Information
Editors
Indications for Plastic Surgery
Essentials
- Plastic surgery does not relate to any specifically defined organ or anatomical area but consists essentially of corrective, restorative surgery.
- A plastic surgeon is often part of a multiprofessional treatment team.
- Conditions such as acute infections or injuries may require emergency plastic surgery. Check local availability of 24-hour emergency plastic surgery services.
- Purely aesthetic surgery is usually not provided in public health care.
- Consult also local policies concerning indications and organization of care.
Skin and soft tissue injuries
- Wounds Treatment of Traumatic Wounds and Wound Infections
- Abrasion injuries, or road rash
- The superficial epidermis or superficial dermis is detached due to abrasive forces.
- There is often plenty of sand, dirt and foreign material on the wound surface.
- After applying superficial or infiltration anaesthesia, all foreign material should be carefully removed from the wound because otherwise the foreign material and dirt will be stuck underneath or inside the epithelial layer as the wound is epithelized. Subsequent removal will be practically impossible.
- The debrided wound should be covered with a non-adhesive foam dressing or other type of non-adhesive dressing.
- Deep injuries may require a skin graft.
- Dermatoporotic ulcers
- Low-energy rupture or haematoma of fragile dermatoporotic skin; the ruptured fragile skin cannot be sutured
- Often leads to slowly healing tissue defects.
- E.g. a pretibial ulcer next to the anterior tibial surface
- Haematomas
- Smaller, non-taut haematomas not jeopardizing blood circulation in the skin can be treated by supportive bandage.
- Extensive haematomas may detach the skin from the fat beneath, which may even lead to extensive necrosis of the skin. Such haematomas should be urgently drained.
- Skin rupture/laceration
- Ruptured fragile skin may in some cases be thinned and an attempt made after debridement to use it as a skin graft.
- An evident skin defect should be repaired by using a skin graft.
- Severe multi-tissue injury
- Replantation, see Replantation of an Amputated Extremity or Body Part.
Skin cancer and soft tissue tumours
Plastic surgery of the head or neck region
- Cancer surgery of the head or neck region, often in cooperation with other specialties
- Eyelid malposition
Plastic surgery of the breast area
- Breast reduction Breast Reduction Surgery
- Gynaecomastia Gynaecomastia
- Breast cancer
- Breast reconstruction Breast Cancer
- Procedures to restore the shape and symmetry of the breasts are used in breast-conserving surgery (oncoplastic surgery).
- Breast asymmetry and developmental disorders
Plastic surgery of the trunk
- Body countouring surgery of the trunk after weight loss
- Repair of tissue defects in cancer or trauma patients as a part of a multiprofessional team
Scars
- Keloids and hypertrophic scars Keloid and Hypertrophic Scar
- For other burdensome scars, a plastic surgeon should be consulted in cases such as the following:
- scars clearly impairing function, such as tight scars preventing the full range of joint movement or associated with other harm
- large or deforming scars.
Lymphoedema
- Lymphoedema means accumulation of fluid containing protein in the subcutaneous tissue due to deficient lymph circulation.
- Lymph circulation may be impaired by surgery, radiotherapy, an injury or an infection (secondary lymphoedema).
- Primary lymphoedemas with congenital causes are rarer.
- The diagnosis of lymphoedema is based on clinical examination (detection of pitting oedema).
- Differential diagnosis: other causes of oedema, such as venous, cardiac or renal failure, venous occlusion, tumours, vascular developmental anomalies
- Imaging should be used to exclude recurrent tumour / lymph node metastases in patients with cancer (including patients with history of cancer) and recently developed lymphoedema.
- Compression therapy with supportive garments is the cornerstone of treating lymphoedema.
- At first, the aim is to remove superfluous tissue fluid, which can usually most easily be done by using a slightly elastic supportive bandage. Measures involving supportive garments should be taken only after pitting oedema has been treated.
- In mild oedema, treatment with supportive garments can be started right away.
- Supportive garments must be replaced often enough to ensure sufficient compression.
- For lower limbs every 3-6 months
- For upper limbs about every 6 months
Surgical treatment
- Surgical treatment is divided into mass removal surgery and microsurgery to restore the function of the lymph system.
- The choice of surgical method depends on factors such as the duration of oedema, the development of fibrotic/fatty tissue, the cause of lymphoedema, the volume of the fluid component, whether and how often the patient has had erysipelas, as well as on the patient's other conditions and functional capacity.
- Mass removal surgery
- Liposuction (requires extremely good compression therapy before surgery and permanently thereafter)
- Excision of damaged tissue and repair by skin grafting is very rarely used today.
- Surgery to restore the function of the lymph system
- Lymph node grafting
- Lymphovenous anastomosis, LVA
Indications for consulting specialized care
- Differential diagnostic problems
- Oedema despite conservative treatment (to intensify compression therapy)
- Consideration of surgical treatment
Sex reassignment surgery
- Patients with gender dysphoria are usually diagnosed at specialized units Transgenderism.
- Patients are referred for assessment of surgical treatment from these units.
- Restorative surgery and genital surgery are available in public health care.
- Depending on individual consideration and the patient's wishes, restorative surgery may include masculinization or feminization of the chest area, or genital surgery, for example. Check local policies.
Complications and sequelae of aesthetic surgery
- Aesthetic surgery means surgical modification of normal structures or features purely for looks or shape.
- Any complications or sequelae of aesthetic surgery should primarily be treated in the private sector.
- Exceptions are emergency situations requiring immediate treatment, such as
- infection
- bleeding
- significant rupture/dehiscence of a wound
- pulmonary thrombosis/embolism, an allergic reaction or other condition requiring immediate treatment.
- Late oedema following breast implant surgery may signify breast implant lymphoma Breast Augmentation, requiring urgent examination at a breast unit.