By Valera Castanov, Meds '22
Plastic and reconstructive surgery is a versatile specialty with a great diversity of subspecialties, surgical techniques, conditions treated, and the ability to transcend multiple anatomical boundaries which restricts other surgical disciplines [1-4]. However, due to its versatility, the exact scope of plastic and reconstructive surgery is often not well understood by the public and other healthcare providers [2-4]. The media further exacerbates the misunderstanding by portraying plastic surgeons as primarily aesthetic (cosmetic) surgeons, while neglecting other subspecialties within the field [1,4]. This article will discuss some subspecialties within plastic surgery to shed light on non-aesthetic procedures and showcase the great diversity available in plastic and reconstructive surgery.
Reconstructive surgery includes breast reconstruction, burn, craniofacial, hand, and oncology surgery.
Breast reconstruction is a surgical procedure aimed to restore the appearance of a breast, most often after a mastectomy, lumpectomy, or trauma. For patients undergoing a mastectomy or lumpectomy, breast reconstruction can be performed at the same time (immediate reconstruction) as the surgery to remove the affected breast tissue, or at a later time (delayed reconstruction). Different techniques of breast reconstruction exist, which include alloplastic and autologous reconstructions. Alloplastic breast reconstruction involves using an implant, whereas, autologous technique uses the patient’s own tissues to restore the breast. Autologous reconstruction is also called “flap” reconstruction, as a “flap” refers to the transfer of tissue from one area of the body to another e.g., abdomen to breast. Plastic surgeons can also decide to do combined techniques, using both the patient’s own tissues and an implant.
Plastic surgeons are involved in the treatment of burns and perform acute and reconstructive surgeries. Acute burn surgery occurs immediately after the injury and includes surgical excision and skin grafting of deeper burn wounds. Reconstructive burn surgery takes place following the healing of burn wounds, with the goal of improving function, comfort, and appearance.
Craniofacial surgery is a surgical subspecialty that deals with the cranium and the facial skeleton, along with the overlying soft tissue. This subspecialty is further divided into adult and pediatric surgery. Adult subdivision focuses primarily on trauma and post-traumatic craniomaxillofacial deformities, orthognathic surgery, orbital defects, and a variety of other craniofacial bony and soft tissue pathologies. Pediatric craniofacial surgery deals mostly with congenital malformations of the craniomaxillofacial skeleton and soft tissue, which include craniosynostosis, cleft lip, cleft palate, craniofacial cleft, micrognathia and many others.
Hand surgery deals with the management of acute, chronic and congenital conditions of the hand and wrist. It involves the treatment of different regional body tissues, including skin, ligaments, tendons, vessels, nerves, and bony structures. Plastic surgeons perform tendon repairs/transfers/releases, fracture repairs, reconstruction of injuries and other deformities. Hand surgery involves the management of conditions such as the carpal tunnel syndrome, trigger finger, dupuytren’s contracture and many others. Microsurgical techniques are used in many procedures, e.g., replantation surgeries of the traumatic hand and digit amputations, for nerve and soft tissue reconstruction and blood vessel re-connection.
Plastic surgeons treat different types of skin cancer, including basal cell carcinoma, squamous cell carcinoma and melanoma. Surgical approach depends on the type, extent, and location of the skin cancer, along with other factors. Some procedures may require flaps or skin grafts. One of the most sophisticated skin cancer surgeries is Mohs surgery. It involves removing the visible portion of the cancerous skin lesion, along with the thin layer of tissue deep to it. The excised deeper tissue layer is then mapped, and a histological analysis is performed. If cancerous cells are detected, the next layer of skin is excised from the affected area and analyzed. The procedure is repeated until cancerous cells are no longer present on microscopic examination of the biopsied tissue.
Aesthetic (cosmetic) surgery is a subspecialty of plastic and reconstructive surgery, which focuses on enhancing a patient’s appearance. It is an elective surgery, with the goals of improving appeal, symmetry, and proportion of a part or a region of the body. There are numerous aesthetic procedures that can be performed, which focus on facial and body contouring and rejuvenation. Discussion of individual procedures will be the topic of a separate article.
Plastic and reconstructive surgery is one of the most diverse surgical fields that medical students can pursue. Despite the media focusing primarily on aesthetic surgery, it is just one of the many subspecialties of plastic and reconstructive surgery. Plastic surgeons operate on different parts of the body, use versatile approaches from macro- to microscopic techniques, treat diverse patient populations - from pediatric to geriatric patients - and work within interdisciplinary teams to deliver comprehensive patient care. The diversity within this surgical field is truly fascinating!
The list of subspecialties mentioned in this article is not all-inclusive, and highlights only a few of the many surgical techniques and approaches used by plastic surgeons. Some of the surgical techniques specified for individual subspecialties, e.g. microsurgery for hand and/or digit replantation, can be used across many different subspecialties. Of note, plastic surgeons often work in large interdisciplinary health teams when treating many of the above-mentioned conditions. For the purposes of this introductory overview article, many things were simplified.
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 Dunkin CSJ, Pleat JM, Jones SAM, Goodacre TEE. Perception and reality-a study of public and professional perceptions of plastic surgery. Br J Plast Surg. 2003;56(5):437-443. doi:10.1016/s0007-1226(03)00188-7
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