plastic surgery

Grafts and flaps

Closure of wounds is a central tenet of reconstructive surgery. Many wounds can be closed primarily (with direct suture repair). However, if the defect is sufficiently large, skin may be taken from other parts of the body and transferred to the area of the wound. Skin grafts are thin layers of skin taken from a remote location that are secured to the site of repair with bolsters, which serve to facilitate eventual integration of the donor skin into the wound.

Larger, more complex wounds have a greater volume and can involve exposed vital structures, such as vessels, nerves, tendon, bone, viscera, and other organs. Such wounds require coverage via transposed or transplanted composite segments of skin, subcutaneous tissue, muscle, and, in some cases, bone and nerve. These tissue constructs are maintained by their own defined blood supply and are called flaps. The pioneering work of Australian plastic surgeon Ian Taylor led to the characterization of angiosomes—the networks of blood vessels that supply flaps—which has allowed for rational matching of flaps to defects. Flaps may be transferred from neighbouring tissue, or they may be disconnected from their original blood supply and reconnected using microsurgical technique to another set of vessels adjacent to the defect.

The use of implants or expander devices can also increase the amount of soft tissue. These devices are useful in cases when a patient has a limited amount of donor skin—for example, in those who are severely burned or in children who have large congenital moles. Implants and expander devices have also been adapted for breast reconstruction following mastectomy in breast cancer patients and for aesthetic breast augmentation.

Craniofacial surgery

Congenital and traumatic defects of the head and neck region fall under the scope of plastic surgery. Cleft lip and cleft palate deformities, premature fusion of skull elements, and persistent clefts in the facial skeleton require complex soft tissue and bone rearrangement. The introduction of internal fixation systems that use screws and plates has greatly facilitated congenital reconstructions as well as correction of traumatic fractures. Novel permutations of these fixation devices have been developed; for example, distraction osteogenesis is a technique used to induce bone growth from hypoplastic (incompletely developed) bone by traction exerted by moveable plate systems. Biomaterials, such as absorbable plate systems and bone cements, are being improved continually and are often used in pediatric craniofacial surgery.

Hand surgery

By virtue of its unique anatomy and functional importance, restoration of hand deformities is a shared focus of both plastic surgeons and orthopedic surgeons. Congenital defects involving the hand range from absent or incomplete development (agenesis) to anomalies of limb structures. Traumatic insult may give rise to complex wounds, fractured bones, severed nerves and tendons, or amputations. In the appropriate context, severed digits and limbs may be replanted with microsurgical connections of vessels and nerves. Rehabilitation of the hand is a critical aspect of surgical care, since loss of strength and motion may occur following injury and reconstruction.

Aesthetic surgery

Aesthetic, or cosmetic, surgery is the enhancement of normal structures that are subject to age-related changes or that have unusual features that are distressing to the patient. The procedures used to address these issues are often performed in the physician’s office (as opposed to a hospital) and are relatively simple, entailing only injections of botulinum toxin or hyaluronic soft-tissue filler. In some cases, however, these procedures are complex, involving elective surgery to correct deformities of the nose or to remove excess sagging skin on the face. The practice of plastic surgery has moved beyond plastic surgeons, and there are many other physicians, such as dermatologists and otolaryngologists, who have the skill to perform these procedures.

The same principles that govern reconstructive surgery are applied to aesthetic surgery: replace like with like, respect anatomic boundaries, minimize tissue trauma, and preserve vascular integrity. Aesthetic surgery is also concerned with scars, especially their length and visibility, and modifications to classic procedures such as face-lifts are made to minimize and hide scars. While age-related changes can weaken the support structures of skin and soft tissue, the advent of bariatric surgery in obese patients can create analogous changes in the tissues of the arms, chest, abdomen, and thighs. Corresponding lifts of these parts of the body can be performed.

Other aesthetic surgeries can reduce or augment parts of the body that are perceived to be too large or too small; common examples include the nose or breasts. In addition, the judicious use of liposuction can improve contour in areas that are unbalanced by excess fat. For the face the use of botulinum toxin can weaken the underlying muscles that create some wrinkles; other wrinkles can be softened by injection of hyaluronic acid. Chemical peels, dermabrasion, and lasers can be used to smooth the fine wrinkles that can form in the uppermost layers of skin.

The heightened public interest in aesthetic surgery also creates clinical, ethical, and medicolegal challenges. A clear understanding of indications, techniques, and complications is important for both surgeon and patient to ensure safe and efficacious outcomes.