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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