Health Resources

Plastic and reconstructive surgery

Reconstructive surgery goals differ from those of cosmetic surgery. Its purpose is to improve function or approximate a normal appearance. It’s performed on abnormal structures of the body caused by:

  • Birth defects
  • Developmental abnormalities
  • Disease
  • Infection
  • Injury
  • Trauma
  • Tumors

In cosmetic surgery, surgeons reshape normal body structures. The goal: To improve the patient’s appearance and self-esteem. No amount of surgery can achieve perfection. Surgeons can make improvements in form and function that were impossible 10 years ago.

Who has reconstructive surgery? 

There are two categories. Those with:

  • Congenital deformities, otherwise known as birth defects
  • Developmental deformities acquired as a result of accident, infection, disease, or aging

Congenital abnormalities include:

  • Birthmarks
  • Cleft-lip and palate deformities
  • Abnormal breast development
  • Hand deformities such as:
    • Extra or absent fingers
    • Webbed fingers

Acquired deformities include:

  • Aging problems
  • Burn wounds
  • Growths
  • Lacerations

Often, aesthetic procedures are constructive as well. Many older adults opt for surgery to remove redundant eyelid skin. Facelifts can balance asymmetrical faces caused by paralysis. 

The function is critical. Enhanced appearance is a byproduct of the procedure.

Breast reduction can give women more comfortable breasts in proportion to their bodies. Large, sagging breasts are a deformity that develops because of the following:

  • Disease
  • Genetics
  • Hormonal changes

Children might have outer-ear surgery to correct deformed or large ears. Health insurance usually covers this, but check with your carrier for limitations. Work with your doctor to get pre-authorization from the insurer for the procedure.

Uncertainty and risk of surgery

All surgery carries some uncertainty and risk. Complications are infrequent and minor when a qualified plastic surgeon performs reconstructive surgery. Patients vary in their anatomy and healing ability, though. So the outcome is never completely predictable.

As with any surgery, complications can occur. These may include:

  • Infection
  • Bleeding (hematoma, blood pooling beneath the skin)
  • Bruising
  • Problems related to anesthesia and surgery.
  • Wound healing difficulties

Some factors can increase the risk of complications, such as smoking, or having a history of:

  • Connective tissue disease
  • Damaged skin from radiation therapy
  • Decreased circulation in the surgical area
  • HIV or an impaired immune system
  • Poor nutrition

You’ll have to suspend medications that affect blood clotting before surgery.

Planning your surgery 

Your plastic surgeon will use the reconstructive ladder rules to assess your condition. The least complex treatments, such as simple wound closure, are at the bottom of the ladder. Complex procedures, such as microsurgery to reattach limbs, are on the highest rungs. 

Plastic surgeons usually start at the bottom when evaluating how to approach treatment. They’ll favor the most direct, least-complex means to achieve the desired result.

Other factors of the deformity or injury in determining treatment and timing:

  • Extent
  • Nature
  • Size

Reconstructive surgery often demands complex planning. It might be necessary to perform surgery in stages.

It’s difficult to predict how growth will impact the outcome. A child might have follow-up visits long-term in case more surgery is necessary as they mature. Patients heal at different rates. Surgeons can’t pinpoint an exact “back-to-normal” date after surgery. They can give you a general idea of when you can expect to notice.

Post-Surgical wound care

Plastic surgeons must assess many factors when deciding how to treat a wound, including:

  • Features
  • Severity
  • Size

Questions they must ask include:

  • Has it affected skeletal support?
  • Is the skin missing?
  • Is there muscle or nerve damage?

It’s imperative for the patient to understand what will happen during the procedure. Ask questions so that you can make an informed decision.

Skin-surface wounds with straight edges, such as a cut, usually get stitched up directly. The aesthetic result gets the most attention. A surgeon will take care to limit noticeable stitch marks.

Wide wounds or those difficult to close might need a skin graft. A skin graft is a patch of healthy skin taken from another area of the body, called the “donor site.” It’s used to cover the area absent of skin or with damage to it. 

There are three types of skin grafts:

  1. Split-thickness. Used to treat burn wounds, it incorporates skin layers closest to the surface. A plastic surgeon will choose an inconspicuous donor site if possible. The color and size of the skin are factors in determining that location. The skin will grow back at the site but might be a lighter color.
  2. Full-thickness. Used to treat a burn wound that is deep and large enough to cover jointed areas. Also, where the patient needs the most skin elasticity and movement. The surgeon will lift all layers of a section of skin from the donor site. This usually results in a thin-line scar from a direct-wound closure at the donor site. 
  3. Composite. Used when the wound needs more underlying support. An example: Skin cancer on the nose. A surgeon takes all layers of fat, skin, and sometimes cartilage from the donor site. This usually results in a thin-line scar on the donor site that will fade in time.

This procedure enables the body to grow extra skin by stretching adjacent tissue. Surgeons insert an expander, a balloon-like device, under the skin near the repair area. They fill the expander with salt water at a gradual pace, causing the skin to grow and stretch.

The individual case and the size of the repair area determine the time this procedure will take.  

Tissue expansion results in a near-perfect match in:

  • Sensation
  • Skin color
  • Texture

The skin remains connected to its original blood and nerve supply. This means there’s a lower risk of tissue loss. Scars are less noticeable than those from flaps or grafts. The expander creates a bulge, which makes it an undesirable option for some. The bulge is temporary.

Flap surgery and microsurgery have improved a plastic surgeon’s ability to help patients. Those with severe disfigurement or injuries benefit most from these advancements. Still, the extent of an injury is the biggest factor. 

Advanced techniques often take hours and involve the use of an operating microscope. Surgeons can replant fingers or transplant large sections of bone, muscle, or tissue. All with the original blood supply intact. 

A flap is living tissue that carries its own blood supply. It’s moved from one area of the body to another. Flap surgery can restore form and function to areas that have lost many things, such as:

  • Fat
  • Muscle movement
  • Skeletal support
  • Skin

A local flap uses a piece of skin and underlying tissue close to the wound. The flap remains attached at one end to stay connected to the original blood supply. It’s then repositioned over the wound.

A regional flap uses a section of tissue attached to a specific blood vessel. When lifted, a flap needs only a narrow attachment to the original site to maintain blood supply. 

A musculocutaneous flap is also called a muscle and skin flap. Surgeons use this when they need more bulk and a robust blood supply to an affected area. It is often used in breast reconstruction after a mastectomy. The flap remains tethered to its original blood supply.

In a bone/soft tissue flap, bone and overlying skin get transplanted to the wounded area with its own blood supply.

A microvascular-free flap is a section of tissue and skin detached from the original site. Surgeons reattach it to the wounded site by hooking up all the tiny blood vessels.

Plastic surgeons treat growth and problems with the supporting structures beneath the skin. These can be cancerous or non-cancerous. Tumors, benign or malignant, vary in many ways. These include:

  • Recurrence
  • Severity
  • Type

Factors that determine the removal method include:

  • Location on the body
  • Stage
  • Types of growth

Surgeons usually use excision and closure for growths and skin cancers. They remove the growth with a scalpel, which leaves a small, thin scar. Surgery is likely for large or spreading cancers. Surgeons will reconstruct affected areas with flaps.

For acquired or congenital hand defects, a plastic surgeon can usually restore:

  • Comfort
  • Mobility
  • Normal appearance

Acquired defects can include:

  • Carpal tunnel and other conditions caused by pressure on the nerves (at the wrist or elbow)
  • Trigger fingers, caused by swelling of a flexor tendon in the hand
  • Ganglion cysts. They’re benign growths and scar contractures when a wound or burn doesn’t heal well. It can form scar tissue that curls fingers or restricts mobility.

Finger separation can benefit children born with webbed fingers. a Zigzag incision separates the fingers and rearranges tissue between them. This helps prevent growth deformities. 

If a child has extra fingers, correction is more complicated than removing them. A surgeon might also need to balance the hand tendons. They might also stabilize the remaining finger joints to restore normal hand functions. 

Surgeons also construct missing digits. This includes the thumb, which accounts for half of the hand’s function. 

In the past decade, laser technology has revolutionized several areas of plastic surgery. Lasers can diminish imperfections or growths with little bleeding, bruising, and scarring. There are many types of laser available, with many more under development. 

The yellow pulsed-dye laser uses a type of dye as its active medium. It has a pulsing beam that hemoglobin absorbs, which gives blood its red color. Surgeons use this for surgery on children with pinkish birthmarks called port-wine stains.

The laser destroys abnormal blood vessels and lightens the birthmark. Scarring, a problem with earlier lasers, is minimal with the yellow pulsed-dye laser.

Pigment-blasting lasers are effective at eliminating black and blue pigments common with:

  • Brown patches and spots that occur with aging
  • Pigmented lesions
  • Tattoos

Pigment-blasting lasers include:

  • Q-switch 
  • Ruby
  • Q-switch YAG
  • Alexandrite

The carbon dioxide laser is the workhorse of lasers. It’s invisible light absorbed by water, the primary component of human skin. The beam can cut tissue and seal blood vessels when focused.

When defocused, it vaporizes. This makes it the treatment of choice for removing warts and other skin growths.

The YAG laser is effective in the surgery of various types of hemangiomas. These are skin growths with heavy concentrations of blood vessels. The YAG laser delivers focused energy. Unlike other lasers, its tip can touch the skin, mimicking a scalpel.

The argon laser is like the yellow pulsed-dye laser. The argon laser emits a blue-green light that is absorbed by red. It is effective to treat abnormalities that have a proliferation of blood vessels. These include:

  • Blood blisters
  • Bulky vascular tumors
  • Hemangiomas
  • Spider blood vessels on the face
  • Strawberry birthmarks

The copper vapor laser is a brand-new type of laser that emits yellowish light. Its uses include treating brown or red-pigmented areas.

The number of laser treatments you’ll need depends on the size and severity of the defect. A child with a large birthmark might need six to 10 treatments for satisfactory results. Removal of some small spider veins on the face might require only one treatment.

Lasers have many valuable uses but they are not magic wands that improve the results of any type of surgery. The scalpel is the instrument of choice for traditional surgery and plastic surgery.