Skin Reconstructive Surgery

Skin Procedure

Reconstructive surgery aims to repair defects and restore function. It is performed to correct structures affected by birth defects, developmental abnormalities, trauma/injuries, infections, tumours and disease. Additionally, plastic surgery is an effective and neat way to treat minor “lumps and bumps”.

Using a wide range of reconstructive techniques, plastic surgeons mend holes and repair damage primarily through the transfer of tissue from one part of the body to another. The main aim is to restore function of a specific part of the body and heal wounds as quickly as possible.

Reconstructive surgery also aims to improve and restore appearance. Wherever possible we attempt to minimise the visual impact of the initial wound or defect, and the impact of the surgery itself. Cosmetic surgery is simply an extension of reconstructive surgery in which the main functional gain to be expected is an improvement in appearance.

Skin Grafts

A skin graft involves taking a healthy patch of skin from one area of the body, known as the donor site, and using it to cover another area where skin is missing or damaged. The piece of skin that is moved is entirely disconnected and requires blood vessels to grow into it when placed in the ‘recipient site.

There are three basic types of skin grafts.

Split thickness skin graft

Basal cells are round cells found in the epidermis, and a basal cell carcinoma is the most common skin cancer. This type of cancer is slow-growing and very rarely spreads to other parts of the body.

Full-thickness skin graft

Squamous cells are the most numerous cells in the epidermis. Cancer arising from these cells is usually due to sun exposure and skin damage. It spreads to other parts of the body in only five percent of all cases.

Composite graft

This aggressive form of skin cancer arises mostly from pigment-producing cells called melanocytes. While being serious, melanoma accounts for only around one percent of all skin cancers. It usually appears as an abnormal mole, although it can vary greatly in appearance.

Tissue Expansion

Tissue expansion is a procedure that enables the body to ‘grow’ extra skin by stretching surrounding tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired, and is then gradually filled with salt water, causing the skin to stretch and grow. The time involved in tissue expansion depends on the individual case and the size of the area to be repaired.

Flap Surgery

Flap reconstruction involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessel that keeps it alive. Unlike a skin graft, flaps carry their own blood supply, so can be used to repair more complex defects. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support.

There are three main types of flap.

Local Flap

Local Flap uses a piece of skin and underlying tissue that lie near to the wound. The flap remains attached at one end so that it continues to be nourished by its original blood supply and is repositioned over the wounded area. 

In the diagram above’s case, a skin cancer has been removed from the nose leaving a defect that cannot simply be stitched up. A local flap, called a bilobed flap is used to close the defect. The flap consists of skin along with the underling soft tissue and its blood supply.

A local flap like this relies on the fact that the skin has some natural elasticity and uses the lax skin in the bridge of the nose to close a defect near the tip of the nose where the skin is naturally tight.

Regional Flap

Uses a section of tissue that is attached by a specific blood vessel. When the flap is lifted, it needs only a very narrow attachment to the original site to receive its nourishing blood supply from the artery and vein.

This picture shows muscle from the calf being transferred, keeping its blood supply intact to cover an open fracture below the knee. 

Free Flap / Microsurgery

Free flap reconstruction also involves the transfer of living tissue from one part of the body to another, along with the blood vessel that keeps it alive.   A free flap is a further modification of flap transfer where the flap is entirely disconnected from its original blood supply and then reconnected using microsurgery in the recipient site. The following are two examples of free flaps.

In this image, the patient has an open fracture of his right lower leg. A muscle is taken from his inner left thigh and transferred to his right leg. The blood vessels that keep this muscle alive are dissected out of his left thigh along with the flap, divided, and then joined up micro-surgically to blood vessels in his right leg. This keeps the flap alive in its new position. To complete the reconstruction a split skin graft is taken from the left thigh and laid over the free muscle flap. This is called a free gracilis muscle flap.

 This procedure involves hooking up the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name microsurgery.  The ability to disconnect and reattach tissue in this way means that the reach of flap is no longer confined by a patient’s anatomy.

More than any other technique, microsurgery has revolutionised plastic surgery as a specialty and is now the definitive treatment option for patients with cancer and major trauma.

In this example of a free flap a portion of skin and fat of the patient’s lower abdomen is transferred to the chest to reconstruct a breast. The blood vessels that keep this tissue alive are divided as they emerge from the groin area and rejoined micro-surgically to blood vessels in the chest in order to restore the blood supply to the flap. This is called a free TRAM flap breast reconstruction.