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The Solar System Model for the Reconstructive Ladder

2011; Lippincott Williams & Wilkins; Volume: 128; Issue: 1 Linguagem: Inglês

10.1097/prs.0b013e318217452a

1529-4242

Valentina Giordano, Simone Napoli, Fabio Quercioli, Andrea Mori, Mario Dini,

Organ and Tissue Transplantation Research

Sir: It was with interest that we read the article by Knobloch et al. entitled "The Reconstructive Clockwork of the Twenty-First Century: An Extension of the Concept of the Reconstructive Ladder and Reconstructive Elevator" published in the October issue of Plastic Reconstructive Surgery.1 Knobloch has described the reconstructive clockwork model to explain the complexity of reconstructive approaches and to emphasize the roles of composite tissue allotransplantation, robotics, and regeneration tissue engineering in the daily reconstructive procedures. In this model, the reconstructive ladder concept has been abandoned. The authors consider all techniques as integral parts of a reconstructive sequence that is not necessarily consecutive but simultaneous. This concept is expressed by clockwork, where each cogwheel represents a different technique that varies from the easiest one to the most complex one; all of these techniques interrelate to achieve the best reconstructive result. In this communication, we would like to point out some historical notes regarding the reconstructive ladder. The concept of the reconstructive ladder has been proposed to establish priorities for technique selection based on the complexity of technique and defect requirements to ensure a perfect wound closure.2 Unfortunately, the simplest reconstructive options may not produce a superior reconstructive result: sometimes, the most complex procedure is necessary to achieve an optimal result. Thus, the surgeon first has to improve his or her abilities and then he or she is ready to climb the ladder. The reconstructive elevator model described by Gottlieb and Krieger let the surgeon range from the simplest to the most complex techniques with the freedom to reach directly the chosen level of complexity. Clearly, this decision is based on the needs of the patient and the skill of the surgeon.3–5 The reconstructive triangle, described by Mathes and Nahai, emphasizes the necessity of selecting the best treatment, not necessarily the simplest one.6 The surgeon uses the reconstructive triangle, exploiting his or her individual experience, for the best technique selection to achieve the goals. In this model, the surgeon is the central figure and has an active part in the choice of the treatment. However, the triangle does not convey the idea of increasing complexity that the ladder concept suggests. The reconstructive stages, described by Wong and Niranjan, are a metaphor for plastic surgeon growth.7 Like a baby who first crawls and then stands up and when his or her confidence increases, and then walks and runs, so too does the surgeon improve his or her surgical ability. This concept conveys the dynamism of surgical training and the sense of maturing as each stage is mastered. On this basis we propose a new iconographic idea of the reconstructive ladder concept: we compare the solar system to the reconstructive diagram. The surgeon represents the sun and the planets symbolize all the reconstructive options. The planets, whose orbits are closer to the core, represent the most simple treatments, and often the most used ones, in medical practice. In the following model, all levels of complexity are represented, and the close correlation between the surgeon's skill, the available techniques, and the patient's needs is exhaustively displayed (Fig. 1 and Table 1).Fig. 1.: Illustration of the solar system.Table 1: Comparison of Each Planet with a Plastic Surgery TermValentina Giordano, M.D. Simone Napoli, M.D. Fabio Quercioli, M.D. Andrea Mori, M.D. Mario Dini, M.D. Plastic and Reconstructive Surgery Unit University of Florence Florence, Italy