Short Notes in Plastic Surgery

September 30, 2011

The Nature of Plastic Surgery

Filed under: Chapter 1 — mthatte @ 3:59 am

1. Plastic surgery is about value addition, to use a modern expression.
2. The value can be added by restoring function or by improving appearance. These two objectives singly or together can also alter for the better, how a person feels about ‘self’ and positively changes one’s relationship with the immediate human environment.
3. This triple effect is probably unique to plastic surgery. In addition the speciality is not restricted to any particular body parts and is also a useful ally of other specialists.
4. Value additions are usually done when tissues are distorted or are deficient or in excess or deficient in function (by whatever cause).
5. In modern times plastic surgery is also performed for what can generally be passed off as normal but when an individual decides to alter his or her looks by choice (aesthetic surgery).
6. At all times plastic surgeons must keep an aesthetic viewpoint when undertaking their work.
7. The above objectives can be achieved by one of the following.
a) Rearranging tissue

A. An x-ray of a radial club hand. The radius is missing. B. Clinical photograph. C. Flap marked on the dorsum of the hand to close a defect to be created to release the radial contracture. D. The defect is created and the dorsal flap is about the set-in. E. Now the lax skin on the ulnar side is transposed into the defect created by the transposition of the dorsal flap. F. Photograph from the radial side to show correction of the contracture. The ulnar defect is closed by primary suturing. Photographs courtesy Mukund Thatte, Mumbai.

b) Substituting tissue

Augmentation Rhinoplasty. Depressed bridge corrected with bone graft

c) Removing tissue

As in Lower Abdominal Lipectomy

d) Building something where nothing existed before

Reconstruction of ear with cartilage in a case of Microtia

Sridhar from Chennai adds the following:
e) Conceal a blemish by tattooing
f) Reduce or alter the function of a part for e.g. a joint by arthrodeses or tenodeses when restoration of the original dynamics of the joint becomes impossible and a static stable solution is the next best option.
g) A muscle might be deliberately paralysed by chemical neurectomy for e.g. injection of botox to eliminate crease lines or to restore muscular balance where a nerve palsy already exists on the contralateral side.
h) And even resort to myotomy or a tenotomy to eliminate spasm or excessive action.

In the same vein Puneet Pasricha from Jalandhar adds that a chemical neurectomy of the levator labii superioris on both sides can hide a gummy smile.
8. These four procedures might overlap. For example if while rearranging tissue a defect gets created in another area a substitution is called for. If and when any excess is removed it might become necessary to rearrange the remaining tissue to make it appear as normal as possible. When building something entirely new removal of unwanted unusable tissue might have to be undertaken to create a sound base.
9. At all times when surgery is undertaken little or no harm must come to areas from where tissue is obtained to undertake substitution.
10. If the above ideal cannot be fulfilled, yet reconstruction is vital, then a ‘just’ decision must be made based on the cost-benefit ratio (another modern expression).
11. This ‘decision making’ must involve the participation of the patient whose needs will always be paramount. The clinician should act as an educator and a guide in this discussion.
12. Although the word defect usually means a short coming (physical or functional) or lack of something essential or required, its meaning also includes words such as a blemish or an imperfection. Therefore the word defect in the field of plastic surgery by common consent, also includes irregularity or excess.
13. In dealing with defects (prior to reconstruction) the plastic surgeon analyses the defect in the following manner
a. How and why did the defect come about, its embryological, pathological or physiological basis.
b. What is the anatomical nature and extent of the defect.
c. How much of the defect is caused by distortion and what component of the defect is caused by a ‘net tissue loss’ or ‘net tissue excess’ and if there is a combination of any of these three.
14. Having thus analyzed the defect the following questions then need to be asked
a. Does this defect endanger life, limb or a vital organ, immediately or over a period of time.
b. At what speed is the defect likely to cause deterioration of any vital function or cause danger to life.
c. Therefore how urgent is the need for reconstruction.

A. A case of Pierre Robin Syndrome. Note the indrawing of the chest. B. Soft tissue x-ray shows the tongue filling the nasopharyngeal air space completely. C. After the lip tongue adhesion was performed. D. Notwithstanding this adhesion, patient’s compliance was poor and therefore a tracheostomy had to be done. E. In order to wean away from the tracheostomy a mandibular distraction was commenced and was completed in six months. F. The child at two years with the mandible stabilised, tracheostomy weaned. The child is thriving. Case and photographs courtesy Nitin Mokal, Mumbai

d. Are there such things in the defect or in the rest of the body which will adversely affect the local reconstruction or life itself.
e. Is it prudent to undertake reconstruction as a whole in ‘one go’ or over a period of time in stages so as not to burden the body as a whole.
f. Is the defect of such a nature that it will evolve favorably over a period of time so that the reconstruction of a much lesser magnitude without an adverse consequence to the final result can be undertaken later.

Capillary Hemangioma of Infancy of the upper lip which would have been difficult to treat as and when it presented but which has resolved over the years to leave minimal scarring and a manageable deformity

Photograph courtesy: from The Management of Hemangiomas and Vascular Malformations of Head and Neck written by Prof. K.S. Goleria, Mumbai.
g. And lastly does the defect really exist or is it being imagined by the individual for some reasons that need to be gone into.

Milind Wagh from Mumbai very pertinently adds that the classical plastic surgical term recreation of defect needs to be mentioned and explained. For example, a defect as it appears (apparent defect) might not be the real defect which needs to be recreated. In a case of a compound fracture of a tibia which has not been treated properly, the case or the patient might present with a small ulcer with dense adherent scar surrounding it and a sequestrum underneath. The fracture might show non-union. The recreated defect will be much larger when the scar is excised, the sequestrum is extracted and the bone ends are freshened. This means the defect will need a flap cover and a bone graft and some form of fixation of bone fragments (please see chapters 8,12,13 and 14). For example in a case below.

A. Apparent post-traumatic defect. Upper one-third of tibia. B. Recreated defect. C. Cross-leg flap in place. D. After the detachment of the flap. These photographs are from nearly a quarter century ago before the advent of microsurgery or digital photography but the recreative philosophy has remained the same.

Dr. James Roy Kanjoor from Coimbatore  points out that surgical procedures such as reduction mastectomies for large pendulous breasts or lower abdominal lipectomies with bolstering of divericated rectii, improve locomotion, reduce backache, prevent intertrigo and most importantly have a positive effect on the person vis-a-vis her/his persona enabling the patient to deal with the outer world with greater confidence. He suggests that such procedures should be called ‘functional, aesthetic procedures’.

The matter will be discussed at length when the section on aesthetic surgery gets written.

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