General
Reconstructive Plastic Surgery
We bring back,
refashion and restore to wholeness the features that nature gave but
chance destroyed, not that they may be an advantage to the living
soul, not as a mean artifice but as an alleviation of illness, not
as becomes charlatans but as becomes good physicians and followers
of the great Hippocrates. For though the original beauty is indeed
restored ... the end for which the physician is working is that the
features should fulfill their offices according to nature's decree.
Gaspare Tagliacozzi,
1597
What Is
Reconstructive Surgery?
It's estimated that
more that one million reconstructive procedures are performed by
plastic surgeons every year. Reconstructive surgery helps patients of
all ages and types whether it's a child with a birth defect, a
young adult injured in an accident, or an older adult with a problem
caused by aging.
The goals of
reconstructive surgery differ from those of cosmetic surgery.
Reconstructive surgery is performed on abnormal structures of the
body, caused by birth defects, developmental abnormalities, trauma or
injury, infection, tumors, or disease. It is generally performed to
improve function but also may be done to approximate a normal
appearance.
Cosmetic surgery is
performed to reshape normal structures of the body to improve the
patient's appearance and self-esteem.
Although no amount of
surgery can achieve "perfection," modern treatment options
allow plastic surgeons to achieve improvements in form and function
thought to be impossible 10 years ago.
This will give you a
basic understanding of some commonly-used techniques in reconstructive
surgery. It won't answer all of your questions, since each problem is
unique and a great deal depends on your individual circumstances.
Please be sure to ask your doctor to explain anything you don't
understand. Also, ask for information that specifically details the
procedure you are considering for yourself or your child.
Who Has
Reconstructive Surgery?
There are two basic
categories of patients: those who have congenital deformities,
otherwise known as birth defects, and those with developmental
deformities, acquired as a result of accident, infection, disease, or
in some cases, aging.
Some common examples
of congenital abnormalities are birthmarks; cleft-lip and palate
deformities; hand deformities, such as syndactyly (webbed fingers) or
extra or absent fingers; and abnormal breast development.
Burn wounds,
lacerations, growths and aging problems are considered acquired
deformities. In some cases, patients may find that a procedure
commonly thought to be aesthetic in nature may be performed to achieve
a reconstructive goal. For example, some older adults with redundant
or drooping eyelid skin blocking their field of vision might have
eyelid surgery. Or an adult whose face has an asymmetrical look
because of paralysis might have a balancing facelift. Although
appearance is enhanced, the main goal of the surgery is to restore
function.
Large, sagging breasts
are one example of a deformity that develops as a result of genetics,
hormonal changes or disease. Breast reduction, or reduction
mammaplasty, is the reconstructive procedure designed to give a woman
smaller, more comfortable breasts in proportion with the rest of her
body.
In another case, a
young child might have reconstructive otoplasty (outer-ear surgery) to
correct overly-large or deformed ears. Usually, health insurance
policies will consider the cost of reconstructive surgery a covered
expense. Check with your carrier to make sure you're covered and to
see if there are any limitations on the type of surgery you're
planning. Work with your doctor to get pre-authorization from the
insurer for the procedure.
All Surgery
Carries Some Uncertainty and Risk
When reconstructive
surgery is performed by a qualified plastic surgeon, complications are
infrequent and usually minor. However, individuals vary greatly in
their anatomy and healing ability, and the outcome is never completely
predictable.
As with any surgery,
complications can occur. These may include infection; excessive
bleeding, such as hematomas (pooling of blood beneath the skin);
significant bruising and wound-healing difficulties; and problems
related to anesthesia and surgery.
There are a number of
factors that may increase the risk of complications in healing. In
general, a patient is considered to be a higher risk if he or she is a
smoker; has a connective-tissue disease; has areas of damaged skin
from radiation therapy; has decreased circulation to the surgical
area; has HIV or an impaired immune system; or has poor nutrition. If
you regularly take aspirin or some other medication that affects blood
clotting, it's likely that you'll be asked to stop a week or two
before surgery.
Planning Your
Surgery
In evaluating your
condition, a plastic surgeon will be guided by a set of rules known as
the reconstructive ladder. The least-complex types of treatments
such as simple wound closure are at the lower part of the ladder.
Any highly complex procedure like micro-surgery to reattach
severed limbs would occupy one of the ladder's highest rungs. A
plastic surgeon will almost always begin at the bottom of the
reconstructive ladder in deciding how to approach a patient's
treatment, favoring the most direct, least-complex way of achieving
the desired result.
The size, nature, and
extent of the injury or deformity will determine what treatment option
is chosen and how quickly the surgery will be performed.
Reconstructive surgery frequently demands complex planning and may
require a number of procedures done in stages.
Because it's not
always possible to predict how growth will affect outcome, a growing
child may have to plan for regular follow-up visits on a long-term
basis to allow additional surgery as the child matures.
Everyone heals at a
different rate and plastic surgeons cannot pinpoint an exact
"back-to-normal" date following surgery. They can, however,
give you a general idea of when you can expect to notice improvement.
Options in
Wound Treatment
In deciding how to
treat a wound, a plastic surgeon must carefully assess its size,
severity and features: Is skin missing? Have nerves or muscles been
damaged? Has skeletal support been affected?
As you and your
plastic surgeon form your surgical plan, it's important to have a
clear understanding of what will happen during the procedure. Asking
questions is key to making an informed decision.
Direct closure is
usually performed on skin-surface wounds that have straight edges,
such as a simple cut. Maximum attention is given to the aesthetic
result, taking extra care to minimize noticeable stitch marks.
 |
| A
simple cut is treated with direct closure. Extra care is given
to minimize stitch marks. |
Skin Grafts
A wound that is wide
and difficult or impossible to close directly may be treated with a
skin graft. A skin graft is basically a patch of healthy skin that is
taken from one area of the body, called the "donor site,"
and used to cover another area where skin is missing or damaged. There
are three basic types of skin grafts.
A split-thickness skin
graft, commonly used to treat burn wounds, uses only the layers of
skin closest to the surface. When possible, your plastic surgeon will
choose a less conspicuous donor site. Location will be determined in
part by the size and color of the skin patch needed. The skin will
grow back at the donor site, however, it may be a bit lighter in
color.
A full-thickness skin
graft might be used to treat a burn wound that is deep and large, or
to cover jointed areas where maximum skin elasticity and movement are
needed. As its name implies, the surgeon lifts a full-thickness (all
layers) section of skin from the donor site. A thin line scar usually
results from a direct wound closure at the donor site.
A composite graft is
used when the wound to be covered needs more underlying support, as
with skin cancer on the nose. A composite graft requires lifting all
the layers of skin, fat and sometimes the underlying cartilage from
the donor site. A straight-line scar will remain at the site where the
graft was taken. It will fade with time.
Tissue
Expansion
Tissue expansion is a
procedure that enables the body to "grow" extra skin by
stretching adjacent tissue. A balloon-like device called an expander
is inserted under the skin near the area to be repaired and then
gradually filled with salt water over time, causing the skin to
stretch and grow. The time involved with tissue expansion depends on
the individual case and the size of the area to be repaired.
The advantages of
tissue expansion are many - it offers a near-perfect match of skin
color, sensation and texture; the risk of tissue loss is decreased
because the skin remains connected to its original blood and nerve
supply; and scars are less apparent than those in flaps or grafts. The
expander temporarily creates what can be an unsightly bulge, making
this option undesirable for some patients.
 |
| Tissue
expansion is ideal for scalp repair because the stretched skin
on the scalp retains normal hair growth. Most other body
tissue does not grow hair to the same degree. |
|
 |
| Following
tissue expansion, the repaired scalp restores a more natural
appearance. |
Advanced
Wound Care: Flap Surgery/Microsurgery
Though success will
largely depend on the extent of a patient's injury, flap surgery and
microsurgery have vastly improved a plastic surgeon's ability to
help a severely injured or disfigured patient. Using advanced
techniques that often take many hours and may require the use of an
operating microscope, plastic surgeons can now replant amputated
fingers or transplant large sections of tissue, muscle or bone from
one area of the body to another with the original blood supply in
tact.
A flap is a section
of living tissue that carries its own blood supply and is moved from
one area of the body to another. Flap surgery can restore form and
function to areas of the body that have lost skin, fat, muscle
movement and/or skeletal support.
A local flap uses a
piece of skin and underlying tissue that lie adjacent to the wound.
The flap remains attached at one end so that it continues to be
nourished by its original blood supply and is repositioned over the
wounded area.
A regional flap uses
a section of tissue that is attached by a specific blood vessel.
When the flap is lifted, it needs only a very narrow attachment to
the original site to receive its nourishing blood supply from the
tethered artery and vein.
 |
| With
flap surgery, tissue, sometimes including underlying fat and
muscle, is taken from the back and tunneled to the front of
the chest wall to support the reconstructed breast. |
 |
| The
transported tissue forms a flap to cover a breast implant,
or it may provide enough bulk to form the breast mound
without an implant. |
A musculocutaneous
flap, also called a muscle and skin flap, is used when the area to
be covered needs more bulk and a more robust blood supply.
Musculocutaneous flaps are often used in breast reconstruction to
rebuild a breast after mastectomy. This type of flap remains
"tethered" to its original blood supply.
In a bone/soft
tissue flap, bone, along with the overlying skin, is transferred to
the wounded area, carrying its own blood supply.
 |
| A
bone/soft tissue flap is used to reconstruct the nose
following skin cancer excision. |
 |
| The
incision lines of the flap are hidden within the natural
creases of the nose and face. |
A microvascular free
flap is a section of tissue and skin that is completely detached
from its original site and reattached to its new site by hooking up
all the tiny blood vessels.
Other
Reconstructive Procedures
In addition to
correcting cuts and other surface wounds, plastic surgeons also
regularly treat both cancerous and non-cancerous growths, and
problems with the supporting structures beneath the skin.
Tumors, both
cancerous and benign, vary widely in type, severity and recurrence.
The removal method chosen will depend largely on the type of growth,
what stage it's in, and its location on the body.
Skin cancers and
growths are usually removed by excision and closure, in which the
growth is simply removed completely with a scalpel, leaving a small
thin scar. If the cancer is large or spreading, major surgery may be
necessary using flaps to reconstruct the affected area.
Hand
Surgery
Whether the defect
is congenital or acquired, plastic surgeons can usually restore
comfort, mobility and normal appearance to patients with hand
problems. Acquired defects include carpal tunnel and other painful
conditions caused by pressure on the nerves (usually at the wrist or
elbow); trigger fingers, a condition caused by swelling of a flexor
tendon in the hand; ganglion cysts, a benign cystic growth and scar
contracture, which occurs when a wound or burn on the hand heals
poorly and forms scar tissue that curls the fingers or restricts
mobility. Dupuytren's disease causes a similar problem of hand
contracture.
Children born with
syndactyly (webbed fingers) can benefit from finger separation,
where a zig-zag-type incision separates the fingers and rearranges
the tissue between them, preventing growth deformities. If a child
had polydactyly (extra fingers), correction is often more than
simply removing the extra digits. The surgeon may also need to
balance the tendons of the hand and stabilize the remaining finger
joints so that the hand functions as normally as possible. Plastic
surgeons also reconstruct missing digits, including the thumb, which
supplies half of the hand's function.
 |
| In
a typical syndactyly, two fingers are fused together. The
surgeon often uses zig-zag incisions to separate the
fingers, creating triangular skin flaps. |
 |
| Skin
flaps cover most of the exposed areas between the fingers.
Skin grafts are used to fill the shaded areas at the base of
the fingers. |
If You're
Considering Laser Surgery ...
In the past decade,
laser technology has revolutionized many areas of plastic surgery.
The laser's allure comes from its ability to "blast" away
or diminish imperfections or growths with a minimum of bleeding,
bruising and scarring.
Currently, there are
many types of lasers available, with many more under development.
Therefore, it's important to understand that not all lasers are
alike.
If you're planning
to have laser surgery, it's best to find a doctor who is well
experienced with, and has access to, a variety of lasers.
The yellow
pulsed-dye laser uses a type of dye as its active medium. It has a
pulsing beam that is heavily absorbed by hemoglobin, which gives
blood its red color. This laser is often used for performing surgery
on children who have pinkish birthmarks called port-wine stains. The
laser destroys the abnormal blood vessels, lightening the birthmark
to the point of being barely noticeable. Scarring, which was a
problem with earlier laser models, is minimal with the yellow
pulsed-dye laser.
The
"pigment-blasting" laser family the Q-switch ruby, the
Q-switch YAG and the alexandrite is a new group of lasers
effective in eliminating the black and blue pigments of tattoos,
pigmented lesions, and the brown patches and spots that often occur
with aging. Though the removal of decorative tattoos is considered a
cosmetic procedure, the removal of "traumatic tattoos" is
a reconstructive process. Traumatic tattoos occur when material
particles are forced under the skin through an accident as in an
explosion or a collision.
The carbon dioxide
laser, sometimes called the "workhorse" of lasers, is an
invisible light absorbed by water, the primary component of human
skin. When the beam is focused, it can cut tissue and seal blood
vessels simultaneously. When defocused, it vaporizes. These
characteristics make it the treatment of choice for removing warts
and many types of skin growths.
The YAG laser has
been shown to be effective in the surgery of various types of
hemangiomas, which are skin growths with heavy concentrations of
blood vessels. It delivers highly-focused energy and unlike
other lasers its tip can be placed directly on the skin,
mimicking a scalpel.
The argon laser is
similar to the yellow pulsed-dye laser. The argon laser emits a
blue-green light that is absorbed heavily by the color red. It is
particularly effective in treating abnormalities that have a
proliferation of blood vessels, such as blood blisters,
"spider" blood vessels on the face, "strawberry"
birthmarks, hemangiomas and bulky vascular tumors.
The copper vapor
laser is a newer type of laser that emits a yellowish light. Its
uses include treating brown or red pigmented areas.
The number of laser
treatments you'll need depends largely upon the size and severity of
the defect. A child with a large birthmark may need six to ten laser
treatments to achieve satisfactory results. Only one treatment may
be needed to remove some small spider veins on the face.
Lasers have a number
of valuable uses, but a laser should not be viewed as a "magic
wand" that improves the results of any type of surgery. For
traditional kinds of surgery and most plastic surgery, the scalpel
is still the proven instrument of choice.
 |
| A
port wine birthmark is lightened using a laser that destroys
the abnormal blood vessels that make up the birthmark. |
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