Plastic & Reconstructive Surgery

Patients to decide on, images to interpret, and the briefing for the first day on the rotation.

• Case

  Scalded in a kitchen fire

  A 34-year-old chef is brought in from a kitchen fire with burns to his chest, both arms and face, and a hoarse voice.

  Take the case

• Case

  A glass cut to the finger

  A 26-year-old woman cut the palmar aspect of her right ring finger on a broken glass and cannot bend the tip.

  Take the case

• Case

  A mole that changed

  A 47-year-old woman has a pigmented lesion on her upper back that her partner says has grown and darkened.

  Take the case

• Case

  The flap that turned blue

  A 58-year-old man has a free fibular flap reconstruction of the mandible after tumour resection.

  Take the case

• Case

  Reconstruction after mastectomy

  A 46-year-old woman with a 3 cm breast cancer needs a mastectomy and is considering reconstruction.

  Take the case

• Scan practice

  Size the burn, find the danger

  A house fire: burns to the anterior trunk and one whole arm, charted on arrival. (Fictional educational case.)

  Practice this image

• A 4 cm defect over the shin after excising a squamous cell carcinoma: periosteum intact over most, a coin of bare bone at the centre. Graft, local flap, or free tissue?

  • Split-thickness graft

    Reliable on the vascularised majority of the bed, but the bare bone will not adopt a graft: honest only if the bone is covered another way.

  • Local flap

    Brings its own blood supply over the bare spot, at the price of a donor scar in a leg with little laxity: the classic mid-rung answer, if the local tissue allows.

  • Free flap

    For defects whose neighbourhood cannot pay: replumbed tissue covers anything, bought with microsurgery, monitoring and a bigger operation.

  The bed chooses the rung: grafts need a vascular bed, flaps bring their own. Read the defect (what is missing, what is exposed) and the reconstruction names itself, with the ladder climbed exactly as far as the exposed structures demand.

• A circumferential full-thickness burn of the forearm, six hours in: fingers cooler, pain on passive stretch, dressings snug. Escharotomy now?

  • Escharotomy at the bedside or in theatre now

    Full-thickness eschar cannot stretch; the swelling beneath it strangles first veins then arteries. The release incisions are along marked lines and the relief is immediate.

  • Elevate, loosen, reassess

    Right for the incomplete picture, wrong as a way to defer the inevitable: reassessment must have a named time and a named person.

  Circumferential deep burns are compartment syndromes wearing a burn's clothing: the perfusion examination, not a pressure number, makes the call, and the escharotomy done 'possibly early' beats the one done certainly late.

• Mastectomy planned for a node-positive cancer likely to need radiotherapy: the patient wants reconstruction. Immediate, delayed, or immediate-delayed?

  • Immediate reconstruction

    One anaesthetic, a preserved skin envelope, the best aesthetic start: but radiotherapy onto a fresh reconstruction, especially an implant, taxes the result.

  • Delayed reconstruction

    Cancer treatment finishes first, then reconstruction on a settled field: safest sequencing for radiotherapy, at the cost of an interval without a breast.

  • Staged approaches

    Temporising expanders and hybrid sequences hold the envelope open while radiotherapy passes: the compromise position, with its own maintenance.

  Radiotherapy is the hinge: it degrades implants and contracts fresh reconstructions, so the oncology plan is established before the reconstructive one is promised. The multidisciplinary sequence, not the strongest personality in clinic, sets the order.