reconstructive pro-
cedure. Tissue expansion could float among the rungs
according to the surgeon’s experience. Finally, if all else
seemed inadequate, the surgeon could climb to the top
rung of the ladder and consider the use of a microsur-
gical flap.
In the 1980s, one of my most valued teachers, Dr.
Bernard Alpert, frequently said that the top rung of
DOI: 10.1002/micr.20125
ª 2005 Wiley-Liss, Inc.
the ladder, a confidently performed microsurgical flap,
was often the most direct route to satisfactory healing,
and therefore could be the simplest solution once the
technical aspects of the procedures were confidently
within the surgeon’s range of operative skill. Rather
than struggling through the use of marginally ade-
quate tissue or multistaged procedures, the surgeon
should not hesitate to consider a microsurgical pro-
cedure.
Dr. Alpert is a teacher of great insight and range.
(Another of his observations is what I call ‘‘Alpert’s
Law of Relative Debt Anxiety,’’ illustrated by the cir-
cumstances that if someone owes a bank $10,000 the
person has a problem: if the person owes the bank
$10,000,000, the bank has a problem.) Dr. Alpert’s cri-
tique of the reconstructive ladder showed me that the
decision process for selection of a reconstructive proce-
dure is not linear. Somehow, arranging ladder rungs and
matching one to a problem does not really tell the story.
Dimensions of patient outcome and surgical skill must
be factored into the process, and the top microsurgical
rung also changes the surgeon’s perception of the other
rungs. In the course of my practice, my ability to use
microsurgical flaps has made me relatively impatient
with the use of questionable tissue and staged proce-
dures, while having a microsurgical flap as a back-up
has given me the confidence to explore the use of
innovative local flaps,2,3 fascia flaps, distal extremity
muscle flaps,5 and other nonmicrosurgical procedures,
greatly expanding my own technical repertoire and
practice.6 8
I have therefore come to think of microsurgical
technique not only as valuable in itself, but as an
important dimension in establishing relative values
among the catalog of reconstructive procedures. A bal-
anced plastic surgery curriculum should strive to
186 Editorial
incorporate such a range of technical curricula for its
residents so that they can acquire a foundation allowing
them exploration of the widest variety of surgical op-
tions with the result that each resident can hope to find
some productive individual balance of patient need and
surgical ability.
So, what about the reconstructive ladder? Does it
need to be wider, longer, deeper, or have parallel and
intersecting units? The philosopher Ludwig Wittgen-
stein published a single book in his lifetime. The trea-
tise attempts to analyze the linguistic basis of
philosophy, and to clarify the persistent problems of
knowledge as facets of the misuse of language.9 The
book is, in turns, fascinating, opaque, baffling, and
terrifying. At one point Wittgenstein states that ‘‘the
process of induction is the process of assuming the
simplest law that can be made to harmonize with our
experience. This process, however, has no logical
foundation but only a psychological one’’ (p. 180 181).
This statement may have something to do with the
reconstructive ladder, but I am not certain. Later in his
treatise (p. 189), Wittgenstein describes his entire
analysis as a ladder:
My propositions are elucidatory in this way: he who
understands me finally recognizes them as senseless,
when he has climbed out through them, on them,
over them. (He must so to speak throw away the
ladder, after he has climbed up on it.)
I cannot wait to see how my chapter turns out.
—WILLIAM C. LINEAWEAVER, M.D.
Editor-in-Chief
Division of Plastic Surgery
University of Mississippi Medical Center
Jackson, Mississippi
REFERENCES
1. Mathes S, Nahai F. Clinical application for muscle and musculo-
cutaneous flaps. St. Louis: CV Mosby Co; 1982 p.3.
2. Shaw W, Hidalgo D. Anatomic basis of plantar flap design: clinical
applications. Plast Reconstrct Surg 1986;78:637 649.
3. Park C, Lineaweaver W, Buncke HJ. New perioral arterial flaps:
anatomic study and clinical application. Plast Reconstrct Surg
1994;94:268 276.
4. Gumener R, Montandon D, Marty F, Zbrodowsk A. Subcutane-
ous tissue flaps in the limbs: an anatomical and clinical approach.
Ann Plast Surg 1986;16:377 385.
5. Beck J, Stile F, Lineaweaver W. Reconsidering the soleus muscle
for coverage of wounds of the distal hird of the leg. Ann Plast Surg
2003;50:631 637.
6. Lineaweaver W, Hui K, Yim K, et al. The role of the plastic
surgeon in the management of surgical infection. Plast Reconstr
Surg 1999;103:1553 1562.
7. Lineaweaer W, Hui K, Krave K, Mailhot C. The economics of
microsurgical cases and routine cases in a medical center. Plast
Reconstr Surg 2000;105:46 58.
8. Lineaweaver W. New microsurgical applications: implications for
the infrastructures of plastic surgery. Clin Plast Surg
2002;29:81 100.
9. Wittgenstein L. Tractatus logico philosophicus. GK Ogdan, trans.
London: Routledge1992.