Plastic and Reconstructive

Modern surgery has developed to such an extent that the body of knowledge and technical skills required have led to surgeons specialising in particular areas, usually an anatomical area of the body or occasionally in a particular technique or type of patient.

There are ten surgical specialties and this briefing covers plastic and reconstructive surgery.

What do plastic surgeons do?

Plastic surgery has two main components: reconstructive plastic surgery which is all about restoring function and appearance to the human body after illness or accident and aesthetic (often called “cosmetic”) plastic surgery, which is primarily to change the appearance from choice. Unlike most surgical specialties that are defined by an anatomical area, plastic surgery is defined by the surgical techniques that are carried out.

Reconstructive procedures are the mainstay of nearly all plastic surgeons’ work: covering all aspects of wound healing and reconstruction after congenital, acquired and traumatic problems, with aesthetic surgery playing a smaller but important part in their working week.

Most consultants will specialise in a particular area, although nearly all take part in on-call rota dealing with emergency admissions. Plastic surgeons have a busy emergency workload of soft tissue and limb injuries as well as burns. Emergency plastic surgery also supports the work of other surgeons, dealing with complex wounds from accidents or after other surgical procedures.

Due to the breadth and application of plastic surgery, these surgeons work closely with a very wide wider range of teams from other specialties. Much reconstructive work is required following major operations and it is the refinement of plastic surgical techniques that have made some other areas of surgery possible. Surgical oncologists, ENT and maxillofacial surgeons all rely on the reconstructive techniques developed by plastic surgeons.

Another area of practice related to plastic surgery techniques is aesthetic surgery, where the body is altered to bring about an improvement in appearance rather than to treat disease. These procedures are not usually available on the NHS.

Subspecialties

Plastic surgeons nearly all subspecialise while providing a more general service to a large population. Among the most common specialisms are:

• Congenital – treatments for conditions like cleft lip and palate, facial and ear deformities and craniofacial defects, hypospadias or other genito-urinary anomalies, upper limb anomalies and congenital skin conditions.
• Breast surgery – reconstruction following cancer, congenital anomalies, cosmetic breast surgery.
• Skin – excision and reconstruction or benign and malignant; management of skin cancer metastases in lymph glands and elsewhere.
• Trauma – reconstructive repair of facial trauma; lower limb trauma including open fractures and burn injury.
• Cancer – removal of malignant tumours and benign lesions of skin; breast reconstruction following cancer treatments; treatment of and reconstruction after others, such as sarcoma, “head and neck” cancer, perineal cancers.
• Hand and upper limb surgery – specialist treatment for a particularly complicated body area where function is vital for quality of life. Dealing with congenital hand abnormalities; repair of injuries to the hand and upper limb and treatment of degenerative hand disease.
• Aesthetic surgery – often called “cosmetic surgery” the changing of appearance by choice and not for the treatment of disease. Although not usually available on the NHS, aesthetic surgical principles inform the reconstructive work that plastic surgeons do and so there are important links between reconstructive and aesthetic procedures.

Other common conditions that can require plastic surgery include reconstruction of large defects; pressure sores and other chronic wounds; venous and other leg ulcers; and the results of devastating infections.

Main techniques

Whereas plastic surgeons once dealt mainly in skin grafts, reconstructive surgery now consists of a range of powerful procedures involving the movement of tissue around the body.

Skin grafts involves taking a healthy patch of skin from one area of the body, known as the donor site, and using it to cover another area where skin is missing or damaged.

Tissue expansion - a procedure that enables the body to ‘grow’ extra skin by stretching surrounding tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired, and is then gradually filled with salt water, causing the skin to stretch and grow.

Flap surgery involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessel that keeps it alive. Unlike a skin graft, flaps carry their own blood supply, so can be used to repair more complex defects.

Microsurgery is the surgical process of using magnification and very small sutures to join together very small arteries, veins and nerves to restore the vital blood or nerve supply to a piece of living tissue. This technique has been the single biggest advance in plastic surgery in the last decades because it allows a surgeon faced with a defect in the body to move tissue from another part of the same body and restore life to the transplanted tissue, so that healing begins immediately. An example might be seen after mastectomy when natural skin and fatty tissue from the abdomen can be made into a breast through microsurgical transfer.

Developments

Much of the research of plastic surgeons is centred on understanding blood supply of tissues, wound healing and scar management, particularly in the management of burns. New techniques and findings from research are being used to improve outcomes for patients.

Further Information

You can find out more information about becoming a plastic surgeon via this career guide, produced by Mr Alex Karidis, MD FRCS.

British Association of Plastic, Reconstructive and Aesthetic Surgeons
Secretariat – Email: secretariat@bapras.org.uk; T:  020 7831 5161
Press office– Email: baprasteam@forster.co.uk; T: 020 7403 2230

British Burns Association

British Society for Surgery of the Hand
T: 020 7831 5162

British Association of Aesthetic Plastic Surgeons