Principles in Plastic Surgery

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PRINCIPLES IN PLASTIC SURGERY

WHAT IS PLASTIC SURGERY?

Plastic = from the Greek word Plastikos
meaning to mold;
also - blending of form and function
Reconstructive
Restore back to normal deformities caused by
congenital anomalies, tumours and trauma
Aesthetic or cosmetic
Surpass what is normal

HISTORY:
650BC: Sushruta (forehead flap)
*patient lost part of nose to infection borrow
skin from forehead set the flap to cover
defect dissect the flap and discard it
Lateral Forehead flap: The defect is so large that
you have to fashion skin to vault over nose
cover secondary defect with skin graft
form into ala once it gains its blood
supply, you can shape it properly to a better
looking nose
Roman Times Celsus (advancement flaps)
actually an incision to cover the central defect;
skin will stretch; infections or cancer may cause
the defect

1597 Tagliacozzi (tube flaps)
Father of Plastic Surgery
from arm, attached to nose; described in detail
how to mobilize the arm

19
th
Century
True Renaissance of Surgery
o Scientific Method
o Use of anesthesia and antisepsis
1818 Von Graefe
1838 - Zeiss
1845 - Dieffenback

World War I
facial injuries were very common; facial plastic
surgery was developed
Gillies
Kazanjian
Blair
Post War Period
Normal patients seeking treatment for defects
Widespread demand for elective surgery
o 1899 Tummy Tuck
o 1901 Facelift
o 1906 Eyelid surgery
o 1912 Sagging cheeks and double chins
o 1920 Fat Injections
o 1920s Transsexual surgeries
o 1950 Breast augmentations
o 1970 - Liposuction
World War II
Refinement in surgical techniques in plastic surgery
Development of plastic surgery units
Training programs
Specialty was recognized

PLASTIC SURGERY TODAY:
Unique because it has no anatomic boundaries
top of the head to sole of the foot
Pre op planning is not algorithmic
no set or prescribed way of covering a defect
It is a problem solving discipline
surgeon should be innovative

SCOPE OF PLASTIC SURGERY
Congenital anomalies
Maxillofacial/craniofacial
Skin, head and neck tumors
Post extirpative surgery
Burns care
Hands surgery orthopaedic subspecialty and plastic surgery
Microvascular/reinplantation surgery
Aesthetic or cosmetic surgery dermatologist, ENTs

PRINCIPLES OF PLASTIC SURGERY
Patient-Doctor relationship
Based on integrity, is fundamental
Doctor should understand patients concerns
Doctor should know what patients want
Patient and doctor should have similar goals.
Elective surgery
Patients elect enthusiastically and rationally to have
surgery
A positive and optimistic attitude tempered with
some degree of anxiety or apprehension
Trade off
risk vs benefits
cost
treatment should not be worse than the problem
True vs. Apparent
Surgeon should determine the true extent of the
deformity.

Picture: A burn patient who did not consult a physician. The wound
became a contracture. Burn patients require a very long procedure.

Pictures above: In electrical burn patients, the true extent of injury is
not apparent. Later on skin becomes necrosed; deeper tissues are
injured since heat comes from the bone. So if you have an electrical
burn px, admit, then observe.

Multidisciplinary Team
Craniofacial
Cleft lip and palate
burns

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Picture: Cleft lip. For cleft surgery, remember the Rules of 10 10 weeks
old, 10kg.

Reconstructive ladder vs. Reconstructive elevator
Simple procedures are chosen before complex
ones
o Primary closure defect is very small that you
can approximate the edges together
o Skin grafts for large defects or defects in the
vascular bed
o Local flaps if the bed does not support the
graft, use local flaps which are those adjacent
to the defect.
o Distant flaps
o Microvascular free flaps for full loss of soft
tissues in nonvascular bone grafts, go directly
to a microvascular skin graft.

SKIN GRAFTS
STSG (Split Thickness Skin Graft)
Whole of the epidermis and part of the dermis
Used to cover extensive areas
Problem: texture will NOT be so good
FTSG (Full Thickness Skin Graft)
good color and texture match
donor site is close primarily
NOT as well as STSG because more cells to be
vascularized

FLAPS
Local
Advancement
rotation/transposition flaps just rotated on an
axis to cover a defect
interpolation wherein it has its own blood supply;
there is normal skin and tissue
Distant
pedicle
microvascular free flap

*Handle the tissues in an atraumatic way. Bring the edges together
(everted NOT flat). When the skin heals, it will become flat. If you
suture it flat, the skin will become depressed later on.

PRINCIPLES OF PLASTIC SURGERY
Less is more
Avoid over aggressive surgery/treatment
Replace with same color and texture
Replace kind with kind
Concept of aesthetic units
Autogenous vs alloplastic
E.g. fat injected to areas where we want more
volume; has complications
3D construction Techniques
Timing of Surgery
Age young patients would usually produce
hypertrophic scars
psychological status
patients who have lived with the deformity for
sometime are more appreciative of the outcome

BEST FRIENDS OF THE PLASTIC SURGEON
Skin lines
Lines of minimal tension (LMT) cut along these
lines and you produce the best scar possible; make
patients do a horse smile to see the lines
Relaxed skin tension lines (RSTL)
Lines of habitual expression
Lines of skin relaxation

Picture of a man with a horse smile
Suture Technique
Distribution of tension to the deeper layers
Gentle or atraumatic handling of tissues
Eversion of skin edges

Z Plasty
Lengthen the scar
Break up the scar
Reorient the scar along lines of minimal tension

*Remember that scars contract along its axis. One long scar will have
more contractions than if you break it.

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The W plasty
Reorient the scar along lines of minimal tension
Break up the scar

V-Y Advancement flap

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PRINCIPLES IN PLASTIC SURGERY

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