Principles in Plastic Surgery

Plastic surgery is a unique specialty that defies definition, has no organ system of its own, is based on principles rather than specific procedures, and, because of cosmetic surgery, is the darling of the media. What is plastic surgery? No complete definition exists. Joe McCarthy defines it as the “problem-solving specialty.” My wife, an anesthesiologist, calls plastic surgeons the “finishers” because they come in when “the other surgeons have done all they can do and the operation has to be finished.” An evenmore grandiose definition is the following from a plastic surgery resident: “Plastic surgery is surgery of the skin and its contents.” There is no way to define this specialty that has acquired “turf” through a combination of tradition and innovation.What is the common denominator between craniofacial surgery and hand surgery? Between pressure sore surgery and cosmetic surgery? Unlike other surgical specialties, plastic surgery is not organized around a specific organ system. Plastic surgery has only traditional areas of expertise and principles on which to rely for its existence and future. Because plastic surgery has loose boundaries and no specific anatomic region, it faces competition from regionally oriented specialties. Traditional areas of expertise can be lost as other specialties acquire the skills to perform the procedures developed by plastic surgeons. Consequently, plastic surgery has both freedom and vulnerability. It is this vulnerability that makes plastic surgery dependent on both the maintenance of superiority in the traditional areas of expertise and on continued innovation and acquisition of new techniques, new procedures, new problems to solve—that is, new turf. Plastic surgery is based more on principles than on the details of specific procedures. This allows the plastic surgeon to solve unusual problems, to operate from the top of the head to the tip of the toe, to apply known procedures to other body parts, and to be innovative. No specialty receives the attention from the lay press that plastic surgery receives. At the same time, no specialty is lesswell understood. Although the public equates plastic surgery with cosmetic surgery, the roots of plastic surgery lie in its reconstructive heritage. Cosmetic surgery, an important component of plastic surgery, is but one piece of the plastic surgical puzzle. Plastic surgery consists of reconstructive surgery and cosmetic surgery but the boundary between the two, like the boundary of plastic surgery itself, is difficult to draw. The more one studies the specialty, the more the distinction between cosmetic surgery and reconstructive surgery disappears. Even if one asks, as an insurance company does, about the functional importance of a particular procedure, the answer often hinges on the realization that the function of the face is to look like a face (i.e., function = appearance). A cleft lip is repaired so the child will look, and therefore hopefully function, like other children. A common procedure such as a breast reduction is enormously complex when one considers the issues of appearance, self-image, sexuality, and womanhood, and defies categorization as simply cosmetic or necessarily reconstructive. This chapter outlines basic plastic surgery principles and techniques that deal with the skin. Cross-references to specific chapters providing additional information are provided. Subsequent chapters in the first section will discuss other concepts and tools that allow plastic surgeons to tackle more complex problems. Almost all wounds and all procedures involve the skin, even if it is only an incision, and therefore the cutaneous techniques described in this text are applicable to virtually every procedure performed by every specialty in surgery.