What is reconstructive surgery?
The goals of reconstructive surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.
Although no amount of surgery can achieve “perfection,” modern treatment options allow plastic surgeons to achieve improvements in form and function thought to be impossible 10 years ago.
Who should consider reconstructive surgery?
There are two basic categories of patients: those who have congenital deformities, otherwise known as birth defects, and those with developmental deformities, acquired as a result of accident, infection, disease, or in some cases, aging.
Some common examples of congenital abnormalities are birthmarks; cleft-lip and palate deformities; hand deformities such as syndactyly (webbed fingers), or extra or absent fingers; and abnormal breast development.
Burn wounds, lacerations, growths, and aging problems are considered acquired deformities. In some cases, patients may find that a procedure commonly thought to be aesthetic in nature may be performed to achieve a reconstructive goal. For example, some older adults with redundant or drooping eyelid skin blocking their field of vision might have eyelid surgery. Or an adult whose face has an asymmetrical look because of paralysis might have a balancing facelift. Although appearance is enhanced, the main goal of the surgery is to restore function.
What are types of reconstructive surgery?
In deciding how to treat a wound, a plastic surgeon must carefully assess its size, severity, and features: is skin missing? Have nerves or muscles been damaged? Has skeletal support been affected?
Direct closure is usually performed on skin-surface wounds that have straight edges, such as a simple cut. Maximum attention is given to the aesthetic result, taking extra care to minimize noticeable stitch marks.
Skin Grafts
A wound that is wide and difficult or impossible to close directly may be treated with a skin graft. A skin graft is basically a patch of healthy skin that is taken from one area of the body, called the “donor site,” and used to cover another area where skin is missing or damaged. There are three basic types of skin grafts.
A split-thickness skin graft, commonly used to treat burn wounds, uses only the layers of skin closest to the surface. When possible, your plastic surgeon will choose a less conspicuous donor site. The skin will grow back at the donor site, however, it may be a bit lighter in color.
A full-thickness skin graft might be used to treat a burn wound that is deep and large, or to cover jointed areas where maximum skin elasticity and movement are needed. As its name implies, the surgeon lifts a full-thickness (all layers) section of skin from the donor site.
A composite graft is used when the wound to be covered needs more underlying support, as with skin cancer on the nose. A composite graft requires lifting all the layers of skin, fat, and sometimes the underlying cartilage from the donor site.
Tissue Expansion
Tissue expansion is a procedure that enables the body to “grow” extra skin by stretching adjacent tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired and then gradually filled with salt water over time, causing the skin to stretch and grow.
The advantages of tissue expansion are many-it offers a near-perfect match of skin color, sensation, and texture; the risk of tissue loss is decreased because the skin remains connected to its original blood and nerve supply; and scars are less apparent than those in flaps or grafts. The expander temporarily creates what can be an unsightly bulge, making this option undesirable for some patients.
Advanced Wound Care: Flap Surgery/Microsurgery
A flap is a section of living tissue that carries its own blood supply and is moved from one area of the body to another. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support.
A local flap uses a piece of skin and underlying tissue that lie adjacent to the wound. The flap remains attached at one end so that it continues to be nourished by its original blood supply and is repositioned over the wounded area.
A regional flap uses a section of tissue that is attached by a specific blood vessel. When the flap is lifted, it needs only a very narrow attachment to the original site to receive its nourishing blood supply from the tethered artery and vein.
A musculocutaneous flap, also called a muscle and skin flap, is used when the area to be covered needs more bulk and a more robust blood supply. Musculocutaneous flaps are often used in breast reconstruction to rebuild a breast after mastectomy. This type of flap remains “tethered” to its original blood supply.
In a bone/soft tissue flap, the bone, along with the overlying skin, is transferred to the wounded area, carrying its own blood supply.
A microvascular free flap is a section of tissue and skin that is completely detached from its original site and reattached to its new site by hooking up all the tiny blood vessels.
Other Reconstructive Procedures
In addition to correcting cuts and other surface wounds, plastic surgeons also regularly treat both cancerous and non-cancerous growths and problems with the supporting structures beneath the skin.
Skin cancers and growths are usually removed by excision and closure, in which the growth is simply removed completely with a scalpel, leaving a small thin scar. If the cancer is large or spreading, major surgery may be necessary, using flaps to reconstruct the affected area.
What are types of laser surgery?
In the past decade, laser technology has revolutionized many areas of plastic surgery. The laser’s allure comes from its ability to “blast” away or diminish imperfections or growths with a minimum of bleeding, bruising, and scarring.
Currently, there are many types of lasers available, with many more under development. Therefore, it’s important to understand that not all lasers are alike.
Yellow Pulsed-Dye Laser
The yellow pulsed-dye laser uses a type of dye as its active medium. It has a pulsing beam that is heavily absorbed by hemoglobin, which gives blood its red color. This laser is often used for performing surgery on children who have pinkish birthmarks called port-wine stains. The laser destroys the abnormal blood vessels, lightening the birthmark to the point of being barely noticeable. Scarring, which was a problem with earlier laser models, is minimal with the yellow pulsed-dye laser.
“Pigment-blasting” Laser
The “pigment-blasting” laser family - the Q-switch ruby, the Q-switch yag, and the alexandrite is a group of lasers effective in eliminating the black and blue pigments of tattoos, pigmented lesions and the brown patches and spots that often occur with aging.
Though the removal of decorative tattoos is considered a cosmetic procedure, the removal of “traumatic tattoos” is a reconstructive process. Traumatic tattoos occur when material particles are forced under the skin through an accident-as in an explosion or a collision.
Carbon Dioxide Laser
The carbon dioxide laser is an invisible light absorbed by water, the primary component of human skin. When the beam is focused, it can cut tissue and seal blood vessels simultaneously. When defocused, it vaporizes. These characteristics make it the treatment of choice for removing warts and many types of skin growths.
Yag Laser
The yag laser has been shown to be effective in the surgery of various types of hemangiomas, which are skin growths with heavy concentrations of blood vessels. It delivers highly-focused energy and-unlike other lasers-its tip can be placed directly on the skin, mimicking a scalpel.
Argon Laser
The argon laser is similar to the yellow pulsed-dye laser. The argon laser emits a blue-green light that is absorbed heavily by the color red. It is particularly effective in treating abnormalities that have a proliferation of blood vessels, such as blood blisters, “spider” blood vessels on the face, “strawberry” birthmarks, hemangiomas, and bulky vascular tumors.
Copper Vapor Laser
The copper vapor laser is a newer type of laser that emits a yellowish light. Its uses include treating brown or red pigmented areas.
The number of laser treatments you’ll need depends largely upon the size and severity of the defect. A child with a large birthmark may need six to ten laser treatments to achieve satisfactory results. Only one treatment may be needed to remove some small spider veins on the face.
Lasers have a number of valuable uses, but a laser should not be viewed as a “magic wand” that improves the results of any type of surgery. For traditional kinds of surgery and most plastic surgery, the scalpel is still the proven instrument of choice.
What are the risks of reconstructive surgery?
When reconstructive surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. However, individuals vary greatly in their anatomy and healing ability and the outcome is never completely predictable.
As with any surgery, complications can occur. These may include infection; excessive bleeding, such as hematomas (pooling of blood beneath the skin); significant bruising and wound-healing difficulties; and problems related to anesthesia and surgery.
There are a number of factors that may increase the risk of complications in healing. In general, a patient is considered to be a higher risk if he or she is a smoker; has a connective-tissue disease; has areas of damaged skin from radiation therapy; has decreased circulation to the surgical area; has hiv or an impaired immune system; or has poor nutrition. If you regularly take aspirin or some other medication that affects blood clotting, it’s likely that you’ll be asked to stop a week or two before surgery.
Planning your surgery
In evaluating your condition, a plastic surgeon will almost always begin at the bottom of the reconstructive ladder in deciding how to approach a patient’s treatment, favoring the most direct, least-complex way of achieving the desired result.
The size, nature and extent of the injury or deformity will determine what treatment option is chosen and how quickly the surgery will be performed. Reconstructive surgery frequently demands complex planning and may require several procedures done in stages.
Because it’s not always possible to predict how growth will affect outcome, a growing child may have to plan for regular follow-up visits on a long-term basis to allow additional surgery as the child matures.
Everyone heals at a different rate-and plastic surgeons cannot pinpoint an exact “back-to-normal” date following surgery. They can, however, give you a general idea of when you can expect to notice improvement.