Plastic and Reconstructive Surgery
Plastic Surgery is the speciality, which is concerned with healing of wounds, restoration and improvement of form and function. The speciality had its origin at around 600BC when Sushruta laid down the foundations of Surgery and described a method to reconstruct the amputated nose, which is still practiced today. Unlike other surgical super specialities (such as Cardiothoracic Surgery or Neurosurgery), Plastic Surgery is not a regional speciality. Today, a Plastic Surgeon operates from head to toe and hence, it is one of the broadest specialities. The word 'Plastic' was derived from Greek word ‘Plastikos’ which means fit for moulding. The term was coined by Desault, a French surgeon and was likely published in 1798 by his pupil Bichat.
Aristotle, as quoted by Webster, wrote- ‘Art indeed consists in the conception of the result to be produced before its realization in the material’. This is just one of the teachings that goes into the rigorous training of a Plastic Surgeon. Sir Harold Delf Gillies, considered by many to be the Father of modern Plastic Surgery, often said- ‘While Reconstructive Surgery aims to restore an individual to normal, Cosmetic Surgery attempts to surpass the normal’. It is this dictum, which most aptly defines the difference between Cosmetic Surgery and Reconstructive Surgery, both being branches of Plastic Surgery. Though the subspecialities of plastic surgery are mostly interlinked, these may be stated as-
- Cosmetic and Antiaging Surgery : An individual, who comes for cosmetic surgery is not suffering from any disease as defined conventionally. Rather, he aims to improve upon his appearance, which helps in restoring his self esteem and improves the body image. Cosmetic surgery is described in detail, elsewhere on this website. Similarly, an individual who wishes to reverse the effects of age on body form and appearance also opts for cosmetic surgery. This topic is discussed in detail on another page in this website.
- Reconstructive Surgery : Typically, the patient is an individual, who has suffered the loss or mutilation of a body part. Reconstructive surgery aims to restore this to normal. The examples are reconstruction of a breast in a patient, who has undergone its removal in the treatment of breast cancer. Similarly, reconstruction of lower jaw, following its resection to treat cancer, is reconstructive surgery. In addition to post cancer resection reconstructive surgery, it is also carried out when the body part has been lost due to injury, infection, other diseases and birth defects. Reconstructive surgery may be carried out with the help of local flaps (tissue situated near the site of defect), distant flaps (tissue situated away from the site of defect, but which can be brought near the site ie cross leg flap) or microvascular free tissue transfer (in this case, the block of tissue consisting of various structures is detached from the site of origin and transferred to the site of defect. At the same time, the blood vessels and if required, nerve are joined to the recipient site vessels and nerve with the help of microsurgery).
Reconstruction of cheek with microvascular free tissue transfer
Reconstruction of right side of lower jaw with microvascular transfer of fibula (leg bone)
Crush injury foot with exposed bones. Reconstructed with microvascular transfer of muscle from back and skin graft
Shotgun wound of leg with exposed bone and fracture site. Covered with microvscular transfer of tissue from forearm
Crush injury of foot. Reconstructed with microvascular transfer of tissue from thigh.Plastic-and-Reconstructive-Surgery
Crush injury of ankle. Reconstruction done with cross leg flap.
Deep electric burns over knee with exposed bone and tendon. Covered with fasciocutaneous flap.
Severe injury of leg with exposed bone and fracture site. Covered with fasciocutaneous flap.
Crush injury leg with exposed fracture site. Covered with gastrocnemius myocutaneous flaps (bipedicle)
Malignant (cancerous) tumour of hand. Excision, tendon reconstruction and coverage with radial artery forearm flap.
Tumour of lower eyelid. Excision and coverage done with Limberg Flap.
Tumour of upper lip. Excision and coverage done with local flap.
Deformity of lower lip. Corrected with local flap.
Microsurgery : In microsurgery magnification from operating microscopes is used to visualize, dissect and join structures, that are very small, such as blood vessels and nerves which supply fingers and toes. Magnification ranges from 4 to 25 times. Thus amputated parts such as fingers, hand, feet, penis, can be joined if brought within time. Microsurgery is also used to transfer large chunks of tissue consisting of skin, soft tissue and sometimes bones from one area in body to another, joining the blood vessels and nerves to recipient area, thus restoring its circulation, sensation and function. Without joining the micro structures, this transferred tissue would die. This procedure is also known as free flap transfer. Microsurgery is also done to restore blood circulation to hand and feet when this disrupted due to severe injury such as in road accidents, industrial accidents, warfare etc. Microsurgery is also carried out to create AV Fistulae in patients with chronic kidney disease, so that dialysis can be carried out.
Case -15, 16
Amputated thumb in a child. Replanted with microvascular surgery
Examples of microsurgery
Construction of AV Fistula to facilitate dialysis in a patient with kidney disease.
Insertion of a vascular graft in a patient, whose veins are thrombosed and hence not available, to facilitate dialysis in a patient with kidney disease.