Plastic & Reconstructive Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

Hand trauma

Small structures, large stakes, and rehabilitation as half the cure.

Why hands are a specialty

The hand packs tendons, nerves, vessels and joints into millimetres, and its function is a livelihood: small errors in assessment or repair compound into permanent disability.

Assessment discipline

Every structure by name: each tendon tested against resistance, each nerve's territory checked with two-point discrimination, perfusion documented digit by digit, and the injury's position reconstructed from where the hand was at the moment of harm.

The urgent list

Devascularised digits, flexor sheath infection (Kanavel's signs), compartment syndrome of the hand and high-pressure injection injuries: the hand's emergencies are easily underestimated by everyone except hand surgeons.

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Repair plus rehabilitation

Tendon and nerve repairs are judged at three months, not in theatre: early protected motion protocols under hand therapy decide whether a technically good repair becomes a functionally good hand.

Flexor tendon repairCase: A glass cut to the finger

X-ray

What should I notice?

• Burns

  A skin injury that becomes a systemic illness.

  Depth and area

  Depth (superficial, partial, full-thickness) decides healing versus grafting; area (rule of nines, palm as 1%) decides physiology: the two axes are assessed separately and both evolve over the first days.

  The systemic illness

  Past roughly 15-20% TBSA, capillary leak makes fluid resuscitation a survival matter: formulas start from area and weight, and the urine output, not the formula, steers the second half.

  Airway and inhalation

  Enclosed fires, facial burns, soot and hoarseness predict airway swelling and carbon monoxide exposure: intubate early on prediction, not late on obstruction.

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  Surgical care

  Deep burns are excised early and covered, autograft where donor sites allow: early excision changed burn mortality, and the operations are staged campaigns rather than single events.

  The long game

  Hypermetabolism, infection surveillance, nutrition, scar management and contracture prevention: burn care runs months after the resuscitation week that gets taught.

  Split-thickness skin graftCase: Scalded in a kitchen fire

• Skin cancer

  The commonest cancers, and the defects their cure leaves behind.

  The three

  Basal cell carcinoma (locally destructive, almost never metastatic), squamous cell carcinoma (real metastatic potential, worse in the immunosuppressed), and melanoma, where millimetres of depth move survival curves.

  Melanoma's staging

  Breslow thickness rules: it sets the wide excision margin, the sentinel node conversation and the prognosis, which is why the first biopsy must be full thickness.

  Treatment

  Excision with appropriate margins cures most skin cancer; radiotherapy, topical therapies and systemic agents (immunotherapy transformed advanced melanoma) fill the spaces surgery cannot.

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  Reconstruction

  The face is the usual battleground: defects after adequate margins get the ladder's honest answer, graft or local flap designed along aesthetic subunits, with cure never traded for closure convenience.

  Local flap reconstructionSplit-thickness skin graftCase: A mole that changed

• The defect: reconstruction as a discipline

  Cancer, trauma and infection leave holes; this is the science of filling them.

  Analysing a defect

  What is missing (skin, muscle, bone, lining), what is exposed (tendon, bone, implant, vessels), and what must the result do (glide, bear weight, seal, look like a face): the reconstruction is chosen by the answer, not the fashion.

  Grafts

  Skin transferred without its blood supply: split-thickness covers area and takes reliably on vascular beds; full-thickness trades quantity for quality. Neither survives on bare bone, tendon or radiated concrete.

  Flaps

  Tissue moved with its blood supply: local flaps borrow neighbouring laxity, pedicled flaps swing on a named vessel, and free flaps detach entirely and are replumbed by microsurgery where the defect's neighbourhood has nothing to lend.

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  Choosing the rung

  The ladder is a discipline, not a dogma: simplest reliable option first, but sometimes the elevator is taken straight to a free flap because only that rung restores function. Saying why is the specialty's core skill.

  Split-thickness skin graftLocal flap reconstructionCase: The flap that turned blue Case: Reconstruction after mastectomy