The 'reconstructive ladder' concept in plastic surgery arranges reconstructive options from simplest to most complex. Which of the following correctly represents the ascending order?

• A Free flap → local flap → skin graft → primary closure → secondary intention
• B Primary closure → skin graft → free flap → local flap → secondary intention
• C Secondary intention → primary closure → skin graft → local/regional flap → distant/pedicled flap → free flap ✓
• D Tissue expansion → V-Y advancement → Z-plasty → free flap → skin graft

Explanation

The reconstructive ladder (Mathes and Nahai) ascends in complexity: (1) secondary intention healing; (2) primary closure; (3) delayed primary closure; (4) split-thickness skin graft; (5) full-thickness skin graft; (6) local tissue rearrangement/flap (Z-plasty, V-Y); (7) regional/pedicled flap; (8) distant pedicled flap; (9) free tissue transfer (microsurgical free flap). The surgeon should use the simplest option that achieves a durable, functional result. The modern concept of a 'reconstructive elevator' acknowledges that sometimes a higher-rung option is immediately preferable (e.g., free flap for an exposed bone that a graft would not cover).

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.