INTRODUCTION
Plastic surgery, although thought of as a technique-oriented specialty, is in fact a problem-solving field. The training of a plastic surgeon allows him or her to see surgical problems in a different light and select from a variety of options to solve surgical problems. Plastic surgeons have received broad training, and most have completed residencies in other fields such as general surgery, ENT surgery, orthopedics, urology, or neurosurgery.
The basic principles of plastic surgery are careful analysis of the surgical problem, careful planning of procedures, precise technique, and atraumatic handling of tissues. Alteration, coverage, and transfer of skin and associated tissues are the most common procedures performed. Plastic surgery may deal with closure of surgical wounds—particularly recalcitrant wounds such as those occurring post radiation or poorly healing wounds in immunocompromised patients—removal of skin tumors, repair of soft tissue injuries or burns, correction of acquired or congenital deformities of the breast, or repair of cosmetic defects. Operations on the head and neck and the hand may require special surgical training.
In the past 2 decades, increased knowledge of anatomy and the development of many new techniques have brought about important changes in plastic surgery. It is now known that in many areas the blood supply of the skin is derived principally from vessels arising from underlying muscles and larger perforating blood vessels rather than solely from vessels of the subcutaneous tissue, as was formerly thought. One-stage transfer of large areas of skin and muscle tissue can be accomplished if the axial pedicle of the underlying muscle is included in the transfer. With the use of microsurgical techniques, musculocutaneous units or combinations of bone, muscle, and skin can be successfully transferred and vessels and nerves less than 1 mm in size can be repaired. These so-called free-flap transplantations are a major advance in the treatment of defects that were previously untreatable or required lengthy or multistaged procedures. More sophisticated knowledge of the blood supply to the skin has introduced a concept of perforator flaps whereby one perforating vessel is identified that may supply a large segment of overlying skin. Similarly, the concept of neurocutaneous arteries and flaps has given rise to the design of additional flap territories such as the so-called sural flap in the lower leg.
The plastic surgeon, as a member of the craniofacial surgical team, is able to dramatically improve the appearance and function of children with severe congenital deformities. Children of normal intelligence who previously had been social outcasts are now able to lead relatively normal lives. Improved understanding of facial growth and abnormal development and diagnostic techniques such as the CT scan, MRI, and three-dimensional computer-assisted imaging enable the reconstructive surgeon to develop a complex strategy for remodeling the deformed craniofacial skeleton. This may involve remodeling or repositioning part or all of the cranial vault, the orbits, the mid face, and the mandible. These complex and at times formidable reconstructions, which were performed by moving both units and adding bone grafts from the ileum, have more recently been somewhat simplified with the introduction of the miniplate method of fixation as well as of bone substitutes that may serve as a scaffold upon which normal bone can regrow.
A recent notable advance in craniofacial surgery has been the introduction of distraction osteogenesis, which borrows from the Ilizarov principle of distraction where one makes a cortical cut in the bone and then applies a distraction apparatus so that in measured amounts (usually 1 mm per day) the bone is transported to bridge a gap. In craniofacial surgery it is more commonly brought to bear to enlarge or cause overgrowth of areas such as an underdeveloped mandible.
Additional areas of involvement for the plastic surgeon entail allotransplantation, particularly with the increasing number of clinical limb allotransplants, which unfortunately at present still require immunosuppression. It is hoped that immunotolerance will some day become a reality, thus allowing transplantation of nonessential organs.
Tissue engineering of bone, cartilage, and nerve is an area of ongoing research for plastic surgeons. Although encouraging experimental results have been reported in anatomic areas difficult to reconstruct such as the external ear, there are as yet no clinical applications.
Fetal surgery—an area pioneered by a number of plastic surgeons—appears to be in a quiescent stage, particularly because of advances in the treatment of cleft lip and cleft palate in the newborn.
Jones JW et al: Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team. N Engl J Med 2000;343:468.