Plastic & Reconstructive Surgery

Cover, function and form: the specialty of the soft-tissue solution.

• Plastic surgery solves soft-tissue problems for the whole body: wounds that will not close themselves, cancers that leave defects, burns that destroy the skin's functions, and hands whose small parts carry outsized function.
• Its organising idea is the reconstructive ladder: for any defect, the simplest reliable option first, direct closure, graft, local flap, free tissue transfer, climbing only as the defect demands.
• Two tissues' blood supply runs the specialty: a graft has none and must be adopted by its bed; a flap brings its own and lives or dies by its pedicle. Most of plastic surgery's judgement lives in that distinction.
• The burn is its systemic disease: past a threshold of surface area, a skin injury becomes a whole-body illness of fluid loss, hypermetabolism and infection risk.

X-ray

What should I notice?

• The major burn

  “A house fire: 30% total body surface area burns, singed nasal hairs, a hoarse voice, and a transfer call from a rural ED.”

  • Airway first and early: soot, hoarseness and enclosed-space fires predict an airway that will swell shut, and intubation is easier now than in two hours.
  • Size the burn honestly (rule of nines, patient's palm as 1%), because the fluid resuscitation formula starts from it and both under- and over-resuscitation kill.
  • Depth decides destiny: superficial partial burns heal; deep partial and full-thickness burns need excision and grafting, and the examination evolves over days.

  Live it as a case Split-thickness skin graft

• The hand that cannot flex

  “A kitchen knife across the palmar fingers: a clean wound, a finger that will not bend at the tip, and a chef who needs it to.”

  • Test each system by name: profundus and superficialis separately for every finger, nerves by two-point discrimination on each side of each digit, and perfusion by colour and refill.
  • The wound is a keyhole: what was cut depends on where the fingers were when the blade crossed, so the tendon's injury may lie centimetres from the skin's.
  • Zone matters: flexor injuries in the fingers' fibro-osseous tunnels (zone II) demand precise repair and even more precise rehabilitation.

  Live it as a case Flexor tendon repair

• The changing pigmented lesion

  “A mole on the calf that has grown, darkened unevenly and bled once: asymmetry, irregular border, and a worried patient.”

  • The ABCDE features (asymmetry, border, colour, diameter, evolution) triage suspicion, and evolution is the strongest word in the list.
  • The first operation is diagnostic: excision biopsy with a narrow margin, full thickness, never a shave of something that might be melanoma, because depth (Breslow) is the entire staging conversation.
  • The second operation is definitive: wide local excision with margins set by Breslow thickness, and the sentinel node conversation for thicker lesions.

  Live it as a case Split-thickness skin graftLocal flap reconstruction

• The free flap on hourly observations

  “Twelve hours after a free flap reconstruction: the flap is darker than an hour ago, brisker to refill, and the junior on nights is asking whether to worry.”

  • A free flap lives on one artery and one vein rejoined under a microscope: monitoring exists because pedicle thrombosis is salvageable only in its first hours.
  • Learn the two failure faces: the pale, cool, slow-refill flap of arterial failure, and the congested, dark, brisk-refill, ooze-on-pinprick flap of venous failure, which is the commoner and the faster.
  • The escalation is binary: concern equals call the flap team now, because the treatment for a failing flap is the operating theatre, not observation from closer range.

  Live it as a case

• Reconstruction after mastectomy

  “A 48-year-old planning mastectomy asks what reconstruction would mean: now or later, implant or her own tissue.”

  • Timing is oncologic first: immediate reconstruction preserves the skin envelope and spares an operation, but planned radiotherapy shifts the arithmetic toward delay or toward autologous tissue.
  • Two families of answer: implant-based (shorter surgery, a device's long-term maintenance) and autologous (the abdomen's DIEP flap as flagship, longer surgery, a reconstruction that lives and ages with the patient).
  • The donor site is half the operation: an abdominal flap is also an abdominal wall decision, and the counselling covers both scars.

  Live it as a case