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Plastic surgery, although considered a technique-oriented and multiregional specialty, is in essence a problem-solving field. The training of a plastic surgeon allows him or her to see surgical problems in a different light and select from a variety of options to solve these surgical problems. Plastic surgeons have received broad training, and many have completed residencies in other fields such as general surgery, otolaryngology, orthopedics, urology, or neurosurgery. Other modalities of training have more recently integrated these and other surgical subspecialties into a more comprehensive training program.
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The basic principles of plastic surgery are careful analysis of the surgical problem, careful planning of procedures, precise technique, and atraumatic handling of tissues. Alteration, coverage, and transfer of skin and associated tissues are the most common procedures performed. Plastic surgery may deal with the closure of surgical wounds—particularly recalcitrant wounds such as those occurring postradiation or poorly healing wounds in immunocompromised patients. Plastic surgery also deals with the removal of skin tumors, repair of soft tissue injuries including burns, correction of acquired or congenital deformities, or enhancement of undesirable cosmetic features. Craniofacial and hand surgery, also within the realm of plastic surgery, may require additional surgical training.
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In the past quarter century, increased knowledge of anatomy and the development of many new techniques have brought about important changes in plastic surgery. It is now known that in many areas the blood supply of the skin is derived principally from vessels arising from underlying muscles and larger perforating blood vessels rather than solely from vessels of the subcutaneous tissue, as was formerly thought. One-stage transfer of large areas of skin, fascia, and muscle tissue can be accomplished if the axial pedicle of the underlying fascia or muscle is included in the transfer. With the use of microsurgical techniques, musculocutaneous units or combinations of bone, fascia, muscle, and skin can be successfully transferred and vessels and nerves less than 1 mm in size can be repaired. These so-called free-flap transplantations are a major advance in the treatment of defects that were previously untreatable or required lengthy or multistaged procedures. More sophisticated knowledge of the blood supply to the skin has introduced the concept of perforator flaps whereby one perforating vessel is identified that may supply a large segment of overlying skin and subcutaneous tissue. Similarly, the concept of neurocutaneous flaps has given rise to the design of additional flap territories such as the sural flap in the lower leg and the sensate radial flap in the forearm.
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The plastic surgeon, as a member of the craniofacial surgical team, is able to dramatically improve the appearance and function of children with severe congenital deformities. Children of normal intelligence who previously had been social outcasts are now able to lead relatively normal lives. Improved understanding of facial growth and abnormal development and diagnostic techniques such as the CT scan, MRI, and 3D computer-assisted imaging enable the reconstructive surgeon ...