General Reconstruction

Reconstructive surgery is typically performed on areas of the body that have some type of deformity. The goal is to improve function in that part of the body, but in certain cases it is also completed for the purpose of re-establishing a normal appearance in the area where the abnormality has occurred.

Understanding Reconstructive Surgery

Experts estimate that up to one million individuals seek reconstructive procedures from a plastic surgeon on an annual basis. This type of surgery can help patients of all ages, from children with birth defects, to older adults experiencing abnormalities caused by aging, or younger adults who were injured in accidents.

In most cases, the goals of reconstructive procedures are quite different from the goals associated with cosmetic surgery. Cosmetic surgery is typically completed for the purpose of reshaping normal body structures to improve the individual’s self-esteem and overall appearance.

Reconstructive surgery is completed on structures of the body that are abnormal. These abnormalities may be caused by the following:

• Trauma
• Age-related structural degeneration
• Injury sustained in an accident
• Disease
• Tumors
• Infection

Therefore, the objectives are quite different between cosmetic procedures and reconstructive surgery. Nevertheless, regardless of the goal and the type of procedure a person is seeking, no surgery results in perfection. However, advances in medical technology now allow plastic surgeons to improve form and function in the human body in ways that would have been impossible a mere decade ago.

Candidates for Reconstructive Surgery

Candidates for reconstructive surgery can typically be divided into two primary categories: those who have birth defects–also referred to as congenital deformities–and those with developmental deformities, such as those resulting from aging, disease, infection or trauma from an accident.

Some examples of common congenital defects include the following:

• Abnormal breast developmental
• Absent or extra fingers
• Hand deformities such as webbed fingers
• Palate deformities or cleft lip
• Odd shaped moles or port wine birthmarks

Acquired deformities may include the following:

• Aging problems
• Lacerations from trauma
• Burn wounds
• “Crusty age spots” on the skin or other skin defects
• Loss of asymmetry or drooping eyelid due to stroke

In many of these cases, patients discover that a surgical procedure commonly believe to be aesthetic in nature is also frequently performed with reconstructive goals in mind. For instance, if someone had suffered some type of paralysis and required a balancing facelift, it not only improves his or her appearance, but also restores function in the process.

Another example is a woman who, due to disease, hormonal changes or genetics, develops large sagging breasts as she ages. Reduction mammaplasty, also referred to simply as breast reduction, is the appropriate reconstructive surgery for this abnormality, and it was developed to give women more comfortable, smaller breasts that are proportionally suitable to their bodies.

Similarly, young children born with deformed or overly large ears may have outer ear surgery–reconstructive otoplasty–to create a more normal appearance. In many cases, reconstructive surgery is covered under insurance, and therefore if you think you or a family member may require such a procedure, check with your carrier about coverage and limitations. You should also work with Dr. Leonard to obtain pre-authorization for the procedure from the insurer.

Risk of Complications

Even when surgery is performed by a competent plastic surgeon, such as Dr. Leonard, complications are possible. However, they are usually minor and do not occur on a regular basis.

Nevertheless, it is important to understand that the results of the surgery and the ability to heal are highly individual aspects, and therefore vary considerably from one patient to the next. For this reason, it is never possible to predict the outcome of any surgical procedure with 100% accuracy.

Complications that may occur include the following:

• Negative reaction to anesthesia
• Slow wound healing
• Significant bruising
• Hematomas–pooling of blood beneath the skin
• Excessive bleeding
• Infection

Additionally, the risk of complications may increase due to specific factors. For example, patients who smoke are regarded as higher risk than those who do not use tobacco products. Individuals who suffer from nutritional imbalances, circulation problems or connective tissue diseases are also at a higher risk for post–surgery complications. In addition, those who have impaired immune systems due to HIV or another autoimmune disorder are usually considered high risk patients.

Advance Planning for Your Procedure

When your condition is initially evaluated, Dr. Leonard is guided by what is called the “reconstructive ladder,” which is a set of rules associated with reconstructive surgery and embraced by the medical community. Procedures that are not very complex, such as simple wound closure, are placed on the lower rung of the reconstructive ladder.

Procedures such as the reattachment of severed limbs or similarly complex surgeries are placed on one of the highest rungs of the ladder. Dr. Leonard essentially always begins at the bottom of the ladder when determining the best approach to a client’s treatment, and favors the least complex, most direct avenue through which to achieve the desired result.

The nature, extent and size of the deformity or injury is determined by Dr. Leonard, after which a treatment option is selected and a time frame for the procedure is set. Reconstructive surgery often requires complex planning and it may even be necessary to complete the procedure in stages.

Due to the fact that it is not always possible to accurately predict how the outcome of the procedure will be affected by growth, a youngster may require multiple follow-up visits at regular intervals to receive additional surgery as he or she matures. In some cases, this means that the child’s care following his or her surgery must be completed on a long-term basis.

Dr. Leonard cannot pinpoint an exact date after your surgery that you will be “back-to- normal,” as each individual heals at a different rate. He can, however, offer a general idea of when you should start noticing an improvement.

Wound Treatment Options

When determining how best to treat a wound, Dr. Leonard will carefully evaluate its features, assess its size, and determine its level of severity. For example, he will evaluate whether the skeletal support under the wound has been affected, if the muscles or nerves have been damaged, or if there is a substantial amount of missing skin.

As you and Dr. Leonard outline your surgical plan, it is essential to thoroughly understand the process. One of the best ways to make an informed decision is to ask questions.

On wounds with straight edges, including simple cuts, direct closure is typically performed. A significant amount of attention is given to the visual result and care is taken to ensure that stitch marks are minimized.

Skin Graft Procedures

Wide wounds that are difficult or impossible to directly close are typically treated with skin grafts. The latter are procedures during which healthy skin is removed from another part of your body, often referred to as the “donor site,” and used to repair damaged or missing skin. Virtually all skin grafts can be placed in one of the following categories:

Split Thickness Skin Graft

Most frequently used for the treatment of burn wounds, a split thickness skin graft utilizes only the layers of skin nearest the surface. Whenever possible, Dr. Leonard chooses the least conspicuous donor site, but this is determined by other factors as well, such as the color and size of the skin required for the patch. The donor site may ultimately end up a bit lighter in color, but the skin will grow back at that site in a normal fashion.

Full Thickness Skin Graft

Typically used to treat large or deep burn wounds, or wounds that cover a mobile area such as a joint, a full thickness skin graft requires that multiple layers be taken from the donor site, hence its name. With this type of skin graft, the donor site will likely have a thin scar resulting from where the wound was closed.

Composite Skin Graft

A composite skin graft is the option of choice when additional underlying support is necessary after the wound is reconstructed. A good example of this is when the surgery is being performed to repair damage from skin cancer on the nose. A composite graft requires multiple layers of skin from the donor site, as well as underlying cartilage and fat in many cases. A straight line scar remains where the skin was removed from the donor site, but will fade as time goes on.

Tissue Expansion Skin “Regrowth”

Tissue expansion is a type of surgery that promotes the “growth” of extra skin by stretching the surrounding tissue. This is accomplished through the use of a balloon-like instrument, referred to as an expander, which is inserted under the damaged area of skin. After it is in place, is it gradually filled with saltwater and this causes the skin to grow and stretch. The time frame involved in tissue expansion procedures is largely dependent upon the size of the area on which the procedure is performed, and the individual circumstances surrounding the wound.

The benefits of tissue expansion are numerous, as such a procedure provides an essentially perfect skin color and texture match, and promotes normal sensation after the recovery period. Additionally, there is a decreased risk of tissue loss, as the skin remains connected to its natural nerve and blood supply. Scars are also less apparent when compared with those seen with traditional grafts or flaps. However, the expander instrument creates an unsightly bulge, which may make this option unappealing to certain individuals, even though the bulge is temporary.

Advanced Wound Care: Microsurgery and Flap Surgery

Although success is largely dependent upon the extent of each person’s injury, microsurgery and flap surgery have significantly improved Dr. Leonard’s ability to help severely disfigured or injured patients. Using advanced techniques, Dr. Leonard can now transplant large sections of skin, reattach amputated fingers, and take bone or muscle from one part of the body to the other without interrupting the original blood supply. This is all done through the use of advanced technology.

Flap Surgery

A flap is regarded as a section of living tissue that is transported from one section of the body to another with its own blood supply. Flap surgery restores function and form to body parts that have lost skeletal support, muscle movement, fat and skin.

Localized flap surgery utilizes underlying tissue and skin that are already situated adjacent to the wound. At one end, the flap remains permanently attached in order to receive nourishment from its original blood supply. The other end of the flap is repositioned over the area where the wound occurred.

Regional flap surgical procedures use a section of tissue that is connected to a specific blood vessel. After the flap is lifted, it only requires an extremely narrow attachment to the initial site in order to obtain a nourishing blood supply from the tethered vein and artery.

A skin and muscle flap, also referred to as a musculocutaneous flap, is the procedure of choice when the section that must be covered requires a robust blood supply and more bulk. Skin and muscle flaps are frequently used in breast reconstruction surgery following a mastectomy. The original blood supply is never separated from this type of flap.

In a bone-soft tissue flap, overlying skin and bone are transferred to the wounded area and from there, both receive their own blood supply.

A microvascular free flap is somewhat different from the aforementioned procedures, as a section of skin and tissue is completely severed from its initial location and reattached to the new site by the connection of multiple tiny blood vessels.

Other Reconstructive Procedures

In addition to reconstructing the skin around cuts and other surface wounds, Dr. Leonard also regularly treats both benign and cancerous growths and issues with the supporting structures under the skin.

Tumors, both benign and malignant, vary significantly from one to the next regarding size, rate of growth and incidence of recurrence. The removal method selected primarily depends on the kind of growth, its stage, and where it is located in the body.

Skin cancers and other malignant growths are typically removed by a scalpel and the wound is closed, leaving a slight scar. If the cancerous skin tumor is large or has metastasized to other areas of the skin, major surgical procedures may be needed, which utilize flaps to reconstruct the damaged area of skin.

Laser Surgery

Many areas of plastic surgery have been revolutionized over the past 10 years due to laser technology. The allure of this type of treatment comes from its ability to diminish growths or imperfections with minimal scarring, bruising or bleeding by “blasting” them away.

In today’s modern medical field, numerous laser types are available and many more are currently being developed. For this reason, it is essential to realize that not all laser treatments are the same. If you plan to have laser surgery, speak to Dr. Leonard to discover the type of laser equipment to which he has access.

The active medium used by the yellow pulse laser is actually a kind of dye. It is the same component that gives blood its red color. This type of laser surgery is often used on youngsters with something called “port wine birthmarks.” The latter are caused by abnormal blood vessels, which the laser destroys so that the birthmark eventually becomes scarcely noticeable. With earlier laser models, scarring was a problem. However, with yellow pulse-dye laser, scarring is virtually a non-issue.

Also in the advanced laser family, are the Q-switch YAG, the alexandrite and the Q-switch ruby which make up a group of lasers that are effective in eradicating the black and blue pigment spectrum often seen with tattoos, age spots, liver spots, “crusty age spots” and pigmented lesions. This group of lasers are also used in the reconstructive process following a “traumatic tattoo.” The latter is a term used to describe a phenomenon that occurs when particles of material are forced under the skin through an explosion or other accident.

Often called the “workhorse” of lasers, the carbon dioxide laser is a water absorbed, invisible light that one focused, can feed blood vessels and cut tissue simultaneously. It vaporizes when the focus is taken away. This makes it a great choice for skin growths such as warts.

The YAG laser was proven effective for skin growths that are characterized by a thick concentration of blood vessels, such is seen with a hemangioma. YAG lasers deliver high-intensity streams of energy. However, unlike many other forms of lasers, it can be used almost like a scalpel and directed under the skin.

Similar to the yellow pulse-lye laser, the argon laser emits a blueish-green light that is heavily absorbed by shades in the red spectrum. It is a great choice for bulky vascular tumors, spider veins, hemangiomas, strawberry birthmarks.

The newest type of laser, and also one that emits a yellowish light, is the copper vapor laser. It is ideal for treating red or brown pigmented regions of the skin.

The severity and size of the defect will determine number of laser treatments necessary to reconstruct the area. A single treatment may be all that is necessary to remove a few small spider veins in an adult, while children with large birthmarks may need 6-10 treatments for satisfactory results.

Lasers have many valuable uses; however, never regard a laser as a “magic wand,” as no treatment is perfect. For conventional plastic surgery and other types of surgery, the instrument of choice is still the scalpel.

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Leonard Plastic Surgery

Water Place │ 500 Liberty Street S.E., Suite 400 │ Salem, OR 97301

(503) 391-2760 │leonardplasticsurgery@gmail.com