Plastic surgery is often misrepresented in the popular media, and as a predominantly postgraduate specialty, many doctors also misunderstand it. Unlike other surgical specialties, it is defined by the application of technical skills throughout the body, rather than by a distinct anatomical area. GP trainees can easily find themselves cross covering plastics on-calls out of hours. Combined with limited previous experience and the varied case-mix, this can be daunting. However, plastic surgery provides an abundance of very relevant learning opportunities.
Box 1. The reconstructive ladder
This is one way of conceptualising the options available for reconstructing a soft tissue defect. In general, start at the lowest rung of the ladder, and ‘climb’ until the simplest solution for the problem is identified:
Heal by secondary intention
Not just the ‘easy option’. This can be labour-intensive, and require frequent attendances for dressing changes.
Primary closure
Suturing appropriate, clean, debrided wounds.
Delayed primary closure
Sometimes a wound is initially cleaned, debrided, and dressed, and only closed at a later stage (typically to reduce the chance of infection). This is sometimes performed for bite wounds.
Grafts
Grafts are pieces of tissue moved from one site on the body to another, but without maintaining any intrinsic circulation. They then have to gradually derive a blood supply from the recipient site. They can comprise different tissues, for example skin or bone.
Local flaps
Flaps are pieces of tissue moved with their own capillary network intact. Again, these can involve different tissues, such as skin or muscle. Local flaps use geometry to reorganise nearby tissue laxity and close a defect.
Regional flaps
Here the tissue is moved from a different region of the body, but without detaching its blood supply. An example is detaching the origin of latissimus dorsi from the central back and swinging it through the axilla (where it derives its blood supply) to reconstruct a breast after a mastectomy.
Free flaps
The flap is completely separated from the body, with the relevant artery and vein dissected and then divided at the donor site. The vessels are then surgically anastomosed to a recipient artery and vein. An example would be detaching both origin and insertion of latissimus dorsi from the back, dividing the thoracodorsal artery and vein supplying it in the axilla, then moving it to the leg and anastomosing these cut vessels to the side of the anterior tibial artery and vein, to use the muscle flap to cover an open tibial fracture.
