Cosmetic Plastic Surgery

Plastic surgery is the surgical specialty that deals with the reconstruction and repair of certain congenital deformities, burns, injuries, surgical defects, and wounds resulting from serious accidents or war. The primary aim of the plastic surgeon is the restoration of function, but restoration of the appearance or cosmetic effect may be just as important. One of the oldest of the surgical specialties, in the sense that many commonly used methods can be traced to medical writings dating from several centuries B.C., this science has come into its own only in the 20th century. Its recognition has been greatly stimulated by the demands of World Wars I and II and by the development of simpler and more satisfactory methods of tissue transplantation, which is the essence of plastic surgery.

That certain inevitable limitations exist in what can be accomplished by plastic surgery is well expressed in the saying: "A tailor is no better than his cloth." Extensive repairs can be completed only by replacement with tissue from other parts of the body; these grafts act as a substitute for, but seldom as a perfect duplicate of, the original tissue. The aim of any repair is to allow the patient to appear inconspicuous, attracting minimal attention to his deformity. Unfortunately, misleading statements have been published concerning what can be accomplished— for example, that scars can be completely eliminated, or that the face, eyelid, or hand can be completely restored to normal following damage or destruction by a burn or other severe injury. At the same time, the lifesaving value of plastic surgical methods in the shortening of periods of disability following injury or disease may be overlooked.

As a consequence of the increasing recognition in the United States of the specialty of plastic surgery, a qualifying board, the American Board of Plastic Surgery, was established in 1938. Its purpose is to set standards and improve the quality of training of young plastic surgeons and to conduct examinations for certification. Certification by this board is a prerequisite for recognition as a specialist in plastic surgery.

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Principles

A thorough knowledge of anatomy, an understanding of the reaction of the tissues to operative procedures, and proper care in their handling during an operation are essential principles of all surgery. Careful asepsis, a proper respect for the tissues and preservation of important structures, avoidance of impairment of blood supply, prevention of hemorrhage (hemostasis), careful suturing of wounds without tension, and protection of tissues with an adequate dressing are all basic to successful surgical results.

The sacrifice of skin, particularly of the mouth, nose, and eyelids, where a minimal loss may destroy a feature or alter a delicate function of the face, is unforgivable. A wise precept with regard to severe lacerations of the face is: "It is better to save a piece of skin that may die than to sacrifice a piece of skin that may recover."

The plastic surgeon must be familiar with and practice all these principles. In addition, he is often challenged with the analysis or diagnosis of deformities resulting from injuries, burns, or wounds that seldom conform to a pattern and therefore do not lend themselves to standardized treatment. Plastic surgery is thus unique, since it is a specialty of methods. The skilled plastic surgeon is familiar with these methods and is able to apply them to the particular problem. Because a number of preliminary operations may be required before final repair can be achieved, an analysis of each problem is combined with a long-range plan for the several steps involved.

It is inexcusable to create a new defect as noticeable as the original or to distort a normal feature in carrying out a repair. The surgeon is constantly aware of the deformity that he may create, and he is alert to alternative methods that may be less deforming and equally appropriate for a particular problem. The type of procedure and the choice of the donor site (the area from which the tissue is to be taken for transplantation) are made with these thoughts in mind.

An important and oftentimes overlooked surgical principle is well expressed in the statement: "Surgery on deep structures can be no better than the surface healing." This is true particularly of the hand, of compound fractures, and of military plastic surgery, since 60 percent of all war wounds require plastic surgery before deep surgery on underlying structures can be carried out. The repair of a nerve or bone, the restoration of a defect in the skull, and the transfer or replacement of missing tendons often require as a preliminary step elimination of unhealthy scar and covering with healthy skin.

Methods

A major part of plastic surgery consists of the transfer of tissues either locally or from remote parts of the body as a substitute for deformed, damaged, or lost tissues of exposed or functioning parts. Most such tissues are used as free transplants or grafts—that is, they are detached completely from all blood supply in the donor area and must be nourished by new vessels in the recipient area or bed. Skin, bone, cartilage, tendon, nerves, fascia lata, mucous membrane, dermis, and fat are all transplanted in this way. Skin with subcutaneous tissue may, however, be transplanted as a flap, receiving its blood supply through a stemlike attachment to the body (pedicle) when a suitable bed is not present, as in a total loss of lip, nose, or cheek or in deeply scarred areas with impaired blood supply.

The free transplantation of skin has been practiced only since the latter part of the 19th century. There is some uncertainty as to who performed the first graft, but Jonathan Mason Warren (1811-1867) of Boston is said to have done one. Jacques Reverdin (1842-1928) is usually credited with the first demonstration that small bits of epidermis can be transplanted from one part of the body to another, and Robert Lawson Tait (1845-1899), Leopold Oilier (1830-1900), Karl Thiersch (1822-1895), John R. Wolfe (1824-1904), and Fedor Krause (1857-1937) are cited in connection with the early development of skin transplantation. Modern widespread use of free skin grafts began with the teachings of American plastic surgeons, particularly Vilray Papin Blair (1871-1955) and James Barrett Brown (1899- ), who in 1929 published the first of a series of papers on the use of skin grafts in the healing of wounds from burns, injuries, or surgical excisions and in the secondary correction of deformities resulting from skin losses. The importance of their contribution lay in the description of a simple, efficient method of obtaining large sheets of skin with a razor-sharp knife blade about six inches long. They indicated the generous amounts of skin available by this method; correctly interpreted the process of healing of the surface from which a graft is cut; and described the essentials for successful skin grafting, particularly hemostasis, the careful fitting of the graft in place with normal skin tension, the application of resilient pressure, and the accurate immobilization of the part. In competent hands failure with this method has become rare.

Another type of free skin graft, the full-thickness graft, is used for smaller restorations, especially in cases where there is delicate kinesis (muscular movement) beneath the surface, appearance is of primary importance, and the matching of skin color and texture is sought. Its greatest usefulness is for the face, particularly the areas about the mouth and eyelids, where the skin is thin and pliable. The skin at the base of the neck and upper chest, which has similar color and texture and is underlain by the platysma muscles (muscles of expression), is particularly suited for facial repairs because of its softness and flexibility.

The skin flap, including both skin and subcutaneous tissue, differs from the graft because it remains attached to the body at all times and receives its blood supply through a broad or narrow pedicle. There are two types of flaps, direct and delayed. In the direct flap, either the breadth of the attachment remaining after the elevation or the presence of a large artery in a narrow attachment assures an adequate blood supply. If one of these conditions cannot be satisfied, the flap must be delayed. In this case, all the vessels carrying blood to the skin except those entering through the pedicle are severed in stages by incising along the margins and by undermining the flap in two or more operative procedures, depending on its size and -location. When the delay is completed, the blood enters the flap only through the pedicle. Either a flat flap, which is sutured back in its original bed at each stage of the delay, or a tubed flap, which is fashioned by rolling the skin together like a suitcase handle so that the two edges can be brought in apposition, can be prepared. Each type has its indications and uses. The advantage of the tubed flap is that it can be migrated end over end from one part of the body to another.

Special Grafts

Special types of grafts include those of fascia lata, bone, cartilage, and tendon, as well as composite grafts from the ear. Fascia lata, the broad, thin, inelastic sheet of tissue on the outer side of the thigh, can be cut into narrow strips and used to support a face paralyzed because of damage to the facial nerve that controls the muscles of expression. It can also be transplanted as a thin sheet to fill a depression in an exposed part of the body caused by atrophy or injury. In rare instances, it can also be used as a substitute for tendons in the
hand or other parts of the body.

Bone from the rib, iliac crest (part of the pelvis), tibia (shinbone), and other parts finds many uses in plastic surgery. It may be used to restore the continuity of the jaw in bony losses from injury or from destruction by cancer, to restore the distorted contours of the face following injury, and to stimulate growth of bone when the union of a fractured bone has failed to progress normally. In addition, bone may be used to elevate a nose flattened because of loss of normal support, to restore the prominence of a depressed brow following injury, and to replace bony losses from the forehead and skull for solid protection to the underlying brain. The successful transplantation of bone requires that grafts be in contact with normal bone at either end.

Cartilage finds many uses similar to those of bone, but since it is a flexible tissue, it lacks the solidity and rigidity required for bridging bony defects. It need not be in contact with bone in order to survive, however, and thus is useful in restoring the contours of the face or nose where a filler only is necessary—for example, in elevating the depressed eyeball following injury or in correcting the so-called saddle deformity of the nose. Cartilage also is useful as a supporting framework for a deformed or defective ear.

Composite grafts of skin and cartilage from the rim of the ear have been used since 1946 in losses of the outer nostril (the ala) and the lower part of the wall separating the nasal passages (the columella). Since the rim of the ear and the rim of the nose both have two layers of skin with cartilage between them, the plastic surgeon's goal of replacing missing tissue with material as nearly like the original as possible can be realized.

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