For reconstructive cases, plastic surgeons follow the reconstructive ladder when considering how to address cases. The lowest rung of the ladder is primary closure. The next step is skin grafting, split thickness, or full thickness. Grafting also may involve allografting, which is human skin temporarily applied for wound coverage to stabilize the wound bed. This is done when the donor sites for skin grafting are limited or when the wound bed is not completely clean so that the graft may die. Grafting is followed in complexity by flap procedures. Local flaps involve movement of adjacent tissue to reconstruct a defect, such as moving local skin into a facial defect for cancer reconstruction or moving adjacent gastrocnemius or soleus muscle into a traumatic lower extremity tibia defect. The highest rung of the reconstructive ladder is free flap reconstruction, moving fat, fascia, muscle, and/or skin and attaching its blood supply to a recipient site which is distant, like the TRAM or DIEP abdominal tissue flaps for breast reconstruction. A reconstructive procedure not covered by the traditional reconstructive ladder is vacuum-assisted closure (VAC), which optimizes an open wound healing in from the edges and depths of the wound from negative pressure applied through a sponge dressing and provided by an attached unit (Drain & Odom-Forren, 2008; Burns & Blackwell, 2007).