Fundamental Principles of

Plastic Surgery
Dr. Asem Qandah
Asst. Prof of Plastic & Reconstructive Surgery (Hashemite University)
Introduction:
• Plastic surgery is an incredibly diverse specialty that is challenging to
define because its scope cannot simply be characterized by patient
age, gender, organ system, or pathology.
• There is an inexorable connection between cosmetic surgery and
reconstruction surgery because every plastic surgery operation aims
to restore both form and function.
• In this lecture will talk about 10 of the most essential fundamental
principles of plastic surgery and provides relevant examples of how
plastic surgeons utilize these principles in a wide range of clinical
scenarios.
Principle I: Make an Informed Decision to
Operate or Not Operate
• Some types of plastic surgery are mandatory. A wound resulting from
resection of a sarcoma with exposed bone requires a reconstructive
operation that provides soft tissue coverage over the defect durable
enough to withstand the infliction of adjuvant radiation therapy.
• However, in many situations, the plastic surgeon must make an informed
decision whether to perform an operation or not based on a thorough
evaluation of the potential benefits against the potential risks. Although
this is conspicuously germane to cosmetic surgery, the same thought
process is necessary for reconstructive surgery. For example, a large but
clean traumatic wound on a patient’s thigh could be treated reasonably
with one of several options, from nonsurgical strategies such as dressing
changes to surgical intervention such as local tissue rearrangement.
• Success is also subjectively gauged by patient satisfaction and is influenced
by patient expectations.
Principle II: Optimize Modifiable Patient
Factors
• Deliberate identification and management of patient risk factors will
decrease the chances of complications and increase the likelihood of
successful surgical outcomes.
• For example, smoking is a commonly encountered modifiable risk factor.
• Other modifiable medical risk factors that also exacerbate poor wound
healing include uncontrolled diabetes, obesity, infection, steroid use,
certain homeopathic medications, and malnutrition.
• For a majority of plastic surgeons, smoking is an absolute contraindication
to any body contouring operation.
• The plastic surgeon should inquire about the social support available to
the patient and ensure that the patient’s postoperative safety is entrusted
to either family members or a rehabilitation center.
Principle III: Perform Adequate Debridement
Prior to Reconstruction
• Debridement is performed to physically remove any barriers to tissue
growth, such as infection, biofilm, and senescent cells.
• The plastic surgeon may choose one of many forms of debridement,
from dressing changes to operative excision of the wound.
• Although adequate debridement is usually a term associated with the
management of chronic wounds, this essential principle also applies
to acute wounds. Acute traumatic wounds, such as open fractures of
the lower extremity or lacerations from bite injury.
• it may even be applied to clean surgical wounds. For example, during
reduction mammoplasty.
Principle IV: If Possible, Replace Like With
Like; If Not Possible, Create It
• The plastic surgeon examines the defect carefully and determines the
best donor tissues necessary to optimally achieve both a durable
reconstruction and an optimal aesthetic outcome.
• For instance, when primary skin closure is not possible after excision of a
cutaneous tumor from an upper eyelid, a frequently chosen donor site is
full-thickness skin from the opposite upper eyelid. 12 This option is elegant
because it replaces the missing tissue with tissue of the same thickness,
color match, pliability, and elasticity.
• When such an ideal donor site is unavailable, the next most similar tissue
substitute is selected; in this example, skin for eyelid reconstruction can be
harvested from postauricular skin or supraclavicular skin.
• In some cases, no suitable donor sites exist, and innovative strategies
must be employed to create sufficient replacement tissues of similar
quality. One example of this is the use of tissue expanders to induce
growth of tissues through cellular proliferation.
Principle V: Optimize Vascularity at Every
Opportunity
• Vascularity is paramount to tissue viability and therefore to the
success of healing
• For example, knowledge of the vastness of the subdermal plexus
allows a plastic surgeon to reliably raise thin flaps of skin during a
facelift operation
• For instance, surgery may be postponed to await smoking cessation
or time may be given for other specialists to help optimize blood flow.
An illustration of the latter is when a patient with arterial insufficiency
and a chronic lower extremity wound is referred to a vascular
surgeon for revascularization prior to surgical treatment of the
wound.
• Vascularity of a particular flap may also be enhanced by performing a
delay procedure….. A delay period allows choke vessels to
physiologically dilate within the flap and results in greater flap
reliability.
• Additionally, at many points during an operation, the plastic surgeon
will tailor numerous surgical techniques to maximize vascularity
Principle VI: Preserve Form and Function
• In many instances, the goals of surgery are both cosmetic and
reconstructive. Patients with excess upper eyelid skin, for example,
may describe dissatisfaction with their appearance as well as visual
field deficits.
• During the preoperative consultation, the plastic surgeon must
establish that the objectives of upper lid blepharoplasty are to both
rejuvenate the upper eyelids and expand the visual field
Principle VII: Minimize Donor Site Morbidity
• When donor tissues are required, the plastic surgeon must focus on
minimizing the functional and cosmetic sacrifices to the patient.
Each operation already possesses inherent risks relating to the
surgical site, such as hematoma, infection, or abnormal scarring.
• The donor site adds an additional anatomic area where
complications may arise, and the plastic surgeon must weigh the
possibility of donor site morbidity against the benefits of the use of
that tissue for reconstruction.
• For example, during a rhinoplasty operation, structural support can
be augmented by performing autologous cartilage grafting to the
nasal framework. 22 Cartilage grafts can be harvested from the nasal
septum, from the conchal bowl of the ear, or from the cartilaginous
portion of a rib. The nasal septum would be an ideal donor site if
septoplasty is also being performed, but use of this cartilage may
cause further destabilization of the nasal framework and has a small
risk of septal perforation. Harvest of conchal cartilage can provide
adequate grafting material but may be complicated by hematoma,
keloid formation, or ear asymmetry. The rib donor site offers an
abundance of high-quality cartilage, but its indications must warrant
the additional scar and added potential for pneumothorax
Principle VIII: Protect the Surgical Site
Postoperatively
• In plastic surgery, an operation cannot be deemed fully successful at
the time of its completion; instead, this evaluation can only be made
several weeks to months after the operation.
• During this critical time, the surgical site must be protected diligently
to facilitate recovery and to prevent injury to the healing tissues. The
plastic surgeon must actively counsel patients to follow strict activity
restrictions and help patients understand the rationale behind the
necessary postoperative protocols
Principle IX: Have a Backup Plan (and a
Backup Plan for THAT Backup Plan)
• Complications will always arise, and the prepared plastic surgeon will
be ready with multiple contingency plans. Most commonly,
complications such as wound infection, marginal flap necrosis, or
dehiscence can be successfully managed with straightforward and
standardized treatment protocols. However, occasionally, the first
operative plan fails to adequately address the goals of surgery, and a
new plan is necessary.
• In reconstructive surgery, an old paradigm known as the
reconstructive ladder advocates for a linear, stepwise approach to
surgical problems whereby less-complicated surgical techniques are
initially attempted, and progression up the ladder to more complex
strategies is pursued only when needed. More recently, significant
advancements in the field of plastic surgery have led to a shift away
from this paradigm in favor of a treatment algorithm that encourages
selection of the most definitive method for reconstruction even if it
means picking a more complex one first.
• Reconstruction of upper extremity defects frequently exemplifies this
fundamental principle. For example, a dorsal hand wound from a full-
thickness burn injury with several exposed extensor tendons and
metacarpal bones can be reconstructed by numerous techniques.
Principle X: Innovate New Solutions to Old
Problems
• Each surgery is individualized according to the clinical situation and
specific patient needs. Thus, the plastic surgeon must strive to tailor
every operation and often makes numerous adjustments to the
accepted standard techniques. For example, a cleft lip repair for one
child is never precisely the same as that for another child. Although
the basic tenets are constant, such as restoring continuity of the
orbicularis oris and re-establishing labial subunits, the surgeon must
remain flexible during the operation and modify the repair technique
to account for the unique abnormalities present in each patient.
• This spirit of adaptation and creative problem-solving is a large part of
what distinguishes plastic surgery from other surgical disciplines and
contributes to the constant evolution of the specialty. Over the course
of the last century, plastic surgery has undergone enormous cycles of
change that has resulted in significant paradigm shifts in patient care.
One of the most profound examples is the advent of microsurgery.
• The ability to raise and transfer a variety of tissue types as free flaps
opened an entire realm of reconstructive solutions for problems that
were once deemed impossible. For instance, distal third injuries of
the lower extremity that commonly resulted in amputation could
now be reconstructed with a free flap
THANK YOU