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Planning is of the essence: a summary of reconstructive surgery techniques (Part 1)
Take a trip through the centuries and the evolution of surgical techniques to the life-giving work of today’s plastic and reconstructive surgeons.
Since the twelfth century techniques have significantly evolved over the centuries to current contemporary methods and surgical techniques essential to the innovative life-giving work of today’s plastic and reconstructive surgeons. In the 1970s, a formal plastic surgery training programme was established at Middlemore Hospital in Auckland.
Reconstructive surgery always begins with a plan, a pen in hand, and an ability to look at the problem in three dimensions. Steps are drawn out with a marker pen, and planning based on techniques and modifications. There is always plan B; what Sir Harold Gillies called “the lifeboat,” as plastic surgeons are faced with varied and often challenging clinical scenarios.
Many of these techniques have been passed on from the Kiwi plastic surgery greats such as Gillies and Sir Archibald McIndoe, through successive generations of plastic surgeons.
The illustration adjacent shows elliptical excision and sliding flap repair. Left: Lesion with excision margins and 4:1 ellipse in the relaxed skin tension lines. Centre: Shading symmetrical undermining each side of the wound. Right: Direct closure with double advancement (sliding flaps).
Caption for top image: A detail of the Sir William Manchester skin grafting knife assembled with strop. Image courtesy of John Williams.
Local flaps
Flap surgery is a technique in plastic and reconstructive surgery where a unit of skin and subcutaneous tissue with an intact blood supply is lifted from a donor site and facia; flap surgery moved to an adjacent recipient site, without creating a secondary defect. The word ‘flap’ probably originated from the sixteenth Dutch word ‘flappe’ which referred to anything that hung broad and loose, fastened only by one side.
The principles of local flaps are the foundation for planning repair. Knowledge of the various types of flap enables the surgeon to create modifications of a standard flap to address the surgical problem.
Advancement flaps
These flaps make use of the elasticity of the skin and soft tissues to repair a wound. The flap is elevated and moves forward into the defect without any lateral movement.
Rotation flaps
Tissue is rotated around the arc of a circle into a triangular defect. With the flap rotated into position, there is a difference in tension on the two sides of the suture line. Ideally this difference of tension is distributed evenly along the suture line by the suturing technique of halving.
Reconstructive surgery always begins with a plan, a pen in hand, and an ability to look at the problem in three dimensions. Steps are drawn out with a marker pen, and planning based on techniques and modifications. There is always plan B; what Sir Harold Gillies called “the lifeboat,” as plastic surgeons are faced with varied and often challenging clinical scenarios. Many of these techniques have been passed on from the Kiwi plastic surgery greats such as Gillies and Sir Archibald McIndoe, through successive generations of plastic surgeons.