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Page 2 of 6 Kumar. Plast Aesthet Res 2020;7:27 I http://dx.doi.org/10.20517/2347-9264.2020.07
[3,4]
Limited Access Dressing (LAD) is a combination of moist wound healing and negative pressure dressing.
Being a dressing technique, it has its own limitations in improving aesthetic appearance. LAD helps in
aesthetic reconstruction by simplifying reconstruction with minimal donor area problems and reducing
complications due to infection, scarring etc. This is achieved in the following ways:

Ultra conservative debridement
LAD delivers ultraconservative debridement to conserve viable tissue maximally. It does so through
autolytic debridement by tissue enzymes and mechanical debridement by negative pressure and LAD
wash. Due to the leech effect, it is possible to keep the wound slough for longer periods with reduced or no
risk of SIRS/sepsis. During this waiting period, the living cells proliferate and tissue enzymes separate the
attachment of slough to the living tissues. Hence, under LAD, all living tissue is preserved while dead tissue
becomes separated. In contrast, when surgery is performed without LAD, much live tissue is removed and
depending on the area operated on, if bones or tendons are exposed, reconstruction becomes more difficult
with relatively more scarring and poorer aesthetic results.

Debridement and LAD: LAD is applied after thorough mechanical wash and surgical removal of dead
tissue. After about 1 week (the actual time required is determined by the appearance of soft and relatively
loose slough), if deemed necessary, the wound is debrided again. During debridement, slough is removed
easily with minimal blood loss. In cases with compound, comminuted fractures, bone pieces should be
preserved, as much as possible, to increase the chances of survival while the wound undergoes LAD.

Minimal scarring
It has been claimed that occlusive dressings promote rapid wound healing by preventing dehydration and
scab formation, facilitating debridement, minimizing the chances of inflammation and infection, reducing
pain, increasing the rate of epithelialization, and thus, diminishing scarring.

Less complications after major reconstruction
After flap cover, intermittent pressure reduces the chances of hematoma formation and venous drainage
is improved, thereby reducing the chances of flap failure. It also reduces the chances of infection and
inflammation, which in turn, reduces scarring.

Simpler reconstructive procedure
When treated under LAD, majority of cases can avoid complex reconstruction and split thickness skin
grafting (SSG) is usually sufficient. Also, skin graft take is 95%-100% and this helps to reduce the chances of
a bulky reconstruction and outcome.

Minimal donor deformity
As the majority of cases can be covered by SSGs, the expected donor area deformity is thus minimal when
compared to flaps. Treatment of the donor area under LAD further reduces the chances of donor site
complications.

Less chance of distal edema
In lower extremity reconstruction, when more than half the circumference is damaged or avulsed and only
the flap donor area is intact, further disruption of lymphatics and veins in the flap donor site, if distally
based flaps are used, may lead to pedal edema distally. The use of SSGs instead of flaps after LAD reduces
or avoids further disruption of the drainage system, which reduces the risk of developing such edema.

Avoiding amputation/major amputation/limb salvage
On several occasions, it has been possible to avoid limb amputation by using LAD. If aesthetic outcome is
the only concern, avoiding major amputation would be an aesthetic gain.