47 Plastic and reconstructive surgery

ABERRANT HEALING
FLAP MONITORING
FURTHER READING
FUTURE DIRECTIONS
Flaps
Grafts
HISTORY
Introduction
LEECH THERAPY
Learning objectives
Lipotransfer
MICROSURGERY
RECONSTRUCTIVE TECHNIQUES
WHAT IS RECONSTRUCTIVE PLASTIC SURGERY
WOUND DRESSINGS
WOUND HEALING

ABERRANT HEALING

Scarring can be aberrant owing to a combination of genetic predisposition and environmental factors. The two main types of abnormal scarring are hypertrophic and keloid scars. Hypertrophic scars are elevated within the borders of the original scar and a ﬀ ect up to 15% of wounds. They tend to occur soon after injury , subsiding over time, and arise in areas of /uni00A0 tension, particularly ﬂ exor surfaces. They may be successfully treated with topical silicone, intralesional corticosteroid injection, compression therapy or surgical excision. Keloid scars, by contrast, extend beyond the original wound borders and can be locally destructive; in extreme cases, they are debilitating. They occur more commonly in darker skin types and may arise some months after the injury , most com monly a ﬀ ecting the face, earlobes, deltoid area and presternal region. They are more resistant to treatment and may require repeated excision with adjuvant radiotherap y . Scars may also be widened, thin and depressed owing to excess tension across the wound. Scars may also be unstable and prone to recurrent ulceration and breakdown; this is most frequently seen at mobile sites (such as overlying major joints or the neck) when healing has been achieved secondarily . These scars can be excised (serially if necessary) or resurfaced with a ﬂap in order to provide more robust coverage. Wounds that fail to heal properly may become populated with unstable and highly vascular granulation tissue (‘over granulated’) that is fragile and prone to intermittent bleeding. These may be tr eated with topical silver nitrate or cortico steroid or may require formal excision and reconstruction. A traumatic w ound can lead to the development of a pyo genic granuloma. This is a benign proliferation of capillary blood vessels of the skin and presents as a painless red ﬂeshy nodule that grows rapidly over several weeks and bleeds inter mittently ( Figur e 47.5 ). It may be treated topically as per over- granulation tissue but frequently requires surgical excision. In chronic wounds, such as in pressure sor es, burns or osteomyelitis, the chronicity of the inﬂammatory environment can lead to the development of a Marjolin ulcer. This is a rare but aggressive form of squamous cell carcinoma that has a high propensity for distant metastasis. A low index of suspicion must be observed in chronic wounds that undergo sudden phenotypic change, so early biopsy is advocated.

Figure 47.5 Pyogenic granuloma following a glass laceration to the base of the right middle /f_i nger.

ABERRANT HEALING

Figure 47.5 Pyogenic granuloma following a glass laceration to the base of the right middle /f_i nger.

ABERRANT HEALING

Figure 47.5 Pyogenic granuloma following a glass laceration to the base of the right middle /f_i nger.

FLAP MONITORING

Following microvascular free-ﬂap reconstruction, patients may be monitored in a high-dependency unit setting as it is crucial to keep the patient physiologically optimised in order that the ﬂap remains well perfused at all times. The traditional adage is that the patient should be kept ‘wet, warm and comfortable’. - Strict ﬂuid balance is monitored with the aim of keeping the circulation hyperdynamic; the ﬂap is kept warm with a Bair ® Hugger device and analgesia is carefully controlled to mini - mise excessive catecholamine production as a result of pain. - The ﬂap is monitored regularly by specialist nurses who assess - the colour, warmth and turgor of the ﬂap. Pressure applied to the skin of a musculocutaneous ﬂap enab les the capillary reﬁll ). time to be assessed; if necessary the ﬂap can be pricked with a hypodermic needle to assess bleeding. The arterial and venous ﬂow to a ﬂap can often be monitored with a hand-help Doppler device, whereas some surgeons use an implantable Doppler (attached to the venous outﬂow of the ﬂap), which is especially useful for muscle ﬂaps (without the beneﬁt of a skin paddle to monitor) or those ﬂaps that are buried and thus not accessible for direct visual monitoring. The survival of a free ﬂap is usually threatened by an interruption to arterial inﬂow or venous drainage; rapid iden tiﬁcation of a problem is essential as an immediate return to theatre is required to salvage the ﬂap. A pproximately 5% of free ﬂaps will require exploration in theatre f or vascular com promise; of these, more than 60% can be salvaged. The earlier a ﬂap is explored the greater the likelihood of salvage success. Approximately two-thirds of cases of vascular compr omise are venous in aetiology , with one-third being arterial; combined inﬂow and outﬂow issues are sometimes seen, and in some situ ations the vessels may be patent but compromised by external pressure (such as a haematoma or an excessively tight dress ing). Thus, when assessing a compromised ﬂap at the bedside, the surgeon must ensur e that the dressings are loosened and any overly tensioned sutures released. Close ﬂap monitoring is of most value in the ﬁrst 48 hours with rapid detection of vascular compromise facilitating early salvage and improved ﬂap survival. A free-ﬂap survival rate in excess 95% is typical in rou tine elective reconstructive cases such as breast reconstruction using a transverse rectus abdominis (TRAM) or deep inferior epigastric perforator (DIEP) ﬂap. Flap survival rates are slightly lower in, for example , cases of complex polytrauma or head and neck reconstruction.

(h) (c) (d) Figure 47.28 Replantation of digit. (a–c) Complete avulsions of the index and middle /f_i ngers at the distal interphalangeal joints. The avulsed middle /f_i nger was not salvageable. (d) The avulsed index /f_i nger was dissected and the digital arteries, veins and nerves were identi /f_i ed. Heterotopic replantation of the avulsed index /f_i nger to the middle. appearance with the range of motion demonstrated. (i) (j) (e–g) Immediate postoperative appearance. (h–j) One-year postoperative

FLAP MONITORING

FUTURE DIRECTIONS

Anatomical discoveries, such as a detailed understanding of the blood supply to the skin as well as technical and engineering innovations that brought about microsurgery , have enabled the ﬁeld of reconstructive plastic surgery to blossom. As populations age and life expectancies continue to improve, the demand for reconstructive surgery , particularly among the elderly popula tion for chronic degenerative and neoplastic conditions, will continue apace. The key to the next phase of reconstructive plastic surgery advances will likely be a combined approach across multiple scientiﬁc and surgical disciplines. T he scientiﬁc areas that will lead to signiﬁcant breakthroughs include wound healing, bioengineering, cancer treatment and immunotolerance for vascularised allotransplantation. Recent discoveries of the genetic, epigenetic and molecular mechanisms that under lie conditions such as craniosynostosis, cleft lip and palate, Dupuytren’s disease and delayed wound healing now Baron Guillaume Dupuytren , 1777–1835, Surgeon in Chief, Hôtel-Dieu, Paris, France. interventions. Bioengineering and tissue engineering will certainly play a major role in modern reconstruction; for example, smart tissue expansion for cleft palate reconstruction and biocompatible sca ﬀ olds that simultaneously pr omote in situ tissue regeneration as well as deliver treatment by eluting antibiotics or chemotherapeutic agents for musculoskeletal and cancer reconstruction. Furthermore, as the cultural and political landscapes evolve, new areas of reconstructive surgery have emerged, including gender-a ﬃ rming surgery . One of the most exciting areas of reconstructive plastic surgery has been the increasing success of vascularised composite allotransplantation, including of the face and upper limb. Outcomes are expected to continue to improve with better understanding of immunological tolerance and increasing social acceptance of the donation of body parts. The ﬁeld of robotic surgery continues to expand. It is par - ticularly useful to assist in surgical approaches where access is limited, such as cleft surgery . The latest devices are able to eliminate hand tremor, increase dexterity and range of motion, provide haptic feedback and thr ee-dimensional views that assist greatly in challenging dissections, and have been successfully adopted in oncological head and neck reconstruction. Reconstructive plastic surgery is unique in its creativity , breadth and variety of reconstructive techniques. While this a ﬀ ords the specialty powerful means to serve the patient, it does also mean the practice of evidence-based surgery is challenging. There are often numerous techniques to treat the same conditions with a lack of high-quality evidence. Moreover, there are often situations where surgery may be technically feasible but not in the best interest of the patient. - For example, patients with complex multifragmentary open tibioﬁbular fractures and neurovascular compromise may have a better quality of life with a below-knee amputation than with a salvage reconstruction with free tissue transfer. Hence, well-designed pragmatic clinical trials and the development of rigorous tools to capture the most relevant data, such as patient-reported outcome measures, together with the building of large-scale clinical research networks at both national and international levels will be crucial to drive complex shared decision making between surgeon and patient. - FUTURE DIRECTIONS

Flaps

A ﬂap is a block of tissue that contains an innate blood supply that may be transferred from a donor site to reconstruct a secondary defect; the pedicle is the ‘base’ of the ﬂap that contains the blood supply . Unlike a graft, a ﬂap can therefore be used to reconstruct a defect that does not have a vascu larised wound bed, such as exposed tendon, cortical bone or a prosthesis. There are numerous methods of classifying ﬂaps: according to their blood supply , their proximity to the defect, the method by which they ar e transferred and the tissue that they contain. The ﬁve Cs methodology is a useful ﬂap classiﬁcation system based on their circulation, composition, contiguity , contour and conditioning ( Figure 47.12 ). 1 Circulation : random pattern ﬂaps have no dominant blood supply whereas axial ﬂaps have a dominant feeding vessel. 2 Composition : cutaneous, fasciocutaneous, fascial, musculocutaneous, muscle, osseocutaneous, osseous, omentum/bowel. 3 Contiguity : local (where the ﬂap shares a side with the defect) ( Figure 47.13 ), regional (where the ﬂap is near but not immediately adjacent to the defect) ( Figures 47.14 and 47.15 ) and distant (where the ﬂap is far from the defect and can be either pedicled or free) ( Figures 47.16 and 47.17 ). Sydney Reese Coleman , contemporary , plastic surgeon, New Y ork, NY , USA. George Carl Cormack , contemporary , plastic surgeon, Cambridge, UK. Byrom George Harker Lamberty , contemporary , plastic surgeon, Cambridge, UK. Bengt Pontén , 1923–2007, Associate Professor of Plastic Surgery , Uppsala University , Uppsala , Sweden. Stephen John Mathes , 1943–2007, Professor of Surgery , University of California, San Francisco, CA, USA. Foad Nahai , contemporary , Professor of Surgery , Emory University , Atlanta, GA, USA. into the defect – advancement ( Figures 47.18 and 47.19 ), transposition ( Figure 47.20 ), rotation ( Figure 47.21 ), interpolation, waltzing, crane principle and free. 5 Conditioning : whether the ﬂap is delayed by partially elevating and resetting the ﬂap prior to deﬁnitive elevation and transfer. Delay enables a larger ﬂap to be harvested by - improving its blood supply . - Fasciocutaneous ﬂaps comprise a fascial component that augments the ﬂap blood supply owing to a network of sub - fascial, fascial and suprafascial vessels. Fasciocutaneous ﬂaps may be classiﬁed according to Cormack and Lamberty (1984) ( Figure 47.22 ): /uni25CF Type A: multiple perforators that can be direct or indirect (e.g. Pontén ﬂap). /uni25CF Type B: single perforator that is usually direct and runs along the axis of the ﬂap (e.g. the scapular or parascapular ﬂaps). /uni25CF Type C: segmental perforators that arise from the same source vessel (e.g. the radial forearm and lateral arm ﬂaps) ( Figure 47.23 ). /uni25CF Type D: similar to type C; however, the ﬂap is raised as an osteomyofasciocutaneous ﬂap (e.g. the free ﬁbular ﬂap). In muscle and musculocutaneous ﬂaps the motor nerve is always accompanied by a vascular pedicle, which is often the major source of the ﬂap circulation. A dominant pedicle can sustain an entire muscle whereas a minor pedicle can nor - mally only sustain a portion of the ﬂap. T he skin in a musculo - cutaneous ﬂap is supplied by perforators. Muscle ﬂaps are - classiﬁed by Mathes and Nahai (1981) ( Figure 47.24 ): /uni25CF Type I: single vascular pedicle (e.g. tensor fascia lata and gastrocnemius). /uni25CF Type II: one dominant pedicle with one or more minor pedicles (e.g. gracilis, biceps femoris, sternocleidomastoid, soleus and trapezius); the ﬂap cannot survive on the minor pedicle(s) alone. /uni25CF Type III: dual dominant pedicles (e.g. gluteus maximus, pectoralis minor, rectus abdominis, serratus anterior and temporalis). /uni25CF Type IV: segmental pedicles (e.g. ﬂexor hallucis longus, sar - torius and tibialis anterior). /uni25CF Type V: dominant pedicle with several smaller segmen - tal pedicles (e.g. latissimus dorsi and pectoralis major) ( Figures 47.25 and 47.26 ); the ﬂap can survive on the minor pedicles alone. A chimeric ﬂap consists of multiple otherwise spatially independent ﬂaps, each of which has an independent vascular supply , with all pedicles linked to a common source vessel. For example, the descending branch of the lateral femoral

TRANSPOSITION FLAP Donor defect (grafted or sometimes closed Defect primarily) Pivot point (b) BILOBED FLAP Uses a /f_l ap to close a convex defect, and a second smaller /f_l ap to close the donor site Secondary ap Flap (c) RHOMBOID Tissue FLAP defect a´ a´ a A parallelogram- shaped transposition Flap /f_l ap a Figure 47.12 Local /f_l ap diagrams. (a) Transposition and Z-plasty /f_l aps. (b) Bilobed and bipedicled /f_l aps. (c) Rhomboid and rotation /f_l aps. ( continued overleaf ) Z-PLASTY Tw o triangular transposition /f_l aps interposed 1 23 B A A B B A 45 6 B B B A A A BIPEDICLE FLAP A ‘bucket-handle’ /f_l ap supplied from both ends. Useful to rebuild the lower eyelid Flap RO TA TION FLAP a a b b

A DVANCEMENT FLAP ectangular Simple r (with or without Bur ow ’s triangle excision at base) Defect Tw o Bu ro w’s triangles can be excised at base of /f_l ap to make it slide V to Y e.g. cut /f_i ngertip Flap (e) 2 1 Mark a long Bu rn scar zig-zag along with long the scar ellipse around it 5 4 The cut lines The /f_i nished wound will look will look something something like like this this each becomes Pad it well, and be a a´ Advance the sure to splint open b´ b tips of the when not exercising zig-zags into the spaces Y to V Usually multiple Area of to r elease band scar scars over joint s shaded This is one of the fective most ef means of r eleasing moderate isolated band bur n scars over /f_l exion cr eases 3 Add in the horizontal lines to the zig-zag; a´ each becomes a b´ a ‘Y’ b Figure 47.12 ( continued ) Local /f_l ap diagrams. (d) Advancement /f_l aps. (e) Multiple Y-to-V plasty for burn scar.

Figure 47.13 Bilobed /f_l ap reconstruction of a nasal defect following excision of a basal cell carcinoma. raised. (c) Transposition of bilobed /f_l ap. (d) Immediate postoperative appearance. (a) (b) Figure 47.14 Forehead /f_l ap reconstruction of nasal defect following excision of multiple basal cell carcinomas. demonstrating the forehead /f_l ap based on the right supratrochlear artery. The pedicle position is con /f_i rmed using a hand-held Doppler probe. /uni00A0 (b) Flap inset to nose – note the bulky pedicle at the right medial eyebrow; donor site closed primarily except at the widest point, where it is allowed to heal by secondary intention. (c) The /f_l ap pedicle was divided at a second stage, allowing contouring of the /f_l ap. Appearance at 6 /uni00A0 months. (a) Excision markings. (b) Bilobed /f_l ap (c) (a) Preoperative markings

(e) (f) (a) (b) (d) Figure 47.16 The medial sural artery perforator (MSAP) /f_l ap can be used as a pedicled /f_l ap for regional defects or as a free /f_l ap for distant defects. (a) Traumatic defect of the anterior knee with a partially transected patellar ligament and cortical loss of the tibial tuberosity following wound debridement. (b, c) The MSAP /f_l ap is harvested – the perforator (arrow) is identi /f_i ed arising from the substance of the gastrocnemius muscle belly. (d, e) The /f_l ap remains attached to a pedicle and is transferred through a subcutaneous tunnel to the anterior knee defect. (f) /uni00A0 Appearance after inset of the /f_l ap. (g) Figure 47.15 Reconstruction of calcaneal osteomyelitis using a pedicled medial plantar artery /f_l ap. (a) Chronic wound over calcaneal osteomyelitis. (b) The medial plantar artery (MPA), a continuation of the posterior tibial (PT) artery, marked out using a Doppler probe and the skin /f_l ap designed accordingly. (c, d) Calcaneal wound debrided and /f_l ap raised. (e) Flap transferred onto the heel. (f) Immediate postoperative appearance of the /f_l ap inset with a meshed split-thickness skin graft laid on the donor site. (g) One-month postoperative appearance. (c) (e) (f)

(d) (f) Figure 47.17 The medial sural artery perforator (MSAP) /f_l ap can be used as a pedicled /f_l ap for regional defects or as a free /f_l ap for distant defects. (a) A longstanding diabetic foot ulcer of the left hallux with underlying osteomyelitis. (b) Marking of the MSAP /f_l ap. (c) Amputation of the hallux – direct closure would have neces

sitated proximal excision of the /f_i rst metatarsal bone, thereby compromising weightbearing. /uni00A0 (d) The MSAP pedicle (arrow) dissected. (e) The detached MSAP /f_l ap with the pedicle (arrow). appearance of the (f, g) Immediate postoperative /f_l ap, with indwelling Doppler monitoring (arrows) for venous anastomosis patency. (b) (a) Figure 47.18 Excision of a basal cell carcinoma of the right alar groove and reconstruction with a V-to-Y nasolabial advancement /f_l ap. /uni00A0 (a) Tumour excision margins and /f_l ap design markings. (b) The defect following excision of the basal cell carcinoma. /f_l ap. (d) Advancement and inset of the /f_l ap. (e) (g) (c) (d) (c) Raising the nasolabial

Figure 47.19 Hatchet /f_l ap reconstruction following excision of a skin cancer of the right eyebrow. the tumour with a back cut to enable /f_l ap advancement. (c) Insetting of the /f_l ap. (a) (b) x x y y Figure 47.20 Reconstruction of a melanocytic lesion of the left pre- auricular region using a rhomboid (transposition) /f_l ap. (a) Preoperative markings. (b) Immediate postoperative appearance. (a) (b) Muscle Figure 47.22 Cormack and Lamberty classi /f_i cation of fasciocutaneous /f_l aps. small, segmental perforators. (d) Osteomyofascial perforators. (a) Preoperative planning. (b) Post excision of (d) Immediate postoperative appearance. (a) (b) Figure 47.21 Rotation /f_l ap reconstruction following excision of a pilonidal sinus. (a) Preoperative marking of the rotational /f_l ap with a back cut. (b) Immediate postoperative appearance. (c) (d) Bone Muscle /uni00A0 (a) Multiple large perforators. (b) Single large perforator. (c) Multiple,

(d) (e) (f) (g) Figure 47.23 Wound debridement and reconstruction with a pedicled /f_l ap based on a perforator arising from the posterior tibial artery. sinus overlying internal /f_i xation of a medial malleolar fracture. skin (X). (c) The perforator (arrow) and a pair of vena comitans were dissected and the fasciocutaneous /f_l ap islanded. 180° clockwise to reconstruct the defect. (g) The donor site was able to be closed primarily owing to local skin laxity. Type I Type II Gluteus maximus Gracilis Tensor fascia lata Figure 47.24 The Mathes and Nahai classi /f_i cation of muscle /f_l aps. /uni00A0 (a) Chronic (b) The perforator has been identi /f_i ed using a Doppler probe and marked on the (d–f) The /f_l ap is propellered Type IV Type V Type III Latissimus Sartorius dorsi

Figure 47.25 The latissimus dorsi /f_l ap can be used as a pedicled /f_l ap to reconstruct regional defects or as a free /f_l ap to reconstruct distant defects. (a) Dermato /f_i brosarcoma protuberans of the left breast. (a) (b) (c) (d) (e) Figure 47.26 (a, b) Limb-threatening, multiplanar degloving injury of the left foot and ankle from a road traf /f_i c accident. debridement, multiple skin defects with exposed extensor tendons and tibiotalar joint. /f_l aps as two separate free /f_l aps. (f, g) Immediate postoperative appearance with meshed split-thickness skin grafts laid over the muscle /f_l aps. (h, /uni00A0 i) /uni00A0 Postoperative appearance at 6 months with normal ambulation. (b) Reconstruction using a pedicled musculocutaneous latissimus dorsi /f_l ap. (f) (h) (i) (g) (c, d) Following wound (e) Harvest of left latissimus dorsi and serratus anterior

circumﬂex artery pedicle can support multiple skin and muscle ﬂaps ( Figure 47.27 ) or the subscapular vascular pedicle can support a scapular ﬂap, a parascapular ﬂap, a latissimus dorsi ﬂap and a serratus anterior ﬂap. This enables the reconstruction of complex composite defects involving di ﬀ erent tissues. For example, following resection of a maxillary sinus tumour, a chimeric scapular ﬂap can be used to reconstruct both the bony and skin defects. V enous ﬂow-through ﬂaps are based on a venous rather than arterial pedicle so that the vein delivers both inﬂow and outﬂow of blood. These ﬂaps are thin and pliable but prone to venous congestion and partial necrosis as there is no arterial input and the ﬂap survives on deo xygenated blood. There is minimal donor site morbidity . Examples include the saphenous ﬂap and those based on the superﬁcial veins of the forearm.

Figure 47.27 (a, b) Chimeric anterolateral thigh /f_l ap comprising spatially independent skin and muscle /f_l aps with all pedicles linked to a common source vessel (arrow), the descending branch of the lateral femoral circum /f_l ex artery.

Flaps

(d) (f) Figure 47.17 The medial sural artery perforator (MSAP) /f_l ap can be used as a pedicled /f_l ap for regional defects or as a free /f_l ap for distant defects. (a) A longstanding diabetic foot ulcer of the left hallux with underlying osteomyelitis. (b) Marking of the MSAP /f_l ap. (c) Amputation of the hallux – direct closure would have neces

Flaps

(d) (f) Figure 47.17 The medial sural artery perforator (MSAP) /f_l ap can be used as a pedicled /f_l ap for regional defects or as a free /f_l ap for distant defects. (a) A longstanding diabetic foot ulcer of the left hallux with underlying osteomyelitis. (b) Marking of the MSAP /f_l ap. (c) Amputation of the hallux – direct closure would have neces

Grafts

Grafts are tissues that are transferred without their blood supply and therefore need to be revascularised through the recipient wound bed. To maximise the success of this procedure, the wound bed must be healthy with a good blood supply such - that angiogenesis into the graft tissue can occur. Graft failure - occurs most commonly as a result of shear forces disrupting the graft from the wound bed, infection (particularly with group - A β -haemolytic Streptococcus spp.) and haematoma or seroma formation (which can lift the graft away from the underlying wound bed). Skin grafts are used to achieve wound closure in situations where the skin defects are too large for primary closure and healing by secondary intention may be inappropriate or lead to an unreasonable delay in complete healing. Ther e are two types of skin grafts, depending on the depth at which they are taken ( Figure 47.7 ): /uni25CF - Split-thickness skin grafts consist of epidermis and a variable amount of dermis and are sometimes referred to as Thiersch grafts. They are commonly harvested from the thigh using a dermatome or graft knife to achieve a consis - tent depth ( Figure 47.8 ). It is relatively simple to harvest large areas of skin to reconstruct sizeable defects such as those following a signiﬁcant burn injury (see Chapter 46 ). The grafted skin can then be meshed or fenestrated to expand and cover a wider surface area as well as avoid the accumulation of an underlying haematoma. The graft is typically sutured, glued or stapled to the recipient site. However, grafts are not entirely robust, for example they can shear o ﬀ , and may contract signiﬁcantly over time. The donor area usually heals by secondary intention within 2 /uni00A0 weeks by means of simple dressings ( Figure 47.9 /uni25CF Full-thickness skin grafts consist of epidermis and dermis. As they include the entire thickness of the dermis, they retain their elasticity and are less prone to secondary scar contracture. However, this also means that the area harvested is limited by the ability to primarily close the do nor site. The common sites for harvest include the supra clavicular skin, groin crease and posterior auricular region (known as a Wolfe graft), where there is adequate skin lax ity . Full-thickness grafts are commonly used for syndactyly release in the hand, reconstruction of facial defects follow ing skin cancer excision or contracture releases following burns ( Figure 47.10 ). /uni25CF Composite skin grafts are a combination of skin and another tissue type, such as fat or cartilage. A commonly used composite skin graft is to harvest a skin/cartilage graft from the helical root of the ear to reconstruct the alar of the nose following skin cancer excision. A hair-bearing composite scalp graft can be used to reconstruct an eye brow . Nerve grafts are used to reconstruct peripheral nerves (including the brachial plexus) and in the surgical manage ment of facial palsy (by utilising a cross-facial nerve graft) and corneal paraesthesia. Common donor nerves include the sural nerve, medial antebrachial cutaneous nerve and the sensory branch of the posterior interosseous nerve (ideal for digital nerve grafts). Whereas vessels are ‘anastomosed’, nerv John Reissberg Wolfe , 1824–1904, Professor of Ophthalmology , University of Glasgow , UK. ‘coapted’ – typically using epineurial sutures with or without ﬁbrin glue in a tension-free manner. Tendon grafts are utilised for the reconstruction of tendons in the upper and lower extremities as a result of trauma, infection (e.g. leprosy) or neurological injury (peripheral nerve or spinal transection). Commonly used donor tendons include ). palmaris longus, extensor digitorum longus and plantaris. Autologous cartilage g rafts can be used for support and augmentation (such as the cartilaginous framework of a staged reconstruction for microtia, a congenital deformity of the outer ear), to correct contour irregularities (such as the - nasal dorsum) or to repair or resurface damaged joints (such - as the temporomandibular joint or small joints of the hand). - - - - es are

(d) Figure 47.8 Power dermatome harvest of a split-thickness skin graft, with the correct method of providing skin tension (a–d) and applying a sterile dressing (e) . (e) Figure 47.9 Typical appearance of a split-thickness skin graft donor site on the left lateral thigh 6 months after harvest. The mild hyper- pigmentation is expected to fade over time.

Common donor sites include the conchal bowl of the ear (elastic cartilage), the nasal septum (which provides rigid hyaline cartilage) and costal cartilage (a plentiful source of hyaline cartilage). Whereas autograft (i.e. graft harvested from the same individual) is considered the ‘gold standard’ for most elective surgical indications, there are certain circumstances when allografting (i.e. from another individual of the same species) or xenografting (i.e. from another species) might be necessary to minimise donor site morbidity or because of a lack of donor tissue. For example, cadaveric allograft or porcine xenograft may be used as a temporising ‘dressing’ following the initial debridement of an extensive burn or necrotising fasciitis. Skin substitutes are engineered dressings that are designed to facilitate wound healing by replicating as many of the key either replace the epidermal or functions as possible. They can dermal components (or both) and can have either a cellular or acellular dermal matrix. Dermal substitutes include Alloderm ® (human dermal matrix) or Integra (bovine collagen with ® chondroitin and a silastic membrane) whereas Epicel example of an epidermal substitute derived from autologous ® keratinocytes. Apligraf is a double-layered bioengineered skin substitute derived from human ﬁbroblasts and keratinocytes and is licensed for the treatment of diabetic and venous ulcers. Their advantage is one of ready availability (in large quantities if required) without the creation of a donor site defect; however, they are expensive and must be employed using a meticulous surgical technique to avoid failure. Tissue expansion is the creation of extra skin and soft tissue by using a subcutaneous silicone balloon in order to reconstruct locoregional defects. The tissue expander is placed within a subcutaneous pocket and then inﬂated with saline solution at als via a ﬁlling port (which can be regular (e.g. weekly) interv buried or externalised). The overlying skin and soft tissue have viscoelastic properties; in response to the underlying mechani - cal force, they permanently elongate through the processes of ‘creep’ and stress relaxation. Angiogenesis leads to increased vascularity within the expanded skin ﬂap and the local response ® ge ﬂaps to a ‘foreign body’ creates a ﬁbrous capsule. Thus lar can be created that have similar physical and mechanical prop - is an erties to the skin that is to be replaced. Common indications include scalp reconstruction following skin cancer excision

(c) Figure 47.10 Full-thickness skin graft reconstruction of a contact burn to the dorsum of the digits. (b) Full-thickness skin grafts from the groin sutured to the wounds. /uni00A0 bed. (d) Postoperative appearance at 1 year. (d) (a) Post excision of burn wounds. (c) Tie-over dressings applied to avoid shearing of the graft off the wound

(ideal for reconstructing hair-bearing skin), breast recon struction following mastectomy and auricular reconstruction. Occasionally , more than one expander is used to reconstruct complex or large defects, such as giant congenital melano cytic naevi ( Figure 47.11 ). Caution must be exercised w considering expansion of irradiated tissue or in patients with comorbidities including diabetes or connective tissue disorders as wound healing is impaired in these scenarios. Prosthetics are widely used in plastic surgery – ranging from ocular, nasal and auricular to hand pr ostheses. Alloplas tic implants are routinely employed in reconstructive plastic surgery , including titanium plates for cranioplasties (re ® ing lost calvarial bone), porous polyethylene (Medpor implants to augment the facial skeleton (e.g. cheek bones or chin tip) and breast implants. Breast implants comprise an Caleb Hillier Parry , 1755–1822, physician, Bath General Hospital, Bath, UK. Moritz Heinrich Romberg , 1795–1873, German neurologist, Director of the University Hospital, Berlin, Germany . - outer shell (typically a silicone elastomer that may be smooth or textured) and a ﬁlling material (saline or silicone gel) and come in a variety of shapes (round or anatomical) and a vast - array of volumes. Implants are prone to capsular contracture, hen ma y interfere with mammographic cancer surveillance and are associated with the development of anaplastic large-cell lym - phoma in a small percentage of cases.

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

ate postoperative appearance after partial excision of the naevus and skin /f_l ap closure. The /f_l aps were subsequently re-expanded to facilitate excision of the residual naevus. (d)

Grafts

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

ate postoperative appearance after partial excision of the naevus and skin /f_l ap closure. The /f_l aps were subsequently re-expanded to facilitate excision of the residual naevus. (d)

Grafts

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

ate postoperative appearance after partial excision of the naevus and skin /f_l ap closure. The /f_l aps were subsequently re-expanded to facilitate excision of the residual naevus. (d)

HISTORY

Although the evolution of plastic surgery as a surgical specialty is comparatively recent, with the ‘masters’ of the First World War years, including Sir Harold Gillies, a New Zealand otolaryngologist working in London, considered to be the founding fathers, its origins hark back to ancient times and - were driven by the need to treat burns, congenital deformity and acquired injuries (whether judicial, vindictive or sustained in battle). The ‘pre-scientiﬁc period’ included a description by the pioneering Indian surgeon Sushruta in 600 /uni00A0 /b.sc/c.sc/e.sc of numerous facial ﬂaps (including a method to repair the split earlobe), which predated the forehead ﬂap being used for nasal reconstruction by some 400 years. Anatomical under - - standing improved markedly from the mid-ﬁfteenth century – the ‘scientiﬁc period’ – as human dissection became widely - practised and the development of printing allowed anatomical drawings to be reproduced and disseminated. During this . How - period the ‘Italian rhinoplasty’, which utilised a two-stage - brachial ﬂap technique , was popularised by Tagliacozzi. The ‘modern period’ – from the nineteenth century to the present day – witnessed a detailed appreciation of the anatomy of the - cutaneous circulation, although the signiﬁcance of the early research undertaken by Manchot took almost a century to be fully recognised, such that the random-pattern ‘waltzed’ tubed the musculocutaneous latissimus dorsi ﬂap by Tansini (1896). This era of surgical discovery was greatly facilitated by the advent of antisepsis by Semmelweis (1847) and Lister (1883), the discovery of anaesthesia by Morton (1846), antibiotics by Fleming (1928) and immunosuppression by Hench (1949) and Calne (1962). The past 50 years have seen an explosion in the complex ity of microsurgical reconstructive techniques, culminating in vascularised composite tissue transplantation becoming part of routine clinical practice. A timeline of some of the key advances in the history of plastic surgical innova tion is given in Table 47.1 . Iginio Tansini , 1855–1943, Professor of Surgery , University of Pavia, Pavia, Italy . Ignaz Philipp Semmelweis , 1818–1865, Pr ofessor of Obstetrics, University of Pest, Pest, Hungary . Joseph Lister, Baron Lister of Lyme Re gis , 1827–1912, Professor of Surgery , University of Glasgow , Glasgow , UK. William Thomas Green Morton , 1819–1868, an American dentist. Sir Alexander Fleming , 1881–1955, a Scottish microbiologist who discovered penicillin at St Mary’s Hospital, London, UK, for which he was jointly awarded the Nobel Prize in 1945. Philip Showalter Hench , 1986–1965, Professor of Medicine, Mayo Clinic, Rochester, USA, was jointly awarded the Nobel Prize in 1950 for his pioneering work on cortisone. Sir Roy Y orke Calne , b. 1930, Emeritus Professor of Surgery , University of Cambridge, Cambridge, UK. Skin is the largest end organ, covering the body’s entire exter - nal surface. Together with its derivatives, including hair, nails and sweat glands, it forms the integumentary system. The skin serves a number of functions that are critical for survival. It provides a protective barrier against mechanical, thermal and irradiation (ultraviolet) injury and infection. It also plays a role - in homeostasis by preventing ﬂuid loss and regulating tempera - ture. As the primary interface with the external environment, it acts as a sensory organ and also produces vitamin D. Hence restoration of the skin is essential even if the under lying struc - tures await delayed reconstruction.

TABLE 47.1 A selection of key advances in the history of plastic surgery innovation. Year Surgeon Nationality c . 1800 /uni00A0 Ancient Egypt BCE – India c . 600 /uni00A0 BCE Sushruta Rome c . 25 /uni00A0 CE Celsus Spain c . 1000 /uni00A0 CE Al-Zahrawi Sicily c . 1400 /uni00A0 CE Branca France 1789 Desault USA 1854 Hamilton UK 1862 Wood Germany 1889 Manchot France 1894 Dauriac Italy 1896 Tansini France 1912 Carrel Russian Empire and UK 1916–1917 Filatov and Gillies USA 1954 Murray UK 1968 Cobbett Australia 1973 Daniel and Taylor Australia 1978 Taylor China 1979 Yang Japan 1989 Koshima France 1998 Dubernard Taiwan 2004 Chen France 2005 Devauchelle Spain 2006 Barret Innovation Wound care techniques Local /f_l aps for nasal reconstruction Local /f_l aps for lip reconstruction Introduced catgut sutures and developed numerous surgical instruments Distant (arm) /f_l ap for nasal reconstruction Recognition of the importance of de /f_i nitive wound debridement Concept of /f_l ap ‘delay’ with the distant cross-leg /f_l ap Concept of axial pattern /f_l aps with the pedicled groin /f_l ap ( Figure 47.1 ) Cutaneous arterial supply using cadaveric arterial injection studies First description of a pedicled muscle (rectus abdominis) /f_l ap Breast reconstruction using a pedicled musculocutaneous latissimus dorsi /f_l ap Nobel Prize for the development of vascular anastomosis and its application to organ transplantation Tubed pedicled /f_l aps and concept of ‘waltzing’ Nobel Prize for the /f_i rst renal transplant between identical twins Free toe-to-hand transfer Fr ee groin /f_l ap to foot Concept of the ‘angiosome’ Free radial for earm (‘Chinese’) /f_l ap Perforator /f_l aps ( Figure 47.2 ) Hand transplant Vascularised lymph node transfer Partial face transplant Full face transplant

The skin’s structure consists of the outer epidermis (ecto dermal in origin), the dermis and the inner hypodermis (of mesodermal origin). The deepest layer of the epidermis is the stratum basale, where stem cells di ﬀ erentiate into keratinocytes and migrate upwards towards the outermost stratum corneum an acellular layer made of dead keratinocytes acting as a barrier to ﬂuid loss and protection against invasion by micro organisms. The epidermis regenerates from deeper follicular elements such as hair follicles and sweat glands. The dermis is connected to the epidermis via the basement membrane and consists of the upper papillary layer, composed of loose connective tissue, and a dee per reticular layer, which is thicker and consists of dense connective tissue and collagen ﬁbres . The dermis houses the hair follicles, sweat glands, sen sory receptors and blood vessels. Geo ﬀ rey Ian Taylor , contemporary , Professor of Plastic Surgery , University of Melbourne, Melbourne, Australia. skin appendages, including hair follicles, sensory receptors, neurones and blood vessels. The relative composition of these lay ers varies depend - ing on the functional requirements of the region concerned. Specialised areas such as hair-bearing scalp skin or glabrous heel skin can be challenging to reconstruct as there are limited donor sites. However, for non-specialised skin, the abdomen and groin make ideal donor sites as the y are elastic and thin and, thus, amenable to primary closure. Blood vessels are found in the dermis and hypodermis and are arranged in a number of plexuses between each anatomical layer ( Figure 47.3 ). Ultimately , they all originate from a main feeding or sour ce vessel, via ﬁne perforating vessels (‘perforators’) either directly or indirectly by traversing through fascia, muscle or bone. This observation gave rise to Taylor’s ‘angiosome’ concept, in which angiosomes refer to three- dimensional blocks of tissue including skin and deeper tissue layers that are supplied by speciﬁc source arteries. Thus, any skin or other tissue types can be detached as a ‘ﬂap’ provided the vessel course from the source vessel to the end organ that is to be transferred is kept intact. - Cutaneous nerves tend to run axially out of the major nerve trunks but are less deﬁned than most perforating blood vessels. It is possible to coapt nerve ends between a cutaneous nerve within a ﬂap and one at the recipient site, so-called , ‘neurotisation’, to r egain some sensation in the ﬂap. -

Figure 47.1 Pedicled groin /f_l ap. Full-thickness burn wounds over the dorsum of multiple digits. The exposed extensor tendons were covered by a pedicled groin /f_l ap. The pedicle was divided at 3 weeks and the digits were subsequently separated in stages. Figure 47.2 Three views of an anterolateral thigh /f_l ap on detachment from the donor site prior to anastomosis at the recipient site. Pedicle (arrow) consisting of one perforator artery and two vena comitans.

HISTORY

Introduction

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LEECH THERAPY

The European medicinal leech ( Hirudo medicinalis ) is an inver - tebrate annelid; its saliva contains hirudin (an anticoagulant), hyaluronidase (which facilitates anticoagulant penetration into - the wound) and histamine (to maintain vasodilatation). The primary indication for leec h therapy is to improve drainage from ﬂaps that are venously congested, i.e. those that are dusky - blue with a brisk capillary reﬁll and a rapid, dark pinprick. Such congestion may result from a particular vein being too small or not present or a venous anastomosis not being technically possible (e.g. a distal digital replant where an artery is reconstructed but not the vein). Leeches are not normally - used in cases of suspected venous obstruction of a free ﬂap as immediate surgical exploration is required; likewise they - are of no beneﬁt in an arterially compromised ﬂap as, again, immediate surgical exploration is mandated. As leeching is used for venous (as opposed to arterial) insu ﬃ ciency , a typical course of treatment may last for up to 2 /uni00A0 weeks – until new vein formation occurs at the margins of the ﬂap ( Figure 47.29 ). The anticoagulant e ﬀ ect persists once the leech has detached from the patient, with bleeding occur - - ring for some hours; each leech will imbibe up to 5 /uni00A0 mL of blood and up to 150 /uni00A0 mL of blood may be lost in the subse - quent ooze; thus, all patients must have their haemoglobin level monitored r egularly and blood transfusion may be necessary . Leeches contain Aeromonas hydrophila , so patients require pro phylactic antibiotics (typically a quinolone) until wound closure is complete.

Figure 47.29 Leeching used for a venously congested replanted right external ear.

LEECH THERAPY

Figure 47.29 Leeching used for a venously congested replanted right external ear.

LEECH THERAPY

Figure 47.29 Leeching used for a venously congested replanted right external ear.

Learning objectives

To be aware of: A variety of plastic surgical techniques used to restore • bodily form and function To know: The relevant anatomy and physiology of skin • Learning objectives

To be aware of: A variety of plastic surgical techniques used to restore • bodily form and function To know: The relevant anatomy and physiology of skin •

Lipotransfer

Lipotransfer, or autologous fat grafting, is a useful reconstruc - tive technique to achieve soft-tissue augmentation, i.e. increase plac - the volume in a speciﬁc region, hence it is sometimes referred to ) onlay as ‘lipomodelling’. Common indications include facial defects in progressive hemifacial atrophy (Parry–Romber g syndrome) comes from the aesthetic industry for facial rejuvenation and buttock/breast augmentation. Lipotransfer is also used to improve scar remodelling, particularly after radiotherapy , the rationale being that adipose tissue contains adipose-derived stromal cells, which can modulate the healing process. Autologous fat is an ideal ﬁller material for soft-tissue reconstruction as it is biocompatible, non-immunogenic, inex pensive and can be easily and repeatedly harv ested. This tech nique was systematised and popularised by Coleman in the late twentieth century . The stages of lipotransfer include: (i) harvesting or ‘liposuction’, whereby adipose tissue is suctioned from a body part, usually the abdomen , thigh or buttock, using local anaesthetic and a cannula; (ii) fat pre paration, including centrifugation of the fat aspirate; and (iii) injection, using a specialised cannula, at the recipient site. One disadvantage is that the grafted fat undergoes an unpredictable amount of fat resorption (typically approximately 20% but may reach 80%). Current research is focused on how to improve the survival of the grafted fat, including through enrichment with a freshly isolated stromal vascular fraction. Although generally safe, there is a small risk of fat embolism, which can have serious complications (including blindness and stroke) and can be fatal. Lipotransfer
Lipotransfer, or autologous fat grafting, is a useful reconstruc - tive technique to achieve soft-tissue augmentation, i.e. increase plac - the volume in a speciﬁc region, hence it is sometimes referred to ) onlay as ‘lipomodelling’. Common indications include facial defects in progressive hemifacial atrophy (Parry–Romber g syndrome) comes from the aesthetic industry for facial rejuvenation and buttock/breast augmentation. Lipotransfer is also used to improve scar remodelling, particularly after radiotherapy , the rationale being that adipose tissue contains adipose-derived stromal cells, which can modulate the healing process. Autologous fat is an ideal ﬁller material for soft-tissue reconstruction as it is biocompatible, non-immunogenic, inex pensive and can be easily and repeatedly harv ested. This tech nique was systematised and popularised by Coleman in the late twentieth century . The stages of lipotransfer include: (i) harvesting or ‘liposuction’, whereby adipose tissue is suctioned from a body part, usually the abdomen , thigh or buttock, using local anaesthetic and a cannula; (ii) fat pre paration, including centrifugation of the fat aspirate; and (iii) injection, using a specialised cannula, at the recipient site. One disadvantage is that the grafted fat undergoes an unpredictable amount of fat resorption (typically approximately 20% but may reach 80%). Current research is focused on how to improve the survival of the grafted fat, including through enrichment with a freshly isolated stromal vascular fraction. Although generally safe, there is a small risk of fat embolism, which can have serious complications (including blindness and stroke) and can be fatal. Lipotransfer
Lipotransfer, or autologous fat grafting, is a useful reconstruc - tive technique to achieve soft-tissue augmentation, i.e. increase plac - the volume in a speciﬁc region, hence it is sometimes referred to ) onlay as ‘lipomodelling’. Common indications include facial defects in progressive hemifacial atrophy (Parry–Romber g syndrome) comes from the aesthetic industry for facial rejuvenation and buttock/breast augmentation. Lipotransfer is also used to improve scar remodelling, particularly after radiotherapy , the rationale being that adipose tissue contains adipose-derived stromal cells, which can modulate the healing process. Autologous fat is an ideal ﬁller material for soft-tissue reconstruction as it is biocompatible, non-immunogenic, inex pensive and can be easily and repeatedly harv ested. This tech nique was systematised and popularised by Coleman in the late twentieth century . The stages of lipotransfer include: (i) harvesting or ‘liposuction’, whereby adipose tissue is suctioned from a body part, usually the abdomen , thigh or buttock, using local anaesthetic and a cannula; (ii) fat pre paration, including centrifugation of the fat aspirate; and (iii) injection, using a specialised cannula, at the recipient site. One disadvantage is that the grafted fat undergoes an unpredictable amount of fat resorption (typically approximately 20% but may reach 80%). Current research is focused on how to improve the survival of the grafted fat, including through enrichment with a freshly isolated stromal vascular fraction. Although generally safe, there is a small risk of fat embolism, which can have serious complications (including blindness and stroke) and can be fatal.

MICROSURGERY

Microsurgery is a surgical subspecialty that makes use of magni ﬁcation, precision tools and surgical techniques to enable the anastomosis of small blood vessels and coaptation of nerves. The diameter of a typical suture is between 0.01 and 0.03 /uni00A0 mm. The adv ent of microvascular anastomotic techniques renders it feasible to transplant tissue to every region of the body , thus vastly expanding the reconstructive armamentarium as it is no longer necessary to rely on grafts that must revascularise from an underlying wound bed or on pedicled ﬂaps that are limited by size, length or the distance they can ‘travel’. Provided the course from the source vessel to the end organ is preserved, it is possible to transfer ﬂaps from any region of the body to any recipient site provided an appropriate recipient vessel exists. This technique o ﬀ ers a highly versatile and ﬂexible approach to reconstructive surgery . Oncological reconstruction for head and neck cancer or mastectomy defects often requires the use of free ﬂaps, provid ing superior functional and aesthetic outcomes. Typical ﬂaps include the anterolateral thigh and deep inferior epigastric artery perf orator ﬂaps, based on the descending branch of the lateral circumﬂex femoral artery and the deep inferior epi g astric artery , respectively . For complex limb injuries or osteo myelitis, microsurgical reconstruction has meant that limb salvage is now possible rather than amputation ( Figure 47.26 Christian Andreas Doppler , 1803-1853, Director of the Institute of Physics, University of Vienna, Vienna, Austria. Common ﬂaps used in this context include the gracilis or latis - simus dorsi muscle ﬂaps. Microsur gical ﬂaps are not always used to reconstruct skin defects. Free functional muscle ﬂaps are used to reanimate the face or the upper limb in facial and brachial plexus palsies, respectiv ely . Free bone ﬂaps such as the free ﬁbular ﬂap may also be used to reconstruct the mandible following oncological resection or to provide a strut following excision of an osteo - myelitic segment of tibia. Microsurgery has also made it possible to replant ampu - tated digits and limbs, or reconstruct missing ﬁngers with free vascularised functioning and sensate toes ( Figure 47.28 ). Fur - thermore, the technique has also made vascularised composite allotransplantation possible, including of the hand and face. Anastomoses are usually hand sewn (using specialist micro - instruments with the aid of an operating microscope), although the adoption of mec hanical coupler devices for venous anasto - moses is becoming increasing ly popular as they are often tech - - nically less demanding and faster than a hand-sewn approach. Supermicrosurgery involving microneurovascular anas - tomosis of vessels and coaptation of single nerve fascicles of the order of 0.3–0.8 /uni00A0 mm has further expanded the ﬁeld. It has enabled the reconstruction of ﬁngertip injuries, which traditionally would have been treated with amputation, and the crea tion of lymphaticovenous anastomosis for the treat - ment of chronic lymphoedema. MICROSURGERY

RECONSTRUCTIVE TECHNIQUES

These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external ﬁxators and tissue expanders. Improved understand - ing of the blood supply to di ﬀ erent tissue types including skin has vastly expanded the number of ﬂap options (see below) available to reconstruct di ﬀ erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a ﬂap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods ﬁrst, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local ﬂap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local ﬂap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus signiﬁcantly reducing the risk of limb-threatening deep infection or osteomyelitis.

Figure 47.6 Negative-pressure wound therapy to promote wound healing in an open abdomen. The system consists of a non-adherent dressing overlaid by a sponge that is sealed with an airtight membrane and connected to a suction device. (primary venous skin graft plexus) Subpapillary Hair Deeper split-thickness plexus skin graft Papillary loops Thick split-thickness skin graft Epidermis Full thickness (Wolfe) skin graft Local /f_l aps Deep Subcutaneous Subcutaneous subdermal vessels tissue plexus Reticular dermis Papillary dermis Figure 47.7 Schematic anatomy of the skin and its relationship to harvesting skin grafts (of varying thicknesses) and raising local /f_l aps.

RECONSTRUCTIVE TECHNIQUES

These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external ﬁxators and tissue expanders. Improved understand - ing of the blood supply to di ﬀ erent tissue types including skin has vastly expanded the number of ﬂap options (see below) available to reconstruct di ﬀ erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a ﬂap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods ﬁrst, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local ﬂap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local ﬂap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus signiﬁcantly reducing the risk of limb-threatening deep infection or osteomyelitis.

RECONSTRUCTIVE TECHNIQUES

These range from the simple, including healing by secondary intention or skin grafting, to the complex, including free tissue - transfer or vascularised composite allotransplantation. They also include the use of autologous tissue, allograft material, biocompatible materials such as skin substitutes, internal and - external ﬁxators and tissue expanders. Improved understand - ing of the blood supply to di ﬀ erent tissue types including skin has vastly expanded the number of ﬂap options (see below) available to reconstruct di ﬀ erent parts of the body . The intro - duction of the operating microscope has ushered in the era of micro surgical reconstruction that has enabled free tissue trans - fer and replantation, procedures whereby the blood supply to a ﬂap is detac hed from the donor site and re-established through vessel anastomosis to local source vessels at the recipient site. Reconstructive plastic surgery is almost always undertaken to impr ove healing. Without it, wounds may heal poorly with unacceptable consequences, including chronic or non-healing wounds, unsightly and debilitating scars or the risk of deep infection. A common scenario is a skin defect that is too large to be closed primarily , thus requiring surgical techniques or adjuncts to achieve wound closure. Several conceptual frame works exist for the appropriate selection of techniques, includ ing the now obsolete reconstructive ladder which advocates using the simplest methods ﬁrst, and the patient-centred ‘recon structive elevator’. In essence, the modern patient-centred reconstructive technique emplo yed must be considered in the context of each individual case, including patient factors, available skills , resources and the consequences of success and failure to achieve the best long-term outcome. In acute burns, for example, split-thickness skin grafting is almost always used to restore skin as soon as possible in order to preserve life. Following facial tumour excision, a local ﬂap is often superior to a skin graft in terms of contour and aesthetics such as skin quality and colour ma tch. For pressure sore recon struction, a local ﬂap comprising both skin and muscle (for dead-space obliteration) would be more durable than a skin graft or primary closure, both of which would place the scar at the site of grea test pressure. For open lower limb fractures, free tissue transfer is often required as there is a lack of local tissue availability; this option provides healthy vascularised tissues to cover the fracture site (including any orthopaedic metalwork), Karl Thiersch , 1822–1895, Professor of Surgery , Leipzig University , Leipzig, Germany . thus signiﬁcantly reducing the risk of limb-threatening deep infection or osteomyelitis.

WHAT IS RECONSTRUCTIVE PLASTIC SURGERY

WHAT IS RECONSTRUCTIVE PLASTIC SURGERY?

Reconstructive plastic surgery is a surgical specialty that aims to restore form and function. The word plastic derives from the ancient Greek plassein – to mould or shape. Unlike all other specialties, plastic surgery is not bound by anatomical or functional region. Instead, it involves the use of a wide array of surgical techniques to reconstruct tissues that have been damaged by congenital loss, infection, trauma, cancer or even the process of ageing. Hence the reconstructive plastic surgeon often works in collaboration with other specialists wherever necessary , including head and neck surgeons, oral surgeons, orthopaedic surgeons, ophthalmologists, urologists, paediatric surgeons, gynaecologists, general surgeons and dermatolo gists. Modern plastic surgery techniques enable clinicians to perform complex surgical procedures that would not have been previously possible, such as major oncological head and neck resections or skeletal ﬁxation of open limb fractures with signiﬁcant soft-tissue defects. Since plastic surgery involves the restoration of form, it is necessarily closely related to aesthetic (or cosmetic) sur gery , which has gained much attention in the media in recent decades. Many of the surgical techniques, including lipo suction, fat grafting, scar management, tissue expansion and ﬂap contouring, are shared between the two specialties ever, plastic surgery also aims to achieve restoration of func tion. An example would be the use of a free neurotised gracilis muscle transfer from the thigh to the face to restore a smile in facial palsy , or the use of a jejunal free ﬂap to restore swal lowing following a pharyngolaryngectomy f or squamous cell carcinoma. Indeed, the microsurgical techniques developed to Sir Harold Delf Gillies , 1882–1960, the ‘father of plastic surgery’, became the ﬁrst President of the British Association of Plastic Surgeons in 1946. Sushruta , c . 600 /uni00A0 /b.sc/c.sc/e.sc , Indian surgeon; his eponymous Samhitá (‘compendium’) was translated into English in 1907. Gaspare Tagliacozzi , 1545–1599, Professor of Surgery , University of Bologna, Bologna, Italy . Carl Herman Manchot , 1866–1932, was born in Switzerland and studied medicine at the University of Strasbourg, Strasbourg, France. enable tissue transplantation within the same individual and the replantation of severed body parts (i.e . autografts) have, together with the discovery of immunosuppressive agents, heralded the ﬁeld of composite tissue allotransplantation in the latter half of the twentieth century – including face, hand and abdominal wall transplants (i.e. homografts).

To understand: The different types of skin grafts • The principles and use of /f_l aps • The concept of microsurgical reconstructive surgery •

WHAT IS RECONSTRUCTIVE PLASTIC SURGERY?

To understand: The different types of skin grafts • The principles and use of /f_l aps • The concept of microsurgical reconstructive surgery •

WHAT IS RECONSTRUCTIVE PLASTIC SURGERY?

To understand: The different types of skin grafts • The principles and use of /f_l aps • The concept of microsurgical reconstructive surgery •

WOUND DRESSINGS

These are a vital part of wound care and are used to optimise healing. The most suitable dressing is selected based on the type Jean-Nicolas Marjolin , 1780–1850, Professor of External Pathology , Hôtel-Dieu de Paris, Paris, France. moist environment to facilitate epidermal migration, enable hange between the wound and environment, provide gas ex c protection against bacterial infection and be non-adherent (to avoid trauma on removal). Furthermore, the dressing should be sterile, non-toxic, non-allergenic and readily available at minimal expense. One of the most traditional dressings in regular use is gauze ® (tulle) impregnated with petroleum jelly (e.g. Jelonet ); it is ideal for clean wounds with minimal exudate. Semipermeable foam ® dressings (e.g. Allevyn ) are suitable for moderately to highly exudating wounds such as leg ulcers. Hydrocolloid dressings ® (e.g. Duoderm ) contain an inner colloidal layer with an impermeable outer layer and are ideal for moderately exudating ® wounds such as minor burns. Alginate dressings (e.g. Kaltostat ) are derived from seaweed and contain calcium salts that facilitate haemostasis; they can be used on moderate to heavily exudating wounds such as split-thickness skin graft donor sites. ® Mepitel is a non-adherent dressing comprising a perforated silicone sheet that is designed for prolonged applications of up to 2 weeks; it is therefore popular in paediatric wounds. Some dressings contain antimicrobial agents such as ionic silver (e.g. ® ® Aquacel Ag ) or povidone iodine (e.g. Inadine ) that may have - additional functionality in contaminated wounds. Negative-pressure wound therapy (e.g. vacuum-assisted ® closure; V AC ) uses intermittent or continuous topical nega - tive pressure (up to –125 /uni00A0 mmHg) through a sealed foam dress - ing in order to stimulate the formation of granulation tissue, reduce local oedema and tissue exudate and reduce bacterial load. The technique has numerous applications, including as a dressing to secure a skin graft to its recipient bed, temporary coverage of a complex acute wound (e.g. an open abdomen; Figure 47.6 ) until deﬁnitive cover can be achieved or to man - age chronic wounds such as pressure ulcers. - WOUND DRESSINGS

WOUND HEALING

There are various ways in which a wound can heal (see Chapter 3 ). Plastic surgeons can a ﬀ ect the way in which wounds heal. Primary healing, or ‘healing by primary inten - tion’, occurs when the wound is closed soon after the injury by reapproximating the wound edges. This is typically achieved - with sutures, although glue, tape and staples can also be used. Incisions are designed so that they lie along the lines of r elaxed skin tension to reduce the appearance of the scar, particularly on the face and in areas of tension ( Figure 47.4 ). Secondary healing, or ‘healing by secondary intention’, occurs w hen the wound is left to heal from its base. The wound is typically kept clean with sterile non-adherent dressings. Over the course of days and weeks, the wound contracts and skin cells migrate across the wound through a process called epithelialisation. Secondary healing is typically employed for wounds that have poor healing potential, such as leg and pressure ulcers, in which surgery risks exacerbating the wound-healing burden. Every reconstructive procedure depends on the poten- tial for wound healing. Furthermore, m uch of reconstructive plastic surgery involves the creation of wounds to heal other wounds – hence the aphorism ‘rob Peter to pay Paul’. There- fore, the plastic surgeon must consider how to maximise the chances of success and adopt their approach accordingly . Edward Ehlers , 1863–1937, Professor of Clinical Dermatology , Copenhagen, Denmark. Henri Alexandre Danlos , 1844–1912, dermatologist, Hôpital St Louis, Paris, France, gave his account of this condition in 1908. Hippocrates of Kos , c . 460–375 /uni00A0 /b.sc/c.sc/e.sc , was a physician in Ancient Greece and considered to be the ‘father of medicine’. For example, in genetic conditions such as Ehlers–Danlos syndrome and epidermolysis bullosa (for which there is cur - rently no cure), the surgeon is required to be less aggressive in their approach as surgical intervention risks creating addi - tional iatrogenic wounds that may fail to optimally heal, thus potentially worsening the patient’s situation (Hippocra tes: primum non nocere ; ﬁ rst, do no harm). Systemic comorbidities including diabetes, peripheral vascular disease, renal failure, corticosteroid use and immunodeﬁ ciency are signiﬁ cant causes of delayed wound healing and must be addressed preopera - tively . For example, diabetic control may be optimised with the help of an endocrinologist, and preoperative angioplasty may augment blood ﬂ ow in a chronically ischaemic lower limb. Nutrition is essential for w ound healing; vitamin and protein deﬁ ciencies should be addressed preoperatively with the guid- ance of a dietician. Smoking is particularly detrimental as it causes vasoconstriction and decreases local oxygen delivery to tissues, thus impairing healing; patients are therefore advised to cease smoking at least 6 weeks prior to elective surgery if possible. Furthermore, it is crucial to optimise a wound bed to promote healing. For example, the wound may require formal debridement and washout to minimise bacterial colonisation and hence the risk of surgical site infection. Perioperative antibiotics may also be necessary .

Subdermal plexus Superficial adipose tissue Deep adipose tissue Deep fascia Muscle Figure 47.3 Diagram of skin anatomy with vascular plexus. Figure 47.4 Lines of relaxed skin tension. Fasciocutaneous Musculocutaneous perforator perforator

WOUND HEALING

47 Plastic and reconstructive surgery

ABERRANT HEALING

FLAP MONITORING

FURTHER READING

FUTURE DIRECTIONS

Flaps

Grafts

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

(c) Figure 47.11 Tissue expansion provides local autologous tissue for reconstruction of large defects. (a) Extensive congenital melanocytic naevus of the back with tissue expanders in situ (arrows). (b) Explantation /uni00A0 of in /f_l ated tissue expanders. (c) Advance

/uni00A0 ment of expanded skin /f_l aps to determine the extent of naevus excision. (d) Immedi

HISTORY

Introduction

Introduction

LEECH THERAPY

Learning objectives

Lipotransfer

MICROSURGERY

RECONSTRUCTIVE TECHNIQUES

WHAT IS RECONSTRUCTIVE PLASTIC SURGERY

WOUND DRESSINGS

WOUND HEALING