Plastic surgery, although considered a technique-oriented and
multiregional specialty, is in essence a problem-solving field.
The training of a plastic surgeon allows him or her to see surgical
problems in a different light and select from a variety of options
to solve these surgical problems. Plastic surgeons have received
broad training, and many have completed residencies in other fields
such as general surgery, otolaryngology, orthopedics, urology, or neurosurgery.
Other modalities of training have more recently integrated these and
other surgical subspecialties into a more comprehensive training
The basic principles of plastic surgery are careful analysis
of the surgical problem, careful planning of procedures, precise
technique, and atraumatic handling of tissues. Alteration, coverage,
and transfer of skin and associated tissues are the most common
procedures performed. Plastic surgery may deal with the closure
of surgical wounds—particularly recalcitrant wounds such
as those occurring post radiation or poorly healing wounds in immunocompromised patients.
Plastic surgery also deals with the removal of skin tumors, repair
of soft tissue injuries including burns, correction of acquired
or congenital deformities, or enhancement of undesirable cosmetic
features. Craniofacial and hand surgery, also within the realm of
plastic surgery, may require additional surgical training.
In the past quarter century, increased knowledge of anatomy and
the development of many new techniques have brought about important
changes in plastic surgery. It is now known that in many areas the
blood supply of the skin is derived principally from vessels arising from
underlying muscles and larger perforating blood vessels rather than
solely from vessels of the subcutaneous tissue, as was formerly
thought. One-stage transfer of large areas of skin, fascia, and
muscle tissue can be accomplished if the axial pedicle of the underlying
fascia or muscle is included in the transfer. With the use of microsurgical
techniques, musculocutaneous units or combinations of bone, fascia,
muscle, and skin can be successfully transferred and vessels and
nerves less than 1 mm in size can be repaired. These so-called free-flap
transplantations are a major advance in the treatment of defects
that were previously untreatable or required lengthy or multistaged
procedures. More sophisticated knowledge of the blood supply to
the skin has introduced the concept of perforator flaps whereby
one perforating vessel is identified that may supply a large segment
of overlying skin and subcutaneous tissue. Similarly, the concept
of neurocutaneous flaps has given rise to the design of additional
flap territories such as the sural flap in the lower leg and the
sensate radial flap in the forearm.
The plastic surgeon, as a member of the craniofacial surgical
team, is able to dramatically improve the appearance and function
of children with severe congenital deformities. Children of normal
intelligence who previously had been social outcasts are now able
to lead relatively normal lives. Improved understanding of facial
growth and abnormal development and diagnostic techniques such as
the CT scan, MRI, and 3D computer-assisted imaging enable the reconstructive
surgeon to develop a complex strategy for remodeling the deformed
craniofacial skeleton. This may involve remodeling or repositioning
of part or all of the cranial vault, the orbits, the mid face, and
the mandible. These complex and at times formidable reconstructions
are performed by moving specific skeletal units and adding autogenous
bone grafts. These structures are kept in place using miniplate
fixation; the miniplates are made of titanium or resorbable material.
A notable advance in craniofacial surgery was the introduction
of distraction osteogenesis, which borrows from the Ilizarov principle
of distraction. A cortical cut is made in the bone, and a distraction apparatus
is applied so that in measured amounts (usually 1 mm per day) the bone
is either stretched to offset a length discrepancy or transported
to bridge a gap. In craniofacial surgery, it is more commonly brought
to bear to enlarge or cause overgrowth of areas such as an underdeveloped
Additional areas of involvement for the plastic surgeon entail
allotransplantation, particularly with the increasing number of
clinical limb allotransplants, which unfortunately still require
immunosuppression. It is hoped that immunotolerance will someday
become a reality, allowing transplantation of nonessential organs
with a minimum of dangerous immunosuppression. Transplantation of the
hand with excellent functional recovery in some cases has been performed successfully
but still requires a great deal of immunosuppression. Face transplants
have been performed with some initial success. The first facial
transplant was performed in France and consisted of a partial segment
of the face. The functional recovery to date has been remarkable.
The problems of facial animation still need to be refined. Additionally,
a number of ethical issues with regard to facial identity and immunosuppression
require further resolution.
Tissue engineering of bone, cartilage, and nerve is an area of
ongoing research for plastic surgeons. Although encouraging experimental
results have been reported in anatomic areas difficult to reconstruct,
such as the external ear, the nose, or the larynx, there are as
yet few clinical applications.
Fetal surgery for cleft disorders and scar considerations, an
area pioneered by a number of plastic surgeons, appears to be in
a quiescent stage, particularly because the persistent real and
potential risks to the fetus and mother may not be warranted for
disorders that are not life threatening. Significant technical advances
in the postnatal treatment of cleft lip and cleft palate have also
lessened the enthusiasm for fetal surgery for these disorders.
Devauchelle B et al: First human face allograft:
early report. Lancet 2006;368:203.
Jones JW et al: Successful hand transplantation. One-year follow-up.
Louisville Hand Transplant Team. N Engl J Med 2000;343:468.
Rohrich RJ, Longaker MT, Cunningham B: On the ethics of composite
tissue allotransplantation (facial transplantation). Plast Reconstr
A graft of skin detaches epidermis and varying amounts of dermis
from its blood supply in the