Holes.

They can occur anywhere on the face or body, and can be composed of missing skin, cartilage, muscle, bone, or any other form of hard or soft tissue.  Holes on the body can result from a myriad of reasons, with the two most common causes been trauma and tumour removal.

A hole on the human body, whatever the cause, will heal on it’s own accord, but may take variable time to achieve final wound healing. If the defect is significant in size however, or the location quite tricky, then the resultant scar may be unstable, not ideal aesthetically, functionally debilitating (such as in burn contractures), or have vital underlying structures that may be placed at risk of exposure or injury.

For centuries, and especially during the first and second world wars, the specialty of Plastic and Reconstructive Surgery has evolved through the development of innovative and anatomically based concepts of “filling in holes”.

The Plastic Surgery Reconstructive Ladder is a phrase used to describe the thinking approach one should take when faced with a physical defect on the body that requires tissue coverage. Let’s take a look at each step of the reconstructive ladder.

The Plastic Surgery Reconstructive Ladder

The first step (or perhapsbetter termed ground level) is healing by secondary intention. This means allowing the wound to heal up naturally on it’s own without any surgical intervention. There are certain areas of the body where a wound defect will heal up nicely as long as it is within a certain size limit and is given optimal conditions for healing (such as been kept moist and clean). A small skin defect, for example, on the inner canthus region of the eyelid or the very tip of the finger will heal up nicely, both aesthetically and functionally, simply with regular dressings.

The next step up the ladder is direct closure. If there is sufficient laxity around the wound to allow the wound to be repaired directly without causing untoward distortion to surrounding structures, then this should always be attempted. The ends of the wound may need to be converted in a tapered fashion into an ellipse in order to prevent “dog ears” at the ends of the wound. Remember, it is better to have a longer smooth-contoured scar (which will fade) than a shorter but irregularly contoured scar. When planning the direction and configuration of direct closures, thought should be given to placing the eventual scar along or parallel to natural skin creases.

Then next step up the reconstructive ladder lands us upon the skin graft step. Skin grafts can be either split or full-thickness, depending on the reconstructive needs and size of the defect. An important point to remember with skin grafts is that the graft is technically a non-viable (dead!) piece of skin, and will depend solely on the vascularity of the recipient defect site to “bring it back to life” by nourishing it with nutrients and re-establishing its circulation. Importantly, during this period of skin graft “take”, it is important to optimise conditions for skin graft survival. These include cessation of smoking, immobilisation of the graft, and keeping the graft moist.

Skin graft to the lower eyelid after skin cancer removal.

If the recipient site is not well vascularized, such as exposure of bare bone, then a skin graft will fail, and the defect will require soft tissue repair that carries with it an intrinsic blood supply – flaps, the next step up our ladder.

Skin flaps by definition have an intact blood supply and do not rely on the re-establishment of circulation through the blood supply of the recipient site. On certain occasions, even on well-vascularized wounds, a flap may be chosen as a preferred form of repair instead of a skin graft if it can give a more superior functional and aesthetic outcome.

Flaps can be further classified according to their geometry (advancement, rotation, transposition), their content (skin, muscle, bone), and their location (local, regional, distant). A local flap comes from an area directly adjacent to the wound; a regional flap is raised from tissue in the near vicinity, whilst a distant flap is taken from a site far from the defect.

A rhomboid transposition flap after removal of skin cancer on cheek.

Finger tip amputation with exposed bone repaired with advancement flap.

Since the advent of microsurgery, we have developed an increasingly better understanding of vascular anatomy. Almost every part of the skin, fascia, muscle, and bony vasculature has been thoroughly mapped out, allowing us to be more liberal and “free-style” in the way we can customise a flap according to the needs of the reconstruction.

As long as there is an artery coupled with a vein that supplies a piece of tissue, we can harvest this “donor” and use it in application to reconstructing a tissue defect. A good example of how advances in microsurgery have improved the quality of reconstruction and outcome has been in the arena of breast reconstruction, where we can elevate a lower abdominal flap, based on one group perforating vessels, join these vessels up to vessels under the rib, and utilize this skin/fat abdominal flap to make a new breast. The bonus is that the woman gets a tummy tuck out of the operation! This is an example of a “free flap” – free in the sense that the flap is completely detached and we can we can apply it anywhere in the body as long as vascular supply can be re-established.

Another example of the versatility of  “free flaps” in customizing and optimizing soft tissue reconstruction is shown in the example below, where the case entails a leg with exposure of metal fixation plates after a wound breakdown post trauma related fracture fixation. In this example, well-vascularized tissue was needed to cover the exposed plates. A piece of Gracilis muscle from the thigh was “harvested” together with its intrinsic supplying artery and vein, and this was then connected to the leg vessels using microsurgical techniques. A skin graft was then applied to the now vascularized and living muscle flap.

Hole in the leg: exposed metal plate after wound breakdown.

Muscle flap with overlying skin graft used to “fill the hole” in the leg.

The reconstructive ladder certainly still forms the basis of thought process in figuring out the reconstructive options a surgeon can employ when faced with a hole that needs to be filled. However, based on more recent evidence and with the better understandings we have these days in flap anatomy and vasculature, we are increasingly becoming more daring in jumping up a step or two on the ladder and heading straight for a reconstructive measure which may be more technically demanding, but which may lead to a more optimal aesthetic and functional outcome!

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What is Dupuytren’s Contracture of the hand?

It’s fixed flexion contracture of the hand due to palmar fibromatosis. Although most commonly limited to the hand, Dupuytren’s disease can have related conditions such as Peyronie’s disease (of the penis), plantar fibromatosis (of the foot), and Garrod’s pads (of the knuckles). There are no specific causes of the condition; however, a well-known risk factor is its linkage to Scandinavian “Viking” heritage.

What are the clinical features?

The disease often begins innocuously as nodules in the palm of the hand. This progresses to development of hard cords along the finger, which “contracts” to form flexion deformities of the affected finger. With an inability to extend fully, this often causes the affected finger to “get in the way” of activities.

Dupuytren’s contracture of right little finger, with visible cord.

When should you treat Dupuytren’s Contracture?

It is important to not wait too long prior to seeking treatment for Dupuytren’s contracture of the hand. The more flexed the finger becomes, the more difficult it is to regain near full extension through surgery, and the higher the rate of recurrence. In some situations, where the finger is in severe fixed contraction, amputation may in fact offer the best functional outcome.

My decision to treat is based general on two clinical considerations. The first is whether the patient’s daily activities are affected by the condition. The second is the presence of a positive “table top test”. This occurs where the patient is unable to place their hand palm down comfortably on a flat surface without interference from the diseased finger/s.

What treatment options are available?

Early Dupuytren’s Contracture of the hand can have the option of been treated non-surgically with injection of Collagenase Clostridium enzyme into the diseased cords. This softens the diseased cord, and is followed by forced rupture of the cords. Beyond early disease, surgery is still the mainstay treatment of choice to get a reliable long-term outcome.  Surgery usually involves a combination of fasciectomy (removal of the diseased fascia), release of joint contracture, and possibly skin grafting or z-plasty closure of the skin.  Equally as important in the management of Dupuytren’s disease is post surgery hand therapy, which involves extension splinting, scar management, and range of motion exercises.

Dissection of finger, exposing diseased cord, and preserving digital nerves.

Removal of diseased cord, and release of metacarpal-phalangeal joint.

Closure with skin graft to small skin defect at MCPJ crease.

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Fat has never enjoyed a good reputation.

Often despised, and never welcomed… until now!

There is immense research occurring at the moment into fat, and in particular, it’s regenerative properties. Through the use of fat injection in the face, breast, and body in both reconstructive and cosmetic applications, we have come to notice that the areas where fat has been introduced into seem to display some form of renewal or rejuvenation. These observations include a softening of skin texture and an improvement in the quality of scars. Whether this phenomenon is due to unique cellular properties of fat that promote regeneration and rejuvenation is yet to be confirmed through rigorous clinical and laboratory studies. Time will tell.

Fat is increasingly becoming an increasingly common tool utilised in plastic surgery. In the face, fat is injected as an autologous (the body’s own) form of filler to augment atrophied (wasted) areas and deep lines. As an example, a facelift by itself does not always completely flatten out the fold between the nose and the lips on each side of the face (the nasolabial fold). In such circumstances, fat injection can be used effectively as an adjunct to further soften these lines. Fat can also be used to correct facial asymmetry in cases of trauma, previous surgeries, or birth deformities. In the breast and body, fat can be used to improve on size, contour, and symmetry. The fat that is used is generally “harvested” from the abdomen or anywhere else on the body where there is excess and unwanted fat.

We’re entering into an era where fat is no longer despised. There is in fact great hope in fat. It’s clinical use in restorative and regenerative plastic surgery is expanding and showing promise. The true details of why and how fat is good for us will be revealed in time through further research. Of equal importance are findings of any potential negative side-effects or risks of fat injections.

The positive application of fat is an example of how plastic surgery is an ever evolving specialty. As always, one must approach any new technique with a cautious eye, balancing it’s risks and benefits, and tailoring the best technique to fit the individual patient.

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Abdominoplasty. Tummy tuck. Apronectomy.

As a result of post-pregnancy changes, most women simply cannot completely “flatten” their abdominal area despite rigorous exercise and dietary control. Part of the reason for this is the irrecoverable stretch of the abdominal skin which exists in the majority of the population. The other less known reason is the irrecoverable stretch of the underlying Rectus Abdominis (“six pack”) muscle, known as rectus diastasis. Irrecoverable, that is, other than from surgical correction!

As the foetus grows within the uterus and causes expansion of the entire abdomen of a pregnant woman, the rectus muscle is stretched in all directions, including sideways. Because the tissue that encompasses the muscle is not elastic (that is, it doesn’t spring back), once the stretch has occurred, it remains in that position. A good analogy of this anatomical finding is to consider a corset that wraps around and gives shape to the waist of the woman wearing it. If the corset looses it’s elasticity, it can no longer retain it’s function of giving shape to the waist. This is why, in the majority of cases, post-pregnancy women will have a less curved waist as compared to their pre-pregnancy state.

A standard abdominoplasty should always include repair of the underlying musculature. Failure to repair the muscle back to an anatomical position risks giving a less than optimal result after an abdominoplasty. Although removal of excess skin and fat in itself will improve the appearance, tightening the muscle will further enhance the natural contour of the waist.

Much of plastic surgery has to do with restoring the face and body to as close as possible to a pristine state, and to mend what nature and the wears and tears of life has brought. Abdominoplasty is no exception.

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The trend of an abundant buttock in Latin America is perhaps most pronounced in Brazil, the home of the Carnival. Funnily, and not surprisingly, it makes perfect sense to me now, at least visually, how this annual Samba-styled festival would simply not possess its renown vibrancy and intensity if most of the participants and dancers were thin and lacked sufficient “substance” to fill their barely-there costumes! In Latin America, there’s an entire smorgasboard of gluteal enhancement surgery options been performed and refined by plastic surgeons, including silicone implants, fat injections, liposculpture, and lifts.

Why?

Is it because a bodacious buttock has evolved to portray feminine sensuality and a heightened level of fertility? Or perhaps one just needs to balance a heavy front end with an equal amount from behind?? Who knows. Whatever the reason, big buttocks as an attractive and desirable female trend is here to stay in Latin America. As we’ve observed in the past with the incremental rise in size of what’s considered to be beautiful breasts, it will be interesting to follow the trend on rising butt sizes, and to see if this will ever eventuate in buttocks that currently may be considered too big to be socially acceptable.

I contrast the desired body habitus and what’s beautiful in Latin America to my observation and plastic surgery experience in other parts of the world. No longer can concepts of beauty be categorised into East versus West. It is now more appropriate to define societal ideals on what’s attractive by regions of the world, and occasionally, by country. So much is influenced by what goes on in a particular part of the world, what’s portrayed in the local media, what the local celebrities look like, and what the local culture exemplifies. In the rest of the western world, and most certainly in Asia, a full and abundant buttock has yet to take off in popularity, and I doubt it ever will.

So, next time you turn around and look at the mirror, don’t ask “does my bum look big in this?”. It may, or it may not. It all depends on where in the world that mirror is.

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