Reconstructive surgery

Definition

Reconstructive surgery is a type of plastic surgery. It is performed to reshape abnormal structures of the body to improve function and appearance. Reconstructive surgery is a different kind of plastic surgery than cosmetic surgery, which is performed to reshape normal structures of the body to improve a patient's appearance and self-esteem.

Purpose

The goals of reconstructive surgery are to reshape abnormal structures of the body, to improve function, and/or to allow a person to have a more normal appearance. Abnormal structures of the body that are corrected during reconstructive surgery may be the result of birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. The three most commonly performed reconstructive surgeries in the United States are tumor ablation (removal) and reconstruction, hand surgery, and breast reconstruction.

Precautions

Reconstructive surgery should not be performed on patients who are not healthy enough to withstand a surgical procedure performed under general anesthetic. People with severe diabetes, an autoimmune disorder such as AIDS, or a suppressed immune system should not undergo reconstructive surgery. This type of surgery is also contraindicated in patients with a history of excessive smoking, obesity, poor wound healing, abnormal scarring and/or a bleeding disorder. Women who are pregnant should not undergo reconstructive surgeries. Patients who have received recent irradiation treatments (generally within the last three to six months) should not undergo surgical procedures involving these tissues. Recently irradiated tissue is highly prone to infection and has poorer wound healing.

In some cases, after tumor removal surgeries, it is necessary to monitor the affected tissue for redevelopment of the tumor. Patients requiring this type of postoperative surveillance should not undergo further reconstructive surgeries since these surgeries could obscure the results of imaging techniques (x ray , computed tomography , or magnetic resonance imaging ) used to monitor tumor recurrence.

Patients with an allergy to collagen, beef, or beef products should not receive collagen injections.

Description

The most commonly performed reconstructive surgeries of cancer patients are breast reconstruction, laceration repair, scar revision, and tumor removal.

Breast reconstruction

Breast reconstruction surgeries can be performed as part of the procedure to remove the breast (immediatemastectomy ). They may also be performed as a separate procedure after recuperation from a mastectomy (delayed). There are two types of breast reconstruction: autogenous free flap reconstruction and breast implants.

Autogenous free flap reconstructions use tissue from another part of the body to form the reconstructed breast. This category of breast reconstruction includes the techniques called TRAM (transverse rectus abdominis myocutaneous), LD (latissimus dorsi), and VRAM (vertical rectus abdominis myocutaneous) flaps. These names refer to the location from which the tissue for reconstruction is taken. In 2001, TRAM, in which tissue is taken from the abdominal region, is the most common breast reconstruction procedure in the United States.

Breast implants involve the placement of an artificial object in the body to simulate the shape and size of the natural breast. The implant is most commonly a saline (salt water) or silicone-filled bag. Because of the health problems reported by many women after silicone breast implants, this technique is no longer as widespread as it once was, particularly for reconstructive surgeries.

Laceration repair

Laceration repair includes the repair of large wounds caused by the removal of large tumors, or tumors associated with the skin. It also includes the surgical repair of wounds that fail to heal, or heal improperly. Laceration repair can be subdivided into four general categories: direct closure, skin grafts, tissue expansion, and flap surgery.

Direct closure (stitches) is usually only performed on wounds that are not very deep beneath the surface of the skin and that have straight edges of skin on either side of the wound. The primary goal in direct closure is to provide a permanent closure of the wound with a minimum of scarring.

Skin grafts are used for wounds that are wide and difficult or impossible to close directly. This technique involves removing healthy skin from a location on the patient (the donor site) and using it to cover the wound site. The skin will grow back at the donor site but often leaves a color mismatch. The donor site is chosen to best match the color of the skin needed in the graft area.

Tissue expansion is used to grow extra skin by stretching skin near the site that will require the skin. A small inflatable balloon is placed under the skin next to the area where the skin will be removed. Over time, this balloon is slowly filled with salt water until the skin has grown to the required size. The surgical procedure that involves the loss of skin is then performed and closed with the extra skin that was formed during the tissue expansion process. The major advantage associated with tissue expansion is that the skin grown in this way remains connected to its original blood and nerve supply, so the risk of loss of sensation in the area of the wound is greatly diminished. Also, the scars that result from tissue expansion are generally less noticeable than those from skin grafts or skin flaps. A final advantage of this method is the near perfect match in color provided by this skin.

Flap surgery involves taking a section of living tissue, with its blood supply, from one part of the patient and moving it to the area where it is needed. In most flap surgeries, one end of the flap remains attached to its original blood supply so that it continues to be nourished as it grows to heal the wound. In cases where the flap is completely removed and transplanted to another part of the body, the surgery involves the reconnection of all the tiny blood vessels of the flap tissue to the blood vessels of the new location (microsurgery). Flap surgery has the advantage of being able to restore both form and function to areas of the body that have lost skin, fat, muscle, and/or skeletal support. The most commonly performed flap surgeries are the autogenous breast reconstructions discussed above. But, this procedure is used throughout the body with a great amount of success.

Scar revisions

Many cancer patients have scarring that results from their particular form of cancer or from the number or severity of surgical procedures or radiation that they have undergone. In some of these cases, surgeries to minimize or reshape the scar, or scars, may be undertaken. Most physicians will recommend that a scar be allowed to heal for at least one year prior to a recommendation of scar revision. But, in extreme cases of loss of mobility, increased sensitivity, or inflamed and irritable scars that do not respond to topical steroid creams, this timetable may be shortened.

Unless proof of the scar contributing to a medical condition or a decrease in physical function can be shown, scar revision surgery is considered by most insurance companies to be a cosmetic surgery that is not covered as an insurance benefit. The most common reason for scar revision to be classified as a reconstructive, rather than a cosmetic, procedure is a loss of mobility of muscles or joints caused by the scar.

The most common procedure for scar revision is called Z-plasty. In this procedure, the old scar is removed and the two sides of the wound are cut into a z-shape that is designed to follow the natural lines and contours of the surrounding skin. This z-shaped wound is then closed with stitches. Other scar revision procedures include skin grafts and flap surgeries. Z-plasty is the least likely of these procedures to be covered by insurance.

Tumor removal

The surgical procedure used to remove a tumor will be chosen by the surgeon based on the type and size of the tumor. Other factors influencing the surgical technique chosen for tumor removal include: the location of the tumor within the body; the potential for recurrence of the tumor at this, or another, location in the body; and, the stage of development of both the tumor itself and the underlying cancer.

Skin cancers are generally removed by a cutting out (excision) of the cancerous portion of skin, with the wound closed by stitches or left to heal on its own. In cases of large, or spreading, skin cancers, major surgery involving skin grafts or flap surgeries may be required. For skin cancers in the facial area, Moh's surgery with primary or flap closure may be performed.

Preparation

The preparation for a reconstructive surgery depends on the type of surgery that is to be performed. Some reconstructive surgeries can be performed on an outpatient basis. These procedures require only a local anesthetic and very little patient preparation other than counseling about the risks, possible achievable outcomes, and alternatives to the surgery. Other reconstructive surgeries are considered major operations. These require hospitalization, a general anesthetic and much more extensive counseling and discussion of possible alternatives.

Prescription medications that may interfere with the performance of reconstructive surgery should be discontinued approximately two weeks prior to surgery, unless the surgeon advises otherwise. These medications include any medicines that may interfere with the anesthetic or that may increase bleeding. Over-the-counter medications, such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS), should not be taken for at least one week prior to surgery unless approved by the doctor who will be performing the surgery. Patients undergoing surgeries that require a general anesthetic will be asked not to eat after the midnight prior to the surgery, and not to drink at least eight hours prior to surgery. The purpose of this is to ensure that the stomach is empty while the patient is unconscious. Otherwise, the stomach contents could end up in the lungs, causing complications with the surgery or the recovery.

For procedures involving skin flaps, the patient may be asked to donate blood for possible use in a later transfusion.

In the case of tissue expansion procedures, the amount of time that will be required for the expansion of the tissue depends on the amount of tissue that must be grown to ensure an adequate closure of the wound. This may take a matter of days or several weeks.

Psychological and emotional preparation is important in reconstructive surgery to manage patient expectations. The patient should not be expecting cosmetically perfect results. Complete understanding of the limitations, as well as the benefits, of this surgery is necessary for a successful outcome.

Aftercare

The aftercare of a patient who has undergone a reconstructive surgery depends on the surgery, the overall health of the patient, and the wound care process. Some outpatient procedures require little aftercare other than a follow-up examination to determine the success of the procedure. Other procedures may require an extended hospitalization followed by extensive physical therapy. Smoking should be avoided, as it may cause delayed wound healing and higher risk of complications, including infection.

Procedures involving skin flaps or grafts require careful monitoring in the first days after surgery to ensure that proper blood circulation is taking place. Bandages and drainage tubes will remain in place for at least a day.

Scars may remain reddened and raised for a month or longer and may cause itching . Many people find that inflammation or severe itching from post-surgical scars is lessened, or completely eliminated, by topical treatments with vitamin E or steroidal creams.

After tumor removal, many patients require follow-up treatments and medical imaging to ensure that the tumor is not redeveloping.

Risks

The risks associated with all reconstructive surgeries are infection, bleeding, an unsightly scar, improper wound closure, and adverse reactions to anesthesia. Complications associated with flap reconstruction of the breasts include unusual firmness of the fatty tissue (fat necrosis), partial flap loss, fluid collection beneath the flap site, and muscle weakness (including abdominal hernias) at the donor site. For breast implants, complications include the formation of fibrous tissue around an implant, rupture or leakage of the implant, or movement of the implant from its intended location.

Normal results

The normal result of a reconstructive surgery is a patient who has an improved ability to function and/or an improved body image as a result of the surgery. A normal result depends also on the patient's realistic goals and expectations. The patient should understand that the feeling and appearance of the reconstructed area will be improved, not fully restored to an unaffected state.

Abnormal results

An abnormal result of a reconstructive surgery is a patient who suffers long-lasting health complications as a result of the surgery. Another abnormal result is a patient who suffers a degradation in the ability to function and/or has a loss of self-confidence caused by the loss of sensation or scarring that may accompany such procedures.

See Also Breast cancer

Resources

BOOKS

Berger, Karen J., and John Bostwick III. A Woman's Decision: Breast Care, Treatment and Reconstruction, 3rd ed. St. Louis, MO: Quality Medical Publishing, 1998.

Kimberly, Henry A., and Penny Heckaman. The Plastic Surgery Sourcebook. Lincolnwood: NTC/Contemporary Publishing, 1999.

ORGANIZATIONS

American Society of Plastic Surgeons Plastic Surgery Educa tional Foundation. 444 E. Algonquin Rd., Arlington Heights, IL 60005. (888) 4-PLASTIC. <http://www.plasticsurgery.org>.

The Foundation for Reconstructive Plastic Surgery. <http://www.frps.org>.

OTHER

Breast Reconstruction. 23 July 2001 <http://www.vanhosp.bc.ca/html/women_breast.html>.

Paul A. Johnson, Ed.M.

KEY TERMS

Cosmetic surgery

—A form of plastic surgery that is performed to alter normal tissue to improve the appearance of that tissue.

Flap surgery

—A procedure in which a portion of living tissue is moved from one part of a patient's body to another to restore shape and/or function to the targeted location.

Plastic surgery

—A type of surgery that is performed to alter the physical characteristics of a patient. This medical discipline is subdivided into cosmetic surgery and reconstructive surgery.

Reconstructive surgery

—A form of plastic surgery that is performed to repair or reshape abnormally formed tissue to improve the form and/or function of that tissue.

Scar revision

—A surgical procedure that attempts to diminish the physical appearance of a scar. This procedure is also used to add flexibility and range of motion to joints and muscles that were previously hindered by a particular scar.

QUESTIONS TO ASK THE DOCTOR

• What are alternatives to this surgical procedure?
• What will the scars look like, and can I expect them to decrease over time?
• How many reconstructions have you performed previously and may I see examples of the results or talk to former patients?
• Will this procedure be covered by my insurance?
• How long will the pre-operation waiting period, the hospital stay, and the recovery procedure be?