Reconstructive Surgery and Wound Management
The reconstructive ladder
Candidates must understand when to allow second-intention healing, when to use primary closure, and when to use grafts or flaps. Site matters: the nose, ear, and eyelid have unique constraints. Know the nasal subunits and the principle of replacing like with like. Understand flap design fundamentals - random vs axial pattern, pivot points, and the need for adequate vascular supply.
Wound management
Know timing of reconstruction (immediate vs delayed), the role of hemostasis, and the management of anticoagulation. Understand infection risk and antibiotic prophylaxis indications. Recognize the difference between a wound that should be closed and one that should be left to heal, particularly on concave surfaces and in patients with comorbidities.
Traps
A frequent trap is choosing a complex flap for a defect that would heal well by second intention. Another is ignoring subunit principles on the nose, leading to contour deformity. Also know that tension and vascular compromise are the main causes of flap failure, and that smoking and prior radiation impair healing.
Worked example
A 1 cm defect on the nasal ala with intact cartilage support may heal by second intention with acceptable cosmesis in a compliant patient; a similar defect involving the alar rim often needs a cartilage graft and local flap to prevent notching. The rule: assess structural support before choosing the repair.