Plastic Surgery: Indications and Practice

1595 Pages·2008·356.95 MB·English

by  Bahman Guyuron

1
CHAPTER
A History of Plastic Surgery
Gregory Pearson and Robert Ruberg
The term ‘Plastic Surgery’ was fi rst used by Eduard Zeis as part of the of facial fl aps for reconstruction and undermining of skin to achieve
title of his classic work, Handbuch der plastischen Chirurgie, published tension free closure of wounds. In his writings, Oribasius likely
in Berlin in 1838. The word ‘plastic’ was derived from the Latin plas- described the fi rst superiorly based nasolabial fl ap.2,4,6,7 Another noted
ticus or the Greek plastikos, meaning to ‘mold or form’. Zeis chose surgeon, Paulus Aegineta, in his book entitled Epitome, described
that term to apply to ‘that part of operative surgery which is concerned hypospadias repair, treatment of jaw and nasal fractures, surgery for
with the living replacement of missing parts’.1,2,3 But many of the ganglions and pressure-sore prevention strategies.8
principles and techniques that have become the essence of the specialty
had origins well before the time of Zeis.
SLOW PROGRESS IN THE DARK AGES
Since ancient times, man has been attempting to modify and
reshape the human body. Frequently, this ‘molding’ involves taking
a damaged or mutilated part and returning it to normal appearance The Middle Ages witnessed a dearth of advances in reconstructive
(most people would call this ‘reconstructive surgery’). At other times, surgery. Emperor Justinian II reportedly underwent nasal reconstruc-
this ‘molding’ is focused on improving upon an already normal struc- tion after being overthrown and was apparently able to return to power
ture (referred to as ‘aesthetic or cosmetic surgery’). for 3 more years.2,6,7 However, mysticism was a prevailing thought
When reviewing the history of plastic and reconstructive surgery process in Europe during this time and Pope Innocent III, during the
one is impressed by the infl uence that the management of trauma has 13th century, forbade surgery.2 Outside of Europe, the conquest of India
had in driving the fi eld. For example, for many centuries reconstruc- by the followers of Islam allowed the permeation of Indian reconstruc-
tion of traumatic deformities of the nose has been an important focus tive principles into Arabic culture. When the same cultural group
of surgical practitioners. Building upon this base, plastic surgery has conquered Sicily, the avenue for entry of these established reconstruc-
grown into a multidisciplinary fi eld with subspecialties in hand, cranio- tive principles into Europe was opened, but little in terms of new
facial, aesthetic, microvascular and oncologic reconstructive surgery. principles and techniques occurred until the Renaissance.2,4,6
FOUNDATIONS IN ANTIQUITY NEW ADVANCES IN THE AGE
OF ENLIGHTENMENT
Some of the earliest attempts at reconstructive surgery date back to
approximately 3000 BC. The Egyptians, as recorded in the Edwin The Renaissance brought about new thinking and important advances
Smith papyrus, described management of facial fractures, particularly in reconstructive surgery. Just as in earlier times, maxillofacial prob-
nasal and mandibular fractures. Sanskrit texts from India also clearly lems served as the driving force for reconstructive efforts. Serafeddin
detailed various reconstructive techniques, particularly for nasal recon- Sabuncuoglu wrote Imperial Surgery, a book detailing repair of maxil-
struction, at around the same time or shortly thereafter.2 During this lofacial injuries, reconstruction of the eyelid and even treatment of
period in Indian history, traumatic deformation of the nose was not gynecomastia. (This description of surgery for gynecomastia is prob-
uncommon. Nasal amputation was often done by foreign invaders or ably one of the earliest examples of reduction mammoplasty.)9
even by domestic authorities as punishment for crimes such as steal- In the 15th century an Italian family of surgeons, the Brancas, was
ing or adultery. The common occurrence of nasal deformity, and the practicing nasal reconstruction using the Indian method. One member
stigma attached thereto, prompted the development of techniques for of the family also described a delayed fl ap from the forearm to repair
reconstruction of the nose around 600 BC by Samhita, the father of nasal defects. The Brancas also applied this delayed fl ap method to lip
Indian medicine, as recorded in his book, the Sushruta.4 Methods for and ear defects.10 The Brancas, just as the early Indian physicians had
ear-lobe reconstruction were also described in the same work. It is not done, attempted to keep their surgical techniques secret. However,
clear whether the nasal reconstruction involved cheek fl aps or forehead contemporary physicians named Fioravanti and Tagliacozzi witnessed
fl aps; however, nasal reconstruction done in this manner has long been the reconstructive procedures and then disseminated the knowledge
known as the Indian method’.2,5,6 that they had gained. Some reports cite Tagliacozzi as ‘inventing’ the
Samhita’s techniques likely infl uenced Roman and Byzantine sur- delayed forearm fl ap (Fig. 1.1).2,10 Fioravanti is also credited with an
geons. Autus Cornelius Celsus, a Roman medical writer (circa 25 BC early description of skin grafting.11,12
to 50 AD), described repairing damage to noses, lips and ears in his Although reports of attempted cleft-lip repair are credited to Chinese
text, Demedicina. His techniques were similar to those detailed by medicine, in the 16th century, Franco and Pare described a two-stage,
Samhita. Oribasius, a Greek medical writer and physician to Roman cleft-lip repair by preliminary cauterizing the edges of the cleft with
emperor Julian the Apostate, wrote a 70 volume series detailing medical later approximation of the defect edges. Then, following the cycle of
care titled Synagogue Medicae. In addition to addressing other medical history, surgery fell out of favor for another 200 years with few advances
issues, this text, specifi cally chapters 25 and 26, reported many prin- or descriptions of new techniques.2
ciples that have been incorporated into modern plastic surgical practice At the end of the 18th century interest in plastic and reconstructive
– e.g. debridement of necrotic bone to promote wound healing, creation surgery was rekindled. Wars were frequent in Europe during this era 3
1
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Fig. 1.2 Dieffenbach’s landmark book, Operative Chirurgie.
Fig. 1.1 Nasal reconstruction using a delayed forearm fl ap, as
popularized by Tagliacozzi.
utilizing a bilayer closure of muscle and skin plus undermining of the
nasal ala.2
Cleft surgery was not the only discipline to expand during the
and the resultant traumatic deformities were commonplace. Lucas, an
1800s. Aesthetic surgical techniques were developed and published.
English surgeon serving in India, learned of the local forehead fl ap
The introduction of ether anesthesia and antiseptic concepts allowed
technique for nasal reconstruction and described it in an English
surgery to be performed in a more comfortable and a safer manner,
publication called Gentleman’s Magazine in 1794. Lucas reported the
and made aesthetic surgery more acceptable. Just as in reconstructive
case of a man named Cowasjee, a driver who transported goods to the
surgery, surgery of the nose had a prominent role. Dieffenbach, a suc-
British Indian Forces, who was captured by his enemies and, as was
cessor to Von Graefe in Germany, wrote Operative Chirurgie (Fig. 1.2),
befi tting of the day, had his nose mutilated. He then went on to have
the Indian method of forehead fl ap nasal reconstruction.2,4,7,13 This in which he described nasal surgical techniques, including reoperative
rhinoplasty for aesthetic purposes, while utilizing anesthesia during
account was read by Joseph Carpue, another British surgeon, who
his operations. At the end of the 1800s, John Roe and Vincent Czerny
then began performing this procedure (after several decades of studying
presented and discussed primary rhinoplasty done for strictly aesthetic
it) and published his accounts in a report entitled Restoration of the
Lost Nose in 1816.2,13 Another important impetus for the renewed purposes.2 In addition to the rhinoplasty and cleft repair other types
of reconstruction were introduced; the end of the 1800s and beginning
interest in reconstructive surgery was Chopart’s description of lip
of the 1900s witnessed Tansini’s description of the latissimus dorsi
reconstruction using neck skin in the late 1790s. Advances in lip
fl ap for breast reconstruction after mastectomy.10
reconstruction continued with Sabattini, Estlander, Abbe and Porta in
the 1800s.10,14 While aesthetic surgery and cleft care advances were being made,
wound closure continued to be a surgical challenge. Although gluteal
grafts may have been described in the Indian literature, interest in skin
DEVELOPMENTS IN THE INDUSTRIAL ERA grafting as a method for closure began with Barionio’s report of skin
grafting in sheep entitled, On Grafting in Animals, published in
Throughout the 1800s interest in reconstructive surgery continued 1804.10,12 Reverdin later performed and reported on tiny, split thick-
and it persisted until today. Although reconstruction after traumatic ness skin grafts to help cover granulating wounds in 1869. Ollier, Le
wounds remained the driving force of the specialty, interest in other Fort and Lawson applied skin grafts for treatment of entropion and
aspects of plastic surgery began to expand. Carl Von Graefe, a German ectropion in the late 1800s.2,16 Warren and Pancoast in the 1840s
surgeon, described repair of a cleft palate in 1816. Then in 1818 he reported full thickness grafts for nasal and ear lobule closure.12,16
reported techniques for rhinoplasty, blepharoplasty, and palatopasty in Advances in skin-grafting techniques have continued until today.
a work entitled Rhinoplastik.4 This book is cited as the fi rst writing to
utilize the term ‘plastic’ to refer to surgical reshaping, although it
20TH CENTURY ADVANCES: WAR
remained merely a term for a technique until Zeis defi ned the specialty
as ‘plastic surgery’ 20 years later. WOUNDS AND NEW TECHNOLOGY
The fi rst palatoplasty in the United States was performed in 1827
by John Peter Mettauer, utilizing instruments designed by the surgeon.15 During the 20th century, the fi eld of plastic surgery underwent con-
Mettauer performed his surgery outdoors beside a stream, and used solidation as a distinct specialty, further development of subspecialties,
cool running water for hemostasis and analgesia. Further advances in and quantum leaps in medical knowledge and patient-care techniques.
4 cleft care came during the 1890s when Rose described a cleft-lip repair Similar to early times, war and the resultant management of its
aftermath propelled the fi eld forward. World War I (1914–1918) pre- proliferation of textbooks, subspecialty journals and organizations, and 1
sented surgeons with signifi cant craniofacial trauma (mandibular frac- multiple regional, national and international meetings devoted to all
tures, skull wounds, facial soft tissue defects). Morestin, a French aspects of plastic surgery.
surgeon, and Gilles, an English surgeon, established centers in their A
respective countries designated to manage and treat the complex facial H
wounds while training other surgeons in this fi eld.1,2,13,17,18 Kazanjian, CONCLUSION is
a US dental surgeon serving in England, added to the treatment of to
facial trauma by applying dental principles into the algorithms.2 The With a fi rm foundation of principles established over hundreds and ry
knowledge regarding the application and manipulation of fl aps dra- even thousands of years, the specialty of Plastic Surgery should con- o
matically increased during this war. Tube fl aps, the delay phenomenon tinue to grow, reinvigorate and reinvent itself though insight and f
P
for long pedicle fl aps, free cartilage grafts for nasal reconstruction, neck innovation in the 21st century. l
a
fl aps for intraoral defects, and scalp and brow fl aps for lip reconstruc- s
t
tion were all developed during World War I.2,13 ic
During the 1930s and 1940s, many additional advances in plastic REFERENCE S
surgery occurred. Once again a major impetus for innovation in the u
r
specialty came from the necessity for treating devastating and disfi gur- 1. McDowell F. Plastic surgery in the twentieth century. Ann Plast Surg g
e
ing injuries incurred during World War II. The introduction of the 1978; 1(2):217–224. r
y
mechanical dermatome in the late 1930s allowed greater ease in har- 2. Ciaschini M, Bernard SL. History of plastic surgery. eMedicine [serial
vesting and application of skin grafts for limb salvage, as well as online] 2005 January 18 [cited 2006 July 13]; Available online from:
meshing of grafts as reported by Douglas in 1930.2,13,16 http://www.emedicine.com/plastic/topic433.htm
Military injury treatment centers were established throughout the 3. The History of Plastic Surgery. [cited 2006 October 24]; Available
online from: http://www.plasticsurgery.com.au/history/index.shtml
United States. Probably the most prominent center for treatment of
4. Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for
plastic surgical problems, the Valley Forge (PA) Army Hospital, not
total nasal reconstruction. Clin Plast Surg 1983; 10(4):635–647.
only produced technical advances, but also served as the training
5. Rana RE, Arora BS. History of plastic surgery in India. J Postgrad Med
ground for many of the future leaders of the specialty.1,2 During this
[serial online] 2002 [cited 2006 Aug 31]; 48:76–8. Available online from:
era, another subspecialty was born. Just as World War I saw the devel- http://www.jpgmonline.com/article.asp?issn=0022–3859;year=2002;
opment of facial trauma techniques, World War II witnessed the volume=48;issue=1;spage=76;epage=8;aulast=Rana
development of hand surgery. Bunnell, incorporating general, orthope- 6. Lascaratos J, Cohen M, Voros D. Plastic surgery of the face in Byzantium
dic and plastic surgery concepts, established a hand surgery center in in the fourth century. Plast Reconstr Surg 1998; 102(4):1274–1280.
the United States. Coupled with Lister’s work in the fi eld, Bunnell’s 7. Sharma S. Clashes, wars and plastic surgery. Journal of Young
principles allowed hand surgery to become a well-defi ned, distinct Investigators [serial online] 2005 [cited 2006 July 13]; 15. Available
discipline.2 online from: http://www.jyi.org/features/ft.php?id=735
From the 1950s until the present day, plastic surgery has continued 8. Gurunluoglu R, Gurunluoglu A. Paulus Aegineta, a seventh century
encylopedist and surgeon: his role in the history of plastic surgery. Plast
to see enormous advances resulting in improved patient care. Buncke
Reconstr Surg 2001; 108(7):2072–2079.
refi ned and perfected microsurgical techniques for replantation and
9. Dogan T, Bayramicli M, Numanoglu A. Plastic surgical techniques in
free tissue transfer, resulting in a quantum leap in traumatic and
the fi fteenth century by Serafeddin Sabuncuoglu. Plast Reconstr Surg
oncologic reconstructive potential. Murray performed the fi rst success- 1997; 99(6):1775–1779.
ful kidney transplant and later received the Nobel Prize for this land- 10. Micali G. The Italian contribution to plastic surgery. Ann Plast Surg
mark achievement.19 Tessier developed new principles for approaching 1993; 31(6):566–571.
and rearranging the facial skeletal, giving rise to the remarkable fi eld 11. Santoni-Rugiu P, Mazzola R. Leonardo Fioravanti (1517–1588): a
of craniofacial surgery. A major advance in aesthetic surgery was the barber-surgeon who infl uenced the development of reconstructive
introduction of the silicone breast implant by Cronin and Gerow in surgery. Plast Reconstr Surg 1997; 99(2):570–575.
the 1960s.2 The work of Mathes and Nahai and many others brought 12. Hauben DJ, Baruchin A, Mahler D. On the history of the free skin
graft. Ann Plast Surg 1982; 9(3):242–245.
musculocutaneous fl aps into the everyday armamentarium of plastic
surgeons, and, subsequently, of many other specialists as well. 13. Morain WD. Historical perspectives. In: Mathes SJ ed. Plastic surgery,
2nd edn. Philadelphia: Saunders-Elsevier; 2006:27–34.
In addition to the surgical advances previously mentioned, the 20th
14. Faga A, Valdatta L. Plastic surgery in the early nineteenth century:
century witnessed increasing organization, recognition and education
notes on the collections in the University of Pavia’s Museum of
of plastic surgeons. Sherer and Brophy organized the American Asso-
History. Plast Reconstr Surg 1990; 86(6):1220–1226.
ciation of Plastic Surgeons (AAPS), the fi rst organization for this spe-
15. Wikipedia, The Free Encyclopedia. Plastic surgery. [Online]. 2006
cialty, founding the group in 1921.2,3 Maliniac established a division October 17 [cited 2006 October 24]; Available online from: http://en.
of plastic surgery distinct from general surgery in New York in 1925. wikipedia.org/w/index.php?title=Plastic_surgery&oldid=81943929
During the 1930s, Maliniac and Aufricht founded The American 16. Leland RC. Brief history and biology of skin grafting. Ann Plas Surg
Society of Plastic and Reconstructive Surgeons (later, ASPS) to provide 1988; 21(4):356–360.
an organization for many of the specialists who were not eligible for 17. Taylor BW. The history of international plastic surgery. [cited 2006
membership in the AAPS.20 The American Board of Plastic Surgery October 24]; Available online from: http://www.plasticsurgery.com.au/
history/international.shtml
was established in 1941 as a means for recognizing and verifying
expertise in this particular discipline.20 18. Rosdeutscher JD. The history of orolaryngology in plastic surgery. Plast
Reconstr Surg 2003; 111(7):2377–2385.
Education in the specialty was advanced signifi cantly with the
19. Jurkiewicz, MJ. Organizations and education. In: Achauer B, Eriksson E,
initiation of the journal, Plastic and Reconstructive Surgery, in 1946.
Guyuron B, et al, eds. Plastic surgery: indications, operations, and
The Plastic Surgery Educational Foundation, now an affi liate of the
outcome, 1st edn. St. Louis (MO): Mosby; 2000:9–14.
ASPS, was formed to focus on education at home and in other coun-
20. Schnur P, Hait P. ‘The history of plastic surgery, ASPS and PSEF’.
tries, and to promote international service and scholarship.20 Today [Online] 2000 [cited 2006 July 13]; Available online from: http://www.
education remains a critical part of the specialty, as evidenced by the plasticsurgery.org/overview/pshistry.htm
5
2
CHAPTER
The Plastic Surgery Consultation and
Patient Selection
Phillip C Haeck
PATIENT SELECTION detail indicating obsessive behavior. Suggesting a hypothetical situa-
tion may also bring out an inability to pinpoint why they are pursuing
Not everyone who seeks a consultation with a plastic surgeon may surgery. A question such as, ‘If you had a magic wand and could change
be physically or emotionally suited to undergo an operation that will anything about your appearance where would you start?’ is an example
bring a signifi cant alteration to their appearance. Who then is the right of a complex open-ended question that can quickly unravel some deep-
person for such an operation and how does one go about deciphering rooted problems. This seemingly simple situation can actually bring
this? At times this question can vex the most sophisticated surgeon out very complex behaviors since it allows the patient free reign to
as well as the beginner and even the experts occasionally get it wrong. critique themselves, and to display their ability to discuss their moti-
Some feel that proper patient selection is the surgeon’s most important vation with a relative stranger. A person who has given much thought
protection against medical liability.1 and contemplation to their appearance and is a reasonable candidate
While patient selection has no hard and fast rules, there are very should be able to handle this question quickly and succinctly. But a
typical red fl ags that might arise during a conversation with the pro- patient who ignores the question completely, or who cannot focus on
spective patient which should lead a surgeon to investigate more any particular area or who gives an overtly obsessive answer may not
directly the patient’s motivation. A person who continually relates the have the correct motivation for surgery. Any person who replies with
need for a change in their appearance to something said to them by a ‘You’re the expert, you tell me what’s wrong’ may have passive-aggres-
signifi cant other or a family member may not be ready to grasp the sive tendencies and might be excessively resentful of anything that
serious nature of the surgery. Many patients will verbalize that they goes wrong after surgery. These types of patients blame everyone but
are beginning to look just like their mother or father did and use this themselves for a complication, regardless of its root cause.
as the reason to want to have a rejuvenated appearance. These types
of patients are usually well satisfi ed after a cosmetic operation. But a
MATCHING THE RIGHT OPERATION TO
patient who states their mother was always critical of a certain facial
feature of the patient may have long-standing psychological harm from THE RIGHT PATIENT
this relationship. This disturbance will not go away simply by chang-
ing the shape of their nose, for instance. On the contrary losing that As Gorney has so appropriately described, the purpose of cosmetic
feature may suddenly lead to feelings of unspoken anger, loss or grief. surgery is not to try to make a sick person well, but to make a well
Eventually these patients can be diffi cult to please, focusing their psy- patient better.2 Both the surgeon and the patient can lose sight of this
chological upheaval on a small aspect of the operation that may seem principle when multiple alternative procedures might be available for
to them to be a failure or in need of further surgery when to the surgeon the individual and the surgeon to choose from.
no such deformity exists. Due to the rise of the internet, patients can vary greatly in their
Other red fl ags include patients who worry excessively over what knowledge of the operation they wish to pursue. They also, however,
might be considered a minor deformity, who seem obsessed with their can become confused or misled by non-scientifi c opinions in on-line
appearance in general, or who cannot focus during the consultation on chat rooms and blogs. These patients may require detailed discussions
anything but the sight of themselves in a mirror. These patients can at the fi rst consult to reset these misconceptions. Patients who stead-
be severely traumatized by routine postoperative side effects or delayed fastly wish to pursue an operative plan that the surgeon feels might
healing. They may put excessive demands on the staff and the surgeon be the wrong choice should be dismissed as having unrealistic expecta-
postoperatively, and, ultimately, be dissatisfi ed with any minor abnor- tions. When more than one type of surgical plan may be available their
mal results. While some of these patients may ultimately be quite confusion as to which one is right for them can be overcome in several
satisfi ed with the change in their appearance, the journey to that end quick ways. The fi rst is to test their ability to tolerate the extent and
can be fraught with emotional peaks and valleys for both the patient location of the scars involved in the alternatives. Patients with severe
and the surgeon. grade III breast ptosis who want an augmentation from a remote site,
How one handles the initial phase of the consultation can be the for instance, need much more counseling to get them to accept a
key to quickly unraveling some fairly complex behavior enabling the mastopexy than a patient who desires a breast reduction and has seen
ready dismissal of patients who will not be good candidates for an the end result in her sister or a best friend. The latter patient already
operation. First of all the surgeon should never assume on fi rst glance knows the general location and extent of the scars and has accepted
what it is the patients wants. By asking a few key questions on the this, and will need little counseling in most instances as to the poten-
patient’s initial intake form regarding which procedures they wish to tial results she might experience.
investigate the surgeon can focus quickly on the points to be covered Secondly, showing a series of pictures of typical results and scars
and not begin talking about a feature the patient might not wish to may help to clear up their confusion. When these patients bring pic-
change, always an embarrassing situation for both parties. tures they have found on the internet this can open up a discussion
How a patient handles some initial open-ended questions can of which alternative is preferred and why.
uncover red fl ags quickly. An ideal patient will be able to discuss in Finally, the patient’s own morphology must be pointed out. Many
some detail their feelings about their appearance, but not in too much times the internet pictures these potential patients have seen are of 7
1 faces or bodies that bare little resemblance to their own. The surgeon Beyond informed consent and continuity of care there lies the
then must delicately and diligently point this out while striving to reset concept that each and every chart should be considered an example of
their expectations as to what they can realistically achieve. the type of service a surgeon typically provides to all his patients. For
P Once the correct surgery has been identifi ed and the patient and example, should an expert witness be needed to help defend a surgeon
R
I surgeon’s expectations for the fi nal result are in line, there is another that witness will be given an opportunity to read the chart before
N
critical step before the procedure that the surgeon must carry out with deciding to offer his or her services. Missing documents, poorly orga-
C
I great skill. nized and sloppy follow-up documentation, and overly casual
P
L approaches to the problem might suggest to a potential defense witness
E that the case may be unworthy of their time. On the other hand, a
S INFORMED CONSENT
well-executed medical record may enhance the chance that a valuable
expert would willingly participate in the defense process despite other
After agreeing on the operative plan the process of informed consent problems in the case. Excellent expert witnesses can be the key to
should begin immediately. Written materials given to the patient prior winning or losing a defense. Their decision to help the defendant
to a discussion of the risks and benefi ts will always enhance the depends not just on the merits of the case, but also on the medical
process. All patients, before the day of surgery, deserve a frank and record; an important reason to maintain excellent records on all
open discussion of the four parts of the informed consent process. patients.
Documenting that this took place should serve to protect a surgeon in Lastly, an excellent chart with documentation of all important
the event that an adverse outcome occurs later. postoperative decision-making, as well as clear references to how each
The stages of the informed consent process must include an expla- issue, such as side effects and complications, were dealt with can be
nation of the surgical condition and the plan for treating it in layman’s a deterrent to litigation. While poor and sloppy medical records can
language. This should be followed by an outline of both the common encourage attorneys to seek litigation, the converse is also true. In
and uncommon risks associated with this particular surgery, the addition, surveys of jurists have shown that deliberations favoring the
general goals associated with any procedure and the type of anesthetic physician have often been determined when an excellent medical
risk associated with this surgery. Thirdly, the alternative procedures record was introduced as evidence.5
that might bring the patient to a similar outcome should be spelled
out and documented. Lastly, the patient should be given a clear chance
CONCLUSIONS
to ask any and all pertinent questions.3,4 Verifying that all four parts
of the process took place must be done to make this protection work.
While experts disagree on how much documentation of the discussion The particular aspects of patient management outlined in this chapter
with the patient is appropriate, there is general consensus that consis- may in many instances be just as signifi cant towards achieving a sat-
tently failing to document anything at all will eventually lead to a isfactory result in plastic surgery as the way the operation is carried
disaster for the surgeon. out. Performing the correct surgery on an appropriate patient who
knew exactly what it was going to achieve will almost always result in
both a happy surgeon and a very happy patient.
THE PURPOSE OF THE MEDICAL RECORD
REFERENCES
Besides documenting the informed consent process the medical record
has multiple other functions. While many surgeons feel that the sole
1. Mavroforu A, Giannoukas A, Michalodimitrakis E. Medical litigation in
purpose of a chart is to help defend themselves should a malpractice
cosmetic plastic surgery. Med Law 2004; 23:479–488.
suit occur, there are actually many other complex reasons for main-
2. Gorney M. The wheel of misfortune. Genesis of malpractice claims. Clin
taining an excellent record.
Plast Surg 1999: 26:15–19.
First and foremost the chart should always be considered a means
3. Cole N. Informed consent: considerations in aesthetic and reconstructive
of providing continuity of care when the surgeon is not available or surgery of the breast. Clin Plast Surg 1988; 15:541–548.
becomes incapacitated. This means that all entries should have this 4. Charles SC, Frisch PR. Adverse events, stress and litigation. Oxford:
one purpose in mind; to allow any subsequent provider the knowledge Oxford University Press; 2005.
of what took place in the care of the patient prior to that point in 5. Karp D. Medical records and malpractice claims. Med Malpractice Cost
time. Containment J 1980; 1(4):303–313.
8
3
CHAPTER
Wound Healing, Including Fetal Skin Healing
Edward P Buchanan and H Peter Lorenz
INTRODUCTION
Summary
1. Surgery causes tissue injury and the resulting healing involves Wound healing is a complex cascade of biologic processes. Repair
a complex cascade of biologic processes. The fi nal result is initiates with injury and ends with restoration of tissue integrity. The
fi brosis and scar in all organ systems except bone, some liver fi nal result of the repair process is fi brosis and scar in all organ systems
conditions and muscle fi bers. except:
2. The overlapping segments of the cutaneous repair process are
● bone;
conceptually defi ned as infl ammation, proliferation, and
● specialized conditions of liver;
remodeling.
● muscle fi ber injury.
3. Infl ammation is the fi rst stage of healing and begins with
Because surgery induces tissue injury, a thorough understanding of the
hemostasis. Within 24 hours neutrophils scavenge debris and
wound repair process is fundamental to the practice of plastic surgery.
secrete cytokines. Macrophages are the predominant
Now armed with a more detailed understanding of the repair processes
infl ammatory cell 2–3 days after injury and regulate repair by
and their regulation, investigators have modulated experimental
secreting multiple growth factors. 3–5 days after injury,
wounds to heal faster than normal. In addition, the healing impair-
fi broblasts are activated and secrete matrix components and
ment that occurs in several pathologic states such as diabetes mellitus
growth factors. Keratinocyte migration begins over the new
and corticosteroid immunosuppression has been reversed experimen-
matrix.
tally. In the near future, surgeons will be active participants in modu-
4. The proliferative phase begins with fi broplasia. After cell
lating the healing process through pharmacologic treatment of
division and proliferation, fi broblasts synthesize and secrete
wounds.
ECM products. Collagen types I and III are the major fi brillar
collagens comprising the ECM and are the major structural
PHYSIOLOGY OF THE CUTANEOUS
proteins in both unwounded and wounded skin.
REPAIR PROCESS
5. Granulation tissue is found in open wounds healing by
secondary intention and its beefy-red appearance is a
The overlapping segments of the cutaneous repair process are con-
consequence of neoangiogenesis. Its presence is a clinical
ceptually defi ned as infl ammation, proliferation, and remodeling
indicator that the wound is ready for skin graft treatment.
(Fig. 3.1):
6. Open wounds undergo contraction, which is less prominent in
closed surgical incisions. Wound contraction can lead to ● during the infl ammatory phase, hemostasis occurs and an acute
contracture. infl ammatory cellular infi ltrate ensues;
7. Scar is defi ned morphologically as a lack of connective tissue ● the proliferative phase is characterized by fi broplasia, granulation,
organization compared to surrounding normal tissue contraction, and epithelialization;
architecture. It is brittle, less elastic than normal skin, and
does not contain any skin appendages such as hair follicles or ● the fi nal phase is remodeling, which is commonly described as scar
maturation.1
sweat glands.
8. The early gestation fetus can heal skin wounds with
Infl ammation
regenerative-type repair. The epidermis and dermis are restored
to a near normal architecture in which the collagen matrix
Infl ammation is the fi rst stage of healing and begins with hemostasis.
pattern is reticular and unchanged from unwounded dermis.
Clot is formed and platelets aggregate and degranulate, releasing potent
The wound hair follicle and sweat gland patterns are normal.
chemoattractants for infl ammatory cells, activation factors for local
9. Clinical factors that impair healing and repair include infection, fi broblasts and endothelial cells, and vasoconstrictors (Table 3.1).
nutritional defi ciency, ischemia, diabetes mellitus and obesity, Platelet adhesiveness is mediated by integrin receptors such as GPIIb/
corticosteroid use, radiation therapy, and chemotherapy. IIIa.
10. Hypertrophic scars and keloids are pathologic scar types. Within minutes, the repair processes are initiated. After the tran-
Hypertrophic scars are raised and usually form secondary to sient vasoconstriction induced by platelet factors, local small vessels
excessive tensile forces across the wound; they do not dilate secondary to the effects of the coagulation and complement
overgrow the original wound boundaries,. Keloids are scars cascades. The local endothelial cells then break cell-to-cell contact,
that overgrow the original wound edges, have a genetic which enhances the margination of infl ammatory cells into the wound
predisposition with autosomal dominant features, and behave site.
like benign skin tumors with continued slow growth. An effl ux of white blood cells (fi rst neutrophils, later monocytes)
and plasma proteins enters the wound site (Fig. 3.2A). 9
1 Fig. 3.1 Timeline of wound repair events,
Timeline of wound repair events
including the repair phases, cellular
infi ltrates, and vascular responses. The
P Major event Clot formation Growth factor Collagen deposition Collagen cross-linking timeline is a rough approximate of the
R Hemostasis Elaboration
I overlapping repair events. (Modifi ed
N
C Inflammatory with permission from Lorenz HP and
I Longaker MT. Wounds: biology, pathology,
P Repair phase Proliferation
L and management. In: Norton JA, et al., eds.
E Remodeling Surgery: scientifi c basis and current practice,
S
1st edn, vol I. New York; Springer-Verlag Inc:
Fibroblasts
2000:222.)
Lymphocytes
Cellular influx
Macrophages
Neutrophils
Vascular response Vasodilation
Vasoconstriction
Injury 3d 7d 3 weeks 1–2 years
Time
Table 3.1 Partial list of growth factors present in the wound site
Growth factor Growth factor Cellular source Target cells Biologic activity
abbreviation
CTGF Connective tissue growth Fibroblasts, endothelial Fibroblasts Downstream of TGF-β
1
factor cells
EGF Epidermal growth factor Platelets, macrophages, Keratinocytes, fi broblasts, Proliferation, chemotaxis
keratinocytes endothelial cells
FGF-1, FGF-2, Fibroblast growth factor-1, Macrophage, fi broblasts, Keratinocytes, fi broblasts, Angiogenesis,
FGF-4 2, and 4 endothelial cells endothelial cells, proliferation, chemotaxis
chondrocytes
FGF-7 (KGF-1), Fibroblast growth factor-1 Fibroblasts Keratinocytes Proliferation, chemotaxis
FGF-10 (KGF-2) (keratinocyte growth
factor-1), fi broblast growth
factor-10 (keratinocyte
growth factor-2)
IGF-1/Sm-C Insulin-like growth factor- Fibroblasts, macrophages, Fibroblasts, endothelial Proliferation, collagen
1/somatostatin-C serum cells synthesis
IL-1α and IL-1β Interleukin-1α and -1β Macrophages, neutrophils Macrophages, fi broblasts, Proliferation, collagenase
keratinocytes synthesis, chemotaxis
PDGF Platelet derived growth Macrophage, platelets, Neutrophils, macrophages, Chemotaxis, proliferation,
factor fi broblasts, endothelial fi broblasts, endothelial matrix production
cells, vascular smooth cells, vascular smooth
muscle cells muscle cells
TGF-β and -β Transforming growth Macrophages, platelets, Infl ammatory cells, Chemotaxis, proliferation,
1 2
factor-β and β fi broblasts, keratinocytes keratinocytes, fi broblasts matrix production
1 2
(fi brosis)
TGF-β Transforming growth Macrophages Fibroblasts Anti-scarring
3
factor-β
TGF-α Transforming growth Macrophages, platelets, Keratinocytes, fi broblasts, Proliferation
factor-α keratinocytes endothelial cells
TNF-α Tumor necrosis factor-α Neutrophils Macrophages, Activation of growth
keratinocytes, fi broblasts factor expression
VEGF Vascular endothelial cell Macrophages, Endothelial cells Angiogenesis
growth factor keratinocytes, fi broblasts
Modifi ed from Lorenz HP and Longaker MT: Wounds: Biology, Pathology, and Management. In Norton JA, et al (eds): Surgery: Scientifi c Basis and Current Practice, 1st
edition, vol I, p224. New York, Springer-Verlag Inc, 2000.
10
Fig. 3.2 Changes at the wound site. 3
Within 24 hours after injury
A, Within 24 hours after injury, there is a
neutrophil infl ux. The neutrophils scavenge
A debris and bacteria, and secrete cytokines W
for monocyte and lymphocyte activation. o
u
Keratinocytes begin migration after the n
provisional matrix is present. B, Macrophages d

are the predominant infl ammatory cell 2–3 H
Keratinocytes
e
days after injury. Macrophages regulate the a
repair processes by secreting multiple growth li
n
factors, including those that induce fi broblast, g
endothelial cell, and keratinocyte migration ,
Neutrophil and proliferation. In
c
l
u
d
i
n
Fibrin matrix g

F
e
t
a
l

S
k
Fibroblast in

H
e
a
l
i
n
g
2 to 3 days after injury
B
Scab
Fibroblast
Neutrophil
Macrophage
11
1 Fig. 3.2, cont’d C, At 3–5 days after injury,
3 to 5 days after injury
fi broblasts are activated and secrete both
matrix components and growth factors.
P C Keratinocyte migration begins over the new
R Scab
I matrix. Migration starts from the wound
N
edges as well as from the epidermal cell
C
IP Keratinocyte nests at sweat glands and hair follicles
L migration within the center of the wound. D, Skin
E wounds heal with scar formation. Scar is
S
composed of densely packed collagen fi ber
bundles and scar remodeling, which consists
of further collagen cross-linking and
regression of capillaries, occurs for 1–2 years
after injury. The scar softens in character and
Fibroblast changes in color from red to white. (Modifi ed
with permission from Lorenz HP and
Longaker MT. Wounds: biology, pathology,
and management. In: Norton JA, et al., eds.
Surgery: scientifi c basis and current practice,
Neutrophil 1st edn, vol I. New York; Springer-Verlag Inc:
2000:223–227.)
Macrophage
Skin wounds heal with scar formation
D
Dermal scar
(collagen)
12