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Plastic surgery is one of the most diverse and exciting of all the surgical disciplines but at times rather mysterious and a little misunderstood. In this article, I aim to introduce you to the basics of a discipline that has kept me interested and learning for the last 20 years.
Plastic surgeons train for an extended time as we have to operate on many different areas of the body and we cover all ages from babies to the very elderly. We are responsible for the reconstruction of both form and function. We, therefore, have to know a lot of anatomy in addition to possessing both a critical and artistic eye.
The defects that we see come from 3 main groups:
- Trauma and burns
- Congenital defects
This is a short list but a diverse range of challenges in each one. I work on the oncological side and cover skin cancer, head and neck cancer and breast reconstruction.
All trainees spend their first years covering trauma and this ranges from fingertip injuries up to massive burns and limb amputations.
Regardless of the defect, the basic principles of surgery are adhered to as with all surgery the patient’s overall condition and especially anything that negatively impacts wound healing must be taken into account. Many elderly people suffer from numerous skin cancers and they often have multiple comorbidities that will influence the choice of procedure.
Once a general assessment is made of fitness for surgery, we have to develop a reconstructive plan. For many years this has been termed the reconstructive ladder and although some have criticised it in recent years, it provides a solid framework to approach any reconstructive challenge.
The reconstructive ladder
The reconstructive ladder involves the following steps:
- Secondary intention
- Primary closure
- Skin grafting
- Local flap
- Regional flap
- Free flap
Meticulous techniques and careful tissue handling ensure that whichever techniques are used the outcome will be the best it can be. Let us look at each in a little more detail.
Any area of the body that has a good blood supply, if kept clean, will eventually heal, but this can take a long time and provide a poor result. It does work well in selected small areas on the face, such as the inner canthus, as the scars contract and can look inconspicuous when compared to a graft or flap.
This is just basic wound closure but an assessment of what is healthy tissue is especially important in primary closure. In dirty wounds, this assessment process can often be delayed and we will sometimes go through two or three returns to theatre for debridement (removing all devitalised tissues) before finally closing the wound to prevent infection and dehiscence.
Skin grafts can be either split grafts or full-thickness grafts. There are advantages and disadvantages to each. Split grafts take only the top layer of the skin using a dermatome and the area that the graft is harvested from will heal and can be used again. This allows coverage of large areas, such as in burn injuries, but the scars are poor and the grafts contract. The skin can be meshed to allow it to cover larger areas and to conform to irregular surfaces. In contrast, full-thickness grafts involve the excision of a patch of skin from an inconspicuous area that can be closed directly. Common sites to use include behind the ear and the groin crease. These provide small, good quality patches that can be used on the face and they provide a better skin and colour match but are limited in size and availability.
Local flaps are a source of endless fascination and creativity. Predominantly they are used on the face to reconstruct after skin cancer excisions. They utilise skin laxity in one area to allow reconstruction of another adjacent region. The key is to design them well and to preserve bloody supply at all times. Common local flaps are the rhomboid flap and the V-Y advancement flap. Some very large flaps can be raised on the face and if the closure is hidden well around the nasolabial folds and behind the ear they can look natural and provide a great cosmetic reconstruction.
Probably the best example of this type of flap is the Lattismus Dorsi flap for breast reconstruction. A regional flap keeps a pedicled blood supply and can be swung around, advanced or rotated into a defect. The flaps can be skin only, muscle only or a combination of both with even bone or nerve added depending on the reconstructive need.
Free flaps and microsurgery are specialised techniques used mainly in breast reconstruction, head and neck cancer and lower limb trauma. They involve tissue being detached from the body and then plumbed into an artery and vein using microsurgery. This takes years of specialised training but provides great power to reconstruct nearly all defects. The tissue can be taken from an area that will have minimal visibility and morbidity such as a groin flap that leaves only a small groin crease scar. It also allows very challenging defects in the head and neck, such as after radiotherapy treatment, to be reconstructed. The limits of microsurgery are still being explored and this has been shown in the recent advances in hand and face transplantation though the limiting frontier here is immunosuppression.
Plastic surgery remains a challenging and innovative specialty with much scope to develop creative solutions to difficult reconstructive problems. Few surgeons are privileged to operate on so many different anatomical areas and such a diverse range of conditions. I hope this article has provided an insight into a job that has kept me excited and interested for more than 20 years.