Plastic Surgery is the surgical specialty with broadest scope. It involves surgery on virtually every portion of the anatomy except the central nervous system. Among the areas in which the general plastic surgeon must demonstrate expertise are:
Surgery of the skin (including skin cancer)
Surgery of the hand
Maxillofacial surgery (the facial skeleton)
Surgery of congenital deformities
Burn surgery
Surgery of peripheral nerves
Cosmetic surgery
Reconstructive surgery of all body regions (following trauma or cancer removal)
In order to practice in these areas, the plastic surgeon must have an extensive knowledge of surgical anatomy, and must be able to employ certain important surgical principles and techniques in seeking a solution to the particular problem at hand. In so doing, he/she may often become architect of a unique surgical method. The innovative spirit that this produces has yielded many procedures which have become crucial, commonplace undertakings, including major tissue transfer and replantation. The techniques developed by plastic surgeons have had application in many surgical specialties, and in some instances, have gone on to become the exclusive pervue of those in other areas, ( e.g. organ transplantation).
The basic techniques upon which most plastic surgical endeavors are based are:
In order for healing to proceed in the most uneventful and cosmetic way after surgery, careful surgical design must be employed. The planning of incisons with respect to size, location, and direction can have enormous impact upon the final outcome, as can the way tissues are handled and arranged beneath the skin. Plastic surgeons must consider not only the maneuvers needed within the body to accomplish the desired result, but the design of their access and its repair.
Placing incisions in shadows, body creases, or the hair will help to mask the scarring inevitable after surgery. When incisions must be made on exposed portions of the anatomy, care to place them in the proper direction can have dramatic effect upon healing. When confronted with a traumatic injury, the surgeon must carefully remove devitalized tissues ( "debride" the wound), with care to spare as much of the critical anatomy as possible. Meticulous, anatomic repair of all tissue layers will then follow.
"Grafting" is a surgical procedure in which tissue is totally severed from the body and transferred to an hospitable bed. The transferred tissue may be skin, cartilage, or bone. The success of such an undertaking is dependent upon the body's ability to regenerate a circulation for the transfer from the bed of tissue which will support or surround it. Thus, the surgeon must be convinced that the site in which the graft will be placed is healthy and well supplied with blood vessels.
Since it will take even healthy tissue some time to "grow" new blood vessels into a graft, the amount of tissue which can be transferred is relatively limited. Until the vascular ingrowth occurs, the graft must be able to subsist on the nourishment provided by diffusion from within the bed.
Tissues may need rearrangment to accomplish the primary surgical goal ( as in facelift), or to repair a tissue deficit left by injury or other surgery. In order for the needed tissues to be moved, they must be freed from all attachment to the body save that of a "pedicle" through which circulation to the transfer is maintained. In some cases this pedicle will be a broad expanse of tissue, while in others it may be only a tiny bridge of tissue containing a few, crucial blood vessels. These elevated portions of tissue are referred to as "flaps."
The introduction of microsurgical techniques has made it possible to isolate flaps on a pedicle of one artery and the accompanying veins, followed by severance of these and the complete detachment of the flap. After placement of the tissues into the defect needing restoration, the operating microscope is used to magnify the vessels and attach them to vessels in the "recipient" area. This type of devascularized-revascularized flap is known as a microsurgical free flap.
