Surgery

Introduction to Reconstructive
and Aesthetic Plastic Surgery
Veronica C Abellera, MD, FPCS, FPAPRAS
October 25, 2019

OUTLINE
DEFINITION ............................................................................................ 1
HISTORY ................................................................................................ 1
FUTURE OF PLASTIC SURGERY ...................................................... 1
GENERAL PRINCIPLES ........................................................................ 1
PLACEMENT OF SKIN INCISIONS ..................................................... 1
BLOOD SUPPLY OF THE SKIN .......................................................... 2
TISSUE RESPONSE TO INJURY........................................................ 2
THE RECONSTRUCTIVE LADDER ....................................................... 2
HEALING BY SECONDARY INTENTION ............................................ 2
PRIMARY CLOSURE ........................................................................... 3
DELAYED PRIMARY CLOSURE ......................................................... 3
SKIN GRAFTS...................................................................................... 3
SPLIT THICKNESS SKIN GRAFT (STSG) .......................................... 3
FULL THICKNESS SKIN GRAFT (FTSG)............................................ 3 FUTURE OF PLASTIC SURGERY
PEDICLED FLAPS ............................................................................... 3
TISSUE EXPANSION........................................................................... 4 • Regenerative medicine
FREE FLAPS/MICROVASCULAR TISSUE TRANSFER ..................... 4 • Fetal surgery
RECONSTRUCTION OF CONGENITAL AND ACQUIRED DEFECTS • Reconstructive transplantation (e.g., allogeneic full-face
BY ANATOMIC REGION ........................................................................ 4
MAXILLOFACIAL TRAUMA ................................................................. 5 transplant)
MANDIBULAR FRACTURES ............................................................... 5
ORBITAL FRACTURES ....................................................................... 6 GENERAL PRINCIPLES
ZYGOMATIC BONE FRACTURES ...................................................... 6
PLACEMENT OF SKIN INCISIONS
LE FORT MAXILLARY FRACTURES .................................................. 7
NASAL BONE FRACTURES................................................................ 8 • Relaxed Skin Tension Lines (“RSTLs”)
SCALP RECONSTRUCTION ............................................................... 9
o It is where wrinkle lines develop
EAR RECONSTRUCTION ................................................................. 10
NASAL RECONSTRUCTION ............................................................. 10 • Exploited to create incisions that minimize anatomic
LIP AND INTRAORAL RECONSTRUCTION ..................................... 11 distortion and improve cosmesis
BREAST RECONSTRUCTION .......................................................... 12
TRUNK AND LUMBAR AREA ............................................................ 12
EXTREMITIES.................................................................................... 12
AESTHETIC PLASTIC SURGERY ....................................................... 13
COMMON AESTHETIC SURGICAL PROCEDURES ........................ 13
CASES .................................................................................................. 15

DEFINITION
• Restoration of form and function
• Congenital and acquired deformities
o Plastic
§ Greek plastikos = “to mold”
• *Not confined to one area but from head to toe
RSTLs in the face follow the natural wrinkle lines
HISTORY
• Earliest written text on facial reconstruction, particularly on
the nose – Sushruta 600 BC
o Amputation of the nose – punishment
o Indian Method
§ Forehead tissue transposed as a flap to the nasal
defect performed by caste of Indian potters, the
Koomas.
• Knowledge filtered to Rome
o Italian Method of Nasal Reconstruction
§ Arm flap transposed to the nasal defect (inner medial RSTLs in the face are generally perpendicular to the fibers
aspect of arms) of the underlying facial muscles
§ Splinting during the healing period
§ Dividing the pedicle after flap is vascularized
• Great advances occurred during WW1 and WW2
o Due to wars, trauma centers were created where “body
repairs” were done.

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 *All of these are needed to close the wound

Patient Factors
• Cardiopulmonary function
• Thermoregulation
• Nutrition
• Infection
• Glycemic control

Surgeon factors
• Technique
• Use of Appropriate materials
• Infection control

THE RECONSTRUCTIVE LADDER

• Definition
o The stepwise application of reconstructive techniques to
achieve a closed wound with optimum cosmesis and
function, minimal morbidity and complications
• Options should be chosen from the simples to the most
RSTLS in the body (note the direction) complex

• Cheeks – Oblique, Mouth – Vertical, Neck – Free Flaps

Horizontal, Body – Varied (transverse, vertical, oblique) Tissue Expansion
• Scars where most indistinguishable – Side of nose & Pedicled Flaps
Forehead Skin Grafts
Primary Closure
Healing By Secondary Intention

BLOOD SUPPLY OF THE SKIN

• Septocutaneous artery - vessels that traverse fascial septa

between muscles, musculocutaneous perforators that
penetrate muscle bellies, or direct cutaneous vessels that
traverse neither muscle bellies nor fascial septa

TISSUE RESPONSE TO INJURY

• Tissue injury, whether traumatic or surgically created, leads The Modified Reconstruction Elevator. Here you can skip
to a chain of events that lead to wound healing. steps, unlike the reconstructive ladder where you should follow
the sequence.
Wound Microenvironment Factors
• Clotting cascade – hemostasis HEALING BY SECONDARY INTENTION
• Complement system – release of growth factors and
• Mechanism is by wound contraction
cytokines
• For wounds that cannot be approximated (requires a
• Platelet activation – inflammatory response
granulation tissue matrix to fill the wound defect).
• All these systems result in:
o Collagen deposition
o Angiogenesis
o Epithelialization
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PRIMARY CLOSURE
• Edges of the wound are brought together and apposed by a
variety of materials
o e.g., fibrin glue, skin tapes, sutures, staples
• Suturing techniques
o e.g., continuous, simple interrupted, vertical and
horizontal mattress, intracuticular

DELAYED PRIMARY CLOSURE

• When wound cannot be closed immediately because of
infection, primary closure may be delayed for a few days to
allow control of infection
Graft In Place
SKIN GRAFTS
FULL THICKNESS SKIN GRAFT (FTSG)
• Technique of resurfacing full thickness wounds using
• Contains epidermis and entire thickness of dermis.
patient’s own skin harvested from a distant donor site.
• Donor site of FTSG must be amenable to primary closure
• Thickness of the skin graft depends on the amount of dermis
included with the epidermis. • FTSG: Wolfe-Krause grafts

SPLIT THICKNESS SKIN GRAFT (STSG)

• Split thickness skin graft (STSG): contains epidermis and
varying thickness of dermis
o Thin STSG: Thiersch-Ollier graft
o Intermediate STSG: Blair-Brown graft
o Thick STSG: Padgett graft
• Donor site of STSGs heal by re-epithelization

Harvesting FTSG and closing the donor site

(The donor site is closed primarily)

Harvesting of STSG
(Harvested using a harmonic scalpel)

FTSG on Nasal Dorsum

• Caucasians have light skin so grafts blend naturally unlike

Asians where the skin is more pigmented.
• Graft donors that will show different pigmentations
o Groin, abdomen and the back of the knees.

Meshing the Graft PEDICLED FLAPS

• Pedicled flaps according to blood supply and composition
o Composition
§ Cutaneous flaps
• Random – dermal-subdermal plexus
• Axial – cutaneous artery
§ Fasciocutaneous flap
§ Myocutaneous flap
§ Osseomyocutaneous flap

Anchoring The Graft

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Anatomy of Pedicled Flaps • Type C – musculocutaneous artery that penetrates fascia

Myocutaneous Flaps
• Consist of skin, subcutis and underlying muscle
Note the arteries supplying the skin, subcutaneous tissue, • Blood supply from the artery/ies supplying the muscle
fascia, and muscle. • Bulkier (used to add more bulk – e.g., in bed sores and deep
Cutaneous Flaps wounds)
• More robust blood supply
• More resistant to infection

Osseomyocutaneous
Flaps
• Flap consists of
segment of bone with
attached muscle and
skin and
subcutaneous tissues

• Random – blood supply is dermal-subdermal plexus

o Used to reconstruct relatively small, full-thickness defects
that are not amenable to skin grafting
• Axial – Supplied by cutaneous artery
Fasciocutaneous Flaps
• Consists of skin, subcutaneous tissue and deep fascia
overlying a muscle
• Blood supply from perforators piercing the fascia and lie on
or adjacent to it.
TISSUE EXPANSION
• Insertion of tissue expander/s
o Serial injection of sterile saline to gradually stretch
overlying tissues
o Removal of Tissue expander and utilizing the expanded
skin as advancement or rotation flaps to reconstruct the
defect
FREE FLAPS/MICROVASCULAR TISSUE TRANSFER
• Utilizes microvascular techniques of anastomosing artery,
vein, and sometimes nerve and bone in the donor flap to the
recipient site.

RECONSTRUCTION OF CONGENITAL AND ACQUIRED

DEFECTS BY ANATOMIC REGION
ORIF
• “Open reduction” means a surgeon makes an incision to
re-align the bone.
• “Internal fixation” means the bones are held together
with hardware like metal pins, plates, rods, or screws.
After the bone heals, this hardware isn’t removed.
o Closed reduction – if the bone is realigned without an
incision.

Mathes and Nahai Fasciocutaneous Flaps

• Type A – direct cutaneous artery that penetrates fascia
• Type B – septocutaneous artery that penetrates fascia

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MAXILLOFACIAL TRAUMA
• Soft Tissues: adequate
debridement but
preserve anatomic
landmarks like eyebrows,
eyelid margins, white roll,
etc.
o Wounds closed by
suturing, skin grafts
or flaps.

• Facial Fracture:
biomechanics of
maxillofacial trauma
o These forces with
level and location of Mandible fractures are favorable (left) when muscles tend to
point of impact will draw bony fragments together and unfavorable (right) when
determine the pattern bony fragments are displaced by muscle forces. Vertically
of injury (the unit is unfavorable fractures allow distraction of fracture segments in
grams). a horizontal direction.

Goals of Treatment
• Restore proper occlusion (Angle I or Neutroocclusion)
MANDIBULAR FRACTURES • Achieve normal alignment and fracture healing
• Mandible is a strong, dense bone but with areas of inherent
weakness:
o Subcondylar area: thin and tapered
o Angle: third molar thins this area
o Parasymphysis: mental foramen thins this area

X-ray

Note the percentage (frequency) of fractures.

• Favorable mandible fractures: fracture segments are Panoramic View

reduced to a position that favors healing
• Unfavorable mandible fractures: fracture segments are
displaced to a position that prevents healing

3D CT Scan

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Techniques
• Open Reduction Internal Fixation (ORIF)
• Interdental Wiring
• Intermaxillary Fixation (IMF)
Interdental Fixation
• Tooth-borne devices are
ideal for patients who
have complete, healthy
teeth. This means that
they are not suitable for
those with multiple
missing teeth, carious or
weak teeth, dental crowns, Palpation of orbital rim
or dental bridges. If the
patient does not qualify for
tooth-borne devices,
doctors will use bone-
borne devices.

Intermaxillary Fixation
• In this technique fractured
fragments are fixed and
immobilized in their
anatomically reduced
position by means of wires
that are placed around the
teeth.
• Various types of tooth
mounted devices like arch
bars, dental and Coronal CT scan showing orbital floor blow-out
interdental wiring, metallic
and nonmetallic splints are Goals Of Treatment
used to achieve • Restore normal intraorbital volume
intermaxillary fixation. • Preserve orbito-ocular function and mobility

Techniques
• ORIF: release entrapped ocular muscle and orbital fat
restore continuity of roof, floor and wall by bone grafts and
alloplastic materials

Internal Fixation with

plates and screws

ORBITAL FRACTURES
• Force hitting the orbital rims (thick bones) are transmitted to
the walls or floor of the orbit (thin bones) resulting in “blow-
out” fracture.

Bone graft to orbital floor

ZYGOMATIC BONE FRACTURES

• Its prominent position makes it susceptible to injury
• Usually includes lateral orbit wall and floor
• Sometimes, isolated fracture of the zygomatic arch

Entrapment of globe on upward gaze

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Physical Examination
• Inspection – inspect the area involved thoroughly

• Palpation – palpate the area cautiously The patient after the surgery

LE FORT MAXILLARY FRACTURES

• Maxilla is principle bone of midface
• Contains paired, large, air-filled maxillary sinuses
• It easily fractures with far less force compared to adjacent
bones

Types: Le Fort I, II, III

• Subject patients to CT scan

• Le Fort I level fractures are essentially a separation of the

hard palate from the upper maxilla due to a transverse
fracture running through the maxilla and pterygoid plates at a
level just above the floor of the nose.
• Le Fort II fractures transect the nasal bones, medial-anterior
orbital walls, orbital floor, inferior orbital rims and finally
Goals of Treatment transversely fracture the posterior maxilla and pterygoid
plates.
• Restore normal positions of zygomaticomaxillary complex • Le Fort III fractures result in craniofacial disjunction.
and normal orbital relationships
Physical Examination
Techniques
• Moon facies
• Closed reduction technique for non-comminuted zygomatic • Positive drawer's test (bone
arch fracture moves in a manner like a drawer)
• ORIF for complex fractures

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 Types

Digital View of The Fracture

Goals of Treatment
• Restore facial
proportions: height and
projection
• Restore normal occlusion
• Bony union

ORIF

Nasal Fracture Patterns

Patient after the surgery Soft Tissue Lateral

NASAL BONE FRACTURES

• Prone to fracture because of its central location and
prominence
• Thin nasal bones and soft cartilaginous septum
• Nasal fractures are either posteriorly or laterally displace

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Close Reduction fracture. C. Use of elevator with digital manipulation to reduce
nasal fracture. D. The length of the elevator should be checked
before nasal insertion so that the force applied for reduction is
correctly placed. E. Walsham forceps may be used to reduce
collapsed or crushed bone segments of the nose. F. Walsham
forceps used to reduce and straighten a dislocated or fractured
nasal septum. G. External nasal splinting to support and
protect the nasal reduction.

Before After

SCALP RECONSTRUCTION
• Anatomy:
o Skin
o C (SubCutis)
o Aponeurosis (Galea)
o Loose Subaponeurotic Layer
o Pericaranium
• General Principles
o Scalp flaps are usually random or axial pattern
o Plan flaps to include artery/ies supplying that area
o Hair bearing: replace “like with like”
o Scalp has alternating loose and tight areas

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A. Hand manipulation of the nose. The direction of finger

pressure is opposite the vector of injury and direction of nasal
displacement. B. Insertion of nasal elevator to reduce

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 Traumatic Ear Loss

• Usually rotation or
advancement flaps
• Score the galea to
increase stretch and
length of flap.
Goals of Treatment
• Creation of an external auditory appendage in the case of
microtia: cartilaginous framework skin coverage
o Restore partial or complete ear defects from trauma or
cancer surgery

Techniques
• Use of tissue expanders to • Simple suturing
increase the size of the scalp • Rotation flaps, advancement flaps
flap by gradual pre- • Cartilage grafts - rib cartilage
expansion • Temporoparietal fascial flaps
• Skin grafts

NASAL RECONSTRUCTION

• Skin Grafts: • Congenital: nasal agenesis, midline facial clefts

o STSG on intact pericranium or granulation tissue; • Acquired: infections like leprosy, necrotizing
hairless gingivostomatitis
o Microvascular flaps o Post-cancer excision

EAR RECONSTRUCTION
• Congenital defects like microtia
• Acquired defects: Trauma
o Excision of malignancy

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 LIP AND INTRAORAL RECONSTRUCTION
• Congenital defects: cleft lip and palate, craniofacial clefts
• Acquired defects: trauma, infection, post cancer ablation

Goals of Treatment
• Restore partial or complete nasal defects by providing
adequate lining, framework and covering
• Restore nasal airway

Techniques
• Flaps, skin grafts, mucosal grafts, bone and cartilage grafts
• Tissue expanders

Tissue Expansion
• 14-year old female post herpes zoster infection with
nasolabial scars

14/F post-herpes zoster After insertion of 150 cc

infection with nasolabial round tissue expander
scars
After Reconstruction

Goals of Therapy
• To restore a competent oral sphincter
• Restore function of speech and feeding

Techniques
• Local rotation and advancement flaps
• Distant flaps from the chest
• Skin grafts
• Free flaps/microvascular surgery
• Bone grafts
After instillation of 50 cc sterile saline

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BREAST RECONSTRUCTION • Congenital: gastroschisis, omphalocoele, hernias,
• Congenital: hypomastia, Poland's syndrome myelomenigocoele
• Acquired: traumatic defects, infection, post mastectomy • Acquired: trauma, infection (bedsores), incisional hernias,
reconstruction post-excision of abdominal wall tumors

Goals of Therapy
• Restore structural integrity of abdominal wall/trunk
• Prevent herniation of abdominal viscera
• Provide dynamic muscular support for proper posture and
movement.

Techniques
• Local flaps, tissue
expanders, myofascial
Goals of Therapy flaps
• Prosthetic mesh
• Restore breast mound and nipple-areola complex • Distant flaps from thigh
• Achieve symmetry • Free tissue
transfer/microvascular
Techniques flaps
• Breast implants (saline or silicone gel)
• Chest tissue expansion + implants (Image: rectus abdominis,
• Myocutaneous flaps ± implants (TRAM, latissimus dorsi) external oblique,
• Free flaps (deep inferior epigastric artery flap) thoracoepigastric flap, groin
• Oncoplastic surgery flap, tensor fascia lata,
• Fat transfer: liposuction + fat reinjection rectus femoris)

Do breast implants cause cancer?

• It does not cause cancer of the breast parenchyma itself.
• However, certain types of textured breast implants MAY EXTREMITIES
cause Breast Implant Associated Anaplastic Large Cell
Lymphoma (BIA-ALCL) in the capsule or seroma • Anatomy:
surrounding the breast implants. • Skin, subcutaneous
• Fascia-muscle: long bellies of muscle-tendon units
arranged in compartments separated by septa
• Bone, blood vessels, nerves
• Congenital: agenesis, reduction, fusion, clefting
• Acquired: trauma, infection, post-tumor ablation, burn
contractures

TRUNK AND LUMBAR AREA

Anterior Posterior
Skin, SQ Skin, SQ
Fascia - Muscle Fascia - Muscle
Peritoneum Peritoneum

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 o Aims to make the patient “more well” and happier
• Ideal outcome
o Careful selection of surgical candidates
o Formulating a treatment plan
o Demands knowledge of rules of symmetry, proportion,
patterns, regularity and simple ratios
o Execution of plan through mastery of anatomy and
surgical skills
o Meticulous post-operative care

Spectrum of Outcomes
Happy patient
Proud surgeon
IDEAL
Happy patient
Dissatisfied surgeon
ACCEPTABLE
Unhappy patient
Dissatisfied surgeon
REVISION
Unhappy patient
Proud surgeon
WORST SCENARIO

• Misconceptions
o “Minor surgery”
o Not considered serious, it is frivolous
o Maximizes glamour and trivializes risks and
complications

COMMON AESTHETIC SURGICAL PROCEDURES

• Blepharoplasty, brow lift, forehead lift, Botulinum toxin,
fillers: improve appearance of upper third of face
o Forehead, brows, upper and lower lids, temporal areas,
lateral canthal area (crow’s feet)
• Midface rejuvenation: improve aesthetics of middle 3rd of
the face
Goals of Therapy o Nose, cheek, malar areas, cheek-nose junction
o Mid-facelift, rhinoplasty, fillers, fat grafting
• Restore stable skin and soft tissue coverage
• Lower third of face and neck rejuvenation: improve
• Restore limb function and mobility aesthetics of mouth, jawline, neck
o Lower face and neck lift, lip and perioral rejuvenation,
Techniques botulinum toxin, fillers
• Skin grafts
• Local flaps Botulinum Toxin
• Distant flaps • Neuromodulators
• Free flaps o Botulinum toxin
• Botulinum toxin is produced by
AESTHETIC PLASTIC SURGERY Clostridium botulinum, a Gram-
• Aesthetics: branch of philosophy dealing with the nature of positive anaerobe
the beautiful and with judgements concerning beauty.
• Beauty: quality or aggregate of qualities in a person or thing
that gives pleasure to the senses or exalts the mind or spirit
• Science and Art
o Demands the most skillful but subtle employment of
surgical modalities
• American Medical Association
o Defines it as “surgery performed to reshape normal
Commercially Available Brands
structures of the body to improve patient's appearance
and self-esteem” • Onabotulinum ToxinA (Botox, Botox Cosmetic)
o Influenced by cultural norms, trends, media • Abobotulinum ToxinA (Dysport)
• As an art, its objective is to give pleasure and satisfaction to • Incobotulinum ToxinA (Xeomin)
the patient. • Prabotulinum ToxinA (Jeuveau)
• Aesthetic surgery is unique • Rimabotulinum ToxinB (Myobloc)
o Treats “well” patients
o “Unnecessary” surgery Mechanism of Action
Surgery: Introduction to Reconstructive and Aesthetic Plastic Surgery • 13 of 15
• Binds to presynaptic cholinergic receptors
• Decrease release of acetylcholine
• Cause a neuromuscular blocking effect
• Recovery after 3 to 4 months through axonal sprouting and
muscle re-innervation
• FDA approved use for pain: migraine
• Untoward side effects:
o Respiratory symptoms, dysphagia, allergic reactions,
facial and other muscle weakness

Breast Aesthetic Surgery

• Augmentation Mammaplasty: increase volume and
projection
o Silicone or saline filled implants
o Autologous fat injection
• Reduction Mammaplasty, mastopexy: correction of
hypermastia, breast and nipple ptosis and breast asymmetry
o Reduce volume by excising breast tissue, rearrange and
resuspend ptotic tissues

Body Contouring
• Suction Assisted Lipectomy: removal of localized adipose
deposits thru a suction device, with or without ultrasound,
radiofrequency, or cryosurgical techniques
o 6-8 liters max
o Morbidly Obese are not candidates, ask them to lose
weight first.
• Abdominoplasty, belt dermolipectomy, brachioplasty,
thighplasty: remove redundant skin, subcutaneous tissue
and fat by direct excision

Hair Restoration Surgery

• Scalp reduction: excision and primary closure
• Local scalp flaps: rotation or advancement flaps
• Hair transplant: hair bearing punch grafts implanted into
areas of thinning or alopecia

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 CASES
Augmentation Rhinoplasty Blepharoplasty Otoplasty Lip Reduction
(correction of eyelids)

Before / After
Before / After Before / After

Before / After
Face Lift Liposuction Abdominoplasty Breast Augmentation

Reduction Mammoplasty

Before After Before After

Editor’s note:
• The pictures above are actual patients. Please refrain from posting them in social media to protect their privacy.

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