New frontiers in plastic surgery

The term “plastic surgery” originates from the Greek word plastikos meaning to give shape. In fact, plastic surgery is an extremely old specialty – with evidence of procedures being performed by the Eygptians as far back as 3,000 years ago. Over the years, plastic surgeons have continued to pioneer new techniques in aesthetic and reconstructive surgery. In the early part of the new millennium, reconstructive microsurgery advanced with the introduction of perforator flaps. This has had significant benefits – the donor site morbidity after flap surgery is reduced by removing the skin with its blood supply, while leaving the muscle intact. The perforator flap is now the highest form of reconstruction available to cover a soft tissue defect with minimal morbidity at the donor site.

Recent advances have also taken place in transplantation surgery, notably partial face transplants. Once the issues of tissue rejection and the side-effects of immunosuppression to overcome rejection can be overcome, significant strides towards normal function and form can be anticipated.

In plastic surgery there is a conceptual hierarchy of the methods that can be used to achieve wound closure. This starts with direct closure, skin graft, local flaps, regional flaps, tissue expansion and free tissue transfer. A trained surgeon will have the technical expertise to perform any technique and more importantly know when to use what is appropriate for the patient.

Sub-specialties

Plastic surgery is a collective surgical specialty that deals with correction of form and function. It requires a multidisciplinary approach and includes a multitude of sub-specialties:

Craniofacial surgery

Paediatric craniofacial surgery involves the treatment of congenital abnormalities and trauma of the skull and face. These cases are complex and require a multidisciplinary approach with input from other specialties. Adult craniofacial surgery deals mostly with trauma and secondary surgery.

The development of the multidisciplinary team approach has greatly helped this progress. The technical advances of osteosynthesis and better radiological examinations have further improved the predictability and stability. Today, craniofacial distraction osteogenesis is a highly refined art and the techniques are now used to correct or treat numerous conditions. Microvascular free tissue transfer is playing an increasing role in certain malformations. Significant technological advancements in imaging have also allowed for more precise diagnosis and surgical planning. Quantitative analysis techniques have been developed allowing for more precise results analysis. Nonsurgical management techniques have improved, as has the understanding of the proper utilisation of non-surgical treatment.

Improvements in surgical management include ways of diminishing the need for transfusions. Operative technical refinements also allow for improved results. Bone cements and absorbable plating systems promise further enhancements. In addition, distraction osteogenesis allows skeletal changes to be made gradually reducing risks. Currently, the aetiologies of craniosynostosis are being elucidated and may allow refined management, reducing or alleviating the need for surgery. Genetic manipulation may eliminate many of the problems.

Hand surgery

Hand surgery deals with the management of congenital anomalies, acute injuries of the upper limb, abnormalities related to peripheral nerve lesions, chronic disease processes involving skin, vessels, tendons, muscles and joints of the upper limb. It is an important part of plastic surgery training in the UK. Proficiency in microsurgery is a requirement in hand surgery for replantation and revascularisation and free flap reconstructive surgery.

Reconstructive surgery

Reconstructive surgery has come a long way in terms of development and advancement with hand surgery. Advancement the field of microsurgery, has led to neurovascular anastomoses performed for thumb reconstruction as well as for digital replantation. Plastic surgeons can now transfer whole muscles from other areas of the body to restore function in the upper extremity. Improvements in understanding of nerve injury and regeneration, along with refinement in microsurgical techniques and use of bipoprosthetic grafts, have allowed surgeons to perform procedures on peripheral nerves that relieve nerve compression or to repair injured nerves following traumatic events. The experience with nerve injuries and paralysis has naturally led to refinements in tendon transfers to improve function in the hand and upper extremity. Better understanding of muscle physiology, nerve repair and biomechanics has enabled hand surgeons to restore function to the injured hand. Hand surgery is shared by the plastic and orthopaedic surgeon and an essential part of the team includes the hand physiotherapist. However, hand transplantation remains controversial.

Burns surgery

Burns surgery involves the resuscitation of large surface area burn patients, acute debridement and grafting. Secondary burns surgery usually deals with the effects of burns scarring. Research and development of new treatment modalities for burn victims have been influenced by the same technology currently affecting all medical specialties. Specific aspects of burn care that have dramatically improved in burn hospitals include: treatment of the wound with prompt eschar excision and immediate wound closure, understanding and meeting the changes in metabolic and nutritional requirements and hence improved anaesthetic care.

Important developments include the evolution of effective skin banks and a vast array of skin and dermal substitutes, infection control, and alternative wound-closure materials and strategies.

Paediatric plastic surgery

Paediatric plastic surgery deals with birth defects and syndromes. There is overlap dealing with paediatric burns, craniofacial surgery, cleft surgery and hand surgery. Super-specialisation is making the latter three specialties in their own right.

Many surgical procedures such as bone lengthening, artificial bone grafting, tissue expansion, local flap operations and microvascular tissue transfer have been developed, and good results are being obtained. However, some problems remain such as relapse of elongated bone and recurrence of deformity.

The absence or failure of an organ or tissue in a child through disease or developmental anomaly is costly and may involve plastic surgery, transplantation, artificial prostheses, biosupport technologies, and intensive medical treatments. The problem with donor shortage, imperfect tissue substitutes, and the chronic nature of specific diseases dictate that new solutions are required. Tissue engineering, as with adult conditions, is a promising development. Advances in gene transfer technology may also soon make it possible to consider in utero gene therapy for certain fatal genetic diseases.

Head and neck surgery

Head and neck surgery may invlove treating defects such as cancer, intra-oral or outside the oral cavity. Experience in reconstruction using local options as well as microsurgical techniques are required in addition to considering a multidisciplinary approach with involvement of other surgical specialties, oncologists, radiotherapists, prosthetists and therapists. Advances in head and neck reconstruction has made significant improvement in the quality of life and resectability of head and neck cancer. Refinements in microsurgical free tissue transfer have made restoration of form and complex functions of head and region a reality. Standardised reconstructive algorithms for common head and neck defects have been developed with predictable results.

Major advances in the field include sensate free tissue transfer, osseo integrated implant and dental rehabilitation, motorised tissue transfer and vascularised growth centre transfer for paediatric mandible reconstruction.

With the availability of reliable, single-stage reconstructive procedures and the often practiced two-team approach, head and neck reconstruction can be performed expeditiously and with predictable outcome. Improved quality of life with primary reconstruction is now considered an overriding argument for primary reconstruction. Availability of high-definition anatomic and metabolic imaging studies also facilitates detection of local recurrence Rapid advances in the field of tissue engineering and stem cell research is expected to deliver significant changes in the field of reconstructive surgery.

Breast surgery

Breast surgery has also become a specialty in its own right. It requires a multidisciplinary approach dealing with tumour ablation, radiotherapy, chemotherapy and the different forms of reconstruction from external prostheses, local reconstruction, the use of tissue expanders and implants, pedicled flaps and free flaps.

The choice of procedure for a given patient is affected by the patient’s age, health, contralateral breast size and shape, personal preference, and the expertise of the reconstructive surgeon. It is difficult to imagine just how much breast reconstruction might advance further as breast-preserving cancer operations are becoming more popular. Large lumpectomy defects and radiated breast deformities still benefit from plastic surgical input. With the advances witnessed in tissue engineering for other parts of the body, a breast replacement could be in sight. The use of permanent fillers for small contour defects might progress to tailor a new breast, perhaps, as an outpatient procedure with an injectable permanent filler.

Cosmetic surgery

Aesthetic/cosmetic surgery deals with the correction of ageing. Commonly this involves breast augmentation, mastopexy, breast reduction, rhinoplasty, rhytidectomy, blepharoplasty, liposuction and abdominoplasty.

The less invasive these procedures become, the more popular they will become as well. The increasing advancements in laser technology is a strong trend and combined treatments involving the use of a number of different types of non-surgical treatment such as injectables and peels, as well as the use of cosmeceuticals, is an increasing feature of the market. The cosmetic industry will continue to achieve remarkable advancements in its field and to produce procedures that can create good outcomes with minimal interference to daily life and, more importantly, less morbidity.

Origins of modern plastic surgery

Egyptian origins of plastic surgery arose more than 3,000 years ago. Physicians or priests performed reconstructive surgery and these techniques were found documented on papyrus dating back to 1600 BC. Wealthy Egyptians of that time placed importance on appearance both during life and also in death, through face masks. There is also evidence from 800 BC of “physicians” in India who performed skin grafts.

It was commonplace for adulterers and criminals to have their noses amputated as a form of punishment and surgeons would take skin grafts to reconstruct the nose from the buttock, which was applied to the defect with a form of adhesive.

Sushruta in approximately 600 BC taught surgery at the Banaras University. His book, Samhita described the reconstruction of the nose by cheek flap, repair of cut earlobes, piercing of earlobe, repair of cut lips, skin grafting, classification of burns, wound care and wound healing. Vaghbat in the 4th Century also described rhinoplasty and emphasised the need for the provision of an inner lining by turning down the nasal skin.

The cheek flap rhinoplasty of Sushruta and Vaghbat was later modified by using a rotation flap from the forehead. This method of rhinoplasty was practised by Marattas of Kumar near Poona, certain Nepaly families and Kanghairas of Kangra (Himachal Pradesh).

The Romans are known to have performed simple techniques such as repairing damaged ears from around 100 BC. Knowledge of surgery and techniques spread across Europe, through eastern Europe and into the Byzantine empire. In AD 700, the emperor Justinian received a forehead rhinoplasty after a traumatic nasal amputation, which proved successful.

In 1465, Sabuncuoglu described hypospadias and the position of the meatus in detail and classified ambiguous genitalia. In mid-15th Century, von Pfolspeundt described total nose reconstruction, suturing skin from the back of the arm into the defect. Such surgery became commonplace in the 19th and 20th Century.

In the 15th Century, Italian physicians Branca Senior and his son, Antonius, refined suturing to reduce scarring and further developed the established methods of ears and lips repair described by Susruta’s texts.

Gaspare Tagliacozzi in the 16th Century in Bologna began to experiment with the use of pedicles, transferring a section of skin, subcutaneous tissues to another area to cover a wound, while preserving its vasculature. His techniques were not popular and only re-emerged in the 19th Century.

India’s knowledge of plastic surgery came to the attention of the British in the late 18th Century as can be seen from the reports published in Gentleman’s Magazine (October 1794).

In the early 19th Century, Karl von Graefe coined the term “plastic surgery”, from the Greek “plastikos”, and published Rhinoplastik (1818) which described new techniques.

Operative Chirurgie was published in 1845. It was the first practical text, describing principles and techniques of reconstructive surgery, for other surgeons. With the introduction of anaesthesia and antiseptics, surgical practice improved and allowed Dieffenbach more complex surgery with reduced infection risk. Dieffenbach is known as the father of plastic surgery.

By the end of the 19th Century, aesthetics, as well as function, became an important part of plastic surgery. Astley Cooper performed the first skin graft in 1817. Mettauer from the US performed the first cleft palate operation with his own instruments in 1827. In 1869, Jacques Louis Reverdin used full thickness grafts in the treatment of large wounds.

War had a significant influence on plastic surgery in the 20th Century. New weapons and forms of warfare resulted in change and advancement in practice. Harold Gillies’s work from World War I centred on the treatment of facial deformities. His work, Plastic Surgery of the Face, was published in 1920 and was recognised with a knighthood in 1930. His colleague and cousin, McIndoe introduced a rehabilitative centre to reintegrate the RAF crewmen, who had suffered severe burns, back into society.

The next major advances in plastic surgery came in the 1960s and 1970s with the use of pedicled and free flaps and the development of microsurgical skills. The first successful reattachment of a severed arm was accomplished in 1970. At around this time, aesthetic surgery started to expand with breast augmentation using implants and face lifts.

Reconstructive microsurgery advanced with the introduction of perforator flaps in the early part of the new millennium, while face transplants started to be performed – with French woman Isabel Dinoire receiving a face transplant in 2005.

Face transplantation advances
Face transplant operations involving a bear attack victim in China and a French patient with a massive facial tumour have taken place. The Chinese patient received a transplant of the lip, nose, skin and muscle from a donor, as well as some facial bone. The second operation, carried out in Paris in January 2007, involved a man disfigured by a neurofibroma growing on his facial nerves.

The Royal Free’s UK facial transplantation team, headed by Professor Butler, has also announced plans to perform the world’s first full face transplant and is currently assessing a number of patients, having been given ethical approval to carry out four full facial transplants.

Complete arm transplant
The Munich University Clinic, in Germany, recently carried out a complete double arm transplant on a patient who had lost his limbs in a farming accident. The patient was reported to be recovering well, although it could be two years before he can move his new hands.

The first arm transplant occurred in Austria in 2003 when a man received transplanted forearms and hands. However, the patient’s limbs in this case were reattached just below the shoulder.

Surgeon Edgar Biemer said the greatest challenge was establishing blood flow to the muscles in the new arms.

Beryl De Souza is a plastic surgery registrar and Kaushick Chakrabarty is a consultant plastic surgeon. Both are based at Chelsea & Westminster Hospital.