Reconstructive Surgery

As one of the main areas of Plastic Surgery, reconstructive plastic surgery deals with the restoration of form and function after soft tissue injuries, tumour operations, severe infections, chronic wounds and the correction of congenital malformations. For each indication there are different ways to perform reconstructive procedures that are tailored to each patient depending on size, location and type of defect. We as reconstructive surgeons deal with the correction of form and function of skin and soft tissue, the reconstruction of muscles and tendons, bone and cartilage as well as procedures for peripheral nerve damage. As a basic principle of plastic surgery, healthy tissue from one anatomical area is transplanted into a defect in another region. Hereby the principles of the surgical ladder is applied whereas the method of least invasiveness is used as first line in the treatment of defects. In the first instance this would be a tension free primary wound closure. In order to cover larger superficial defects, the techniques of skin grafting can be applied. This can either be full thickness or partial thickness skin grafting. If the size of the defect and the viability of the surrounding tissue allows, local flaps can be used, where neighbouring tissue can be moved to close the wound. Very large defects often require more complex procedures. Usually this is done using microsurgical techniques with free flap or pedicled flap surgery. Here, blood vessels are moved with the harvested tissue and recommended at the site of the defect. Flaps can contain skin, fat, fascia, muscle, bone or a combination of each. Microsurgical techniques for tissue transfer have substantially extended the spectrum to restore form and function after severe injuries and extensive soft tissue excisions. This includes also the replantation of severed digits.

Main areas of expertise in this clinic:

• Excision of skin and soft tissue tumours
• Reconstruction of skin, soft tissue and bone defects after operations, trauma or burn injuries
• Breast reconstruction after tumour operations
• Breast surgery for congenital malformations
• Treatment of chronic wounds and deep soft tissue defects
• Plastic surgery for trauma patients
• Congenital Malformations

 

Skin tumours

Skin tumours are a common problem in people of all ages. With the increase in UV exposure the incidence of malignant skin tumours like Basal Cell Carcinomas, Squamous Cell Carcinomas and Malignant Melanomas has risen rapidly. These tumours warrant urgent surgical excision and adequate follow-up. We have established close working-relations with Dermatologists (Skin Specialists) in order to ensure appropriate treatment according to oncologic guidelines.

Most of the time, we use a two-step approach to these problems: In the first step, the tumour is excised surgically, with an appropriate safety margin. The defect is closed with a temporary wounddressing. After confirmation of a histologically complete excision – this can take up to 3 days - the wound is closed in a second step approach. According to the reconstructive principles of restoring form and function, the most suitable method of closing the defect is chosen. This can be direct closure, skin grafting or even local flaps, where adjacent skin is moved into the defect. With our special expertise in this field of surgery we aim to achieve cosmetically excellent results, especially in the important regions of the face.

 

Soft tissue tumours

Soft tissue tumours are often first noticed as lumps and bumps under the skin. Patients are referred to us for further investigations, in order to differentiate benign from malignant tumours, and to plan their surgical excision.
In most cases, especially with common benign lesions like lipomas or cysts, the diagnosis is made on a clinical basis. The tumours are removed surgically and the wounds closed primarily. In some cases of large tumours (e.g. sarcomas), special scans like magnetic resonance imaging (MRI) are used to confirm the diagnosis and to establish the extent and depth of invasion of the lesion. When bones are involved, computer tomography (CT) scans are useful tools of investigation. In rare instances, an incisional biopsy can help to establish a diagnosis by histological analysis.

After a thorough pre-operative work-up, surgery is planned carefully in order to obtain complete clearance of the tumour while maintaining vital and functionally important structures.  We use a multi-specialist team approach in order to establish post-operative oncological follow-up if necessary.

The surgical approach is again according to the 2-step approach using the surgical ladder.  In the first step, the tumour is excised surgically, with an appropriate safety margin. The defect may then be closed with a temporary wounddressing. After confirmation of a histologically complete excision – this can take up to 3 days - the wound is closed in a second step approach. According to the reconstructive principles of restoring form and function, the most suitable method of closing the defect is chosen. This can be direct closure, skin grafting or even local flaps, where adjacent skin is moved into the defect. Depending on the anatomical region on the body, we can reconstruct large defects by moving pedicled or free flaps into different regions of the body, using microsurgical principles of connecting blood vessels and even nerves.

 

Reconstruction of large defects after operations, trauma or severe burns

This is one of the most important and challenging aspects of Plastic Reconstructive Surgery. Reconstructive procedures to restore form and function are vital to close large defects that are left over when patients have undergone tumour operations or when severe trauma has left large soft tissue wounds. After successful reconstruction of the wound, the patient can start rehabilitation on both a physical as well as psychological level. A therapeutic pathway is designed for each individual patient to meet the unique challenges posed by large wounds after tumour operations or mutilating trauma, and followed-through in order to achieve the best possible outcome.

Breast reconstruction after tumour surgery

A diagnosis of breast cancer can be very traumatising to the patient. In cases where conservative breast surgery is not possible and surgical removal of the entire breast is indicated (mastectomy), patients should be made aware of the possibility and options of reconstruction of the breast. Breast reconstruction is the process of recreating a breast mound aiming to match the remaining natural breast. It has been shown to improve mental health, emotional well-being, energy level and satisfaction with breast appearance after mastectomy. Reconstruction of the breast, if desired, can be performed as a primary procedure during the same operation as the mastectomy, or as a delayed procedure, months or even years later.

There are 2 main types of reconstruction: prosthetic and autologous. Prosthetic reconstructions use silicon implants to recreate the breast mound whereas autologous reconstructions use tissue from elsewhere in the body to recreate the breast.  Which option is most suitable depends on the characteristics of the remaining natural breast, the quality of reconstruction required and the type of surgery the patient is prepared to undergo to achieve the reconstruction.  

Our department provides the specialist facilities in order to perform both the prosthetic reconstruction as well as the more complex procedure of a breast reconstruction using autologous tissue by using microsurgical techniques for pedicled or free tissue transfers.

Autologous reconstructions involve moving tissue from back (Latissimus dorsi flap), buttocks (S-GAP flap), thighs (Gracilis flap) or abdomen (DIEP or TRAM flap) to the site of the breast and reshaping the tissue to form a new breast mound. As the tissue is alive and natural, it provides the most natural shape and feel to the reconstructed breast at the expense of undergoing surgery and creating scars in healthy parts of the body. In contrast to prosthetic reconstructions, there is a full-size breast mound immediately after the operation, although it is likely to change shape and size slightly over the first few months following reconstruction.  

It may be necessary to undergo one or two subsequent smaller procedures, aimed at slightly altering the shape of the breast or creating a nipple and areola (the darker skin around the nipple), or adjusting the shape of the other breast in order to improve symmetry. This is done earliest after 6 months.  

Specialist clinic appointments

 

 

Breast Surgery for congenital abnormalities:

We use modern plastic surgical techniques to operatively restore symmetry and form of many breasts affected by congenital or acquired deformities. This includes conditions like Poland´s syndrome (missing pectoralis muscle), macromastia, micromastia, asymmetries or tubular breasts.

Treatment of chronic wounds and deep tissue infections

A large portion of reconstructive procedures are performed for patients with chronic wounds that have developed due to chronic illness, recurrent infections, and limitations in mobility or poor nutritional status. These wounds do not progress through the normal stages of healing.

Pressure Sores

Pressure sores or decubitus ulcers are wounds most often caused by immobility and unrelieved pressure. Other factors such as friction, humidity, shearing forces, age and incontinence play a role in the progression of these wounds that can occur to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, ankles and buttocks. Although easily prevented and completely treatable if found early, bedsores can be detrimental to the patient’s health if not treated appropriately.
Early signs of reddening of the skin can progress to deep wounds involving skin, fat, muscle and even bone if the pressure on the tissue is not relieved, causing a disruption of blood flow and consequent necrosis. If these wounds become infected, urgent surgical involvement is necessary.
Apart from nutritional supplementation and antibiotic treatment of infection, optimal positioning of the patient is of utmost importance, placing much responsibility to intensive nursing and the provision of special mattresses as a basis for operative procedures. The first stage involves debridement of all necrotic and dead tissue, followed by a second stage of reconstructing the defect with healthy tissue. This will mostly be skin, fat and muscle from the surrounding regions. In order to prevent a recurrence of the pressure sore, rehabilitation of the patient with optimal positioning and physiotherapy is necessary.

Sternumosteomyelitis

A small number of patients (0.5 – 4%) undergoing open chest operations (eg. after sternotomy for coronary bypass operations) develop a wound dehiscence and problems with wound healing. This can be superficial and heal promptly with minimal surgical intervention, but sometimes a deep sternal infection develops, placing the patient at a high risk. In cases like that, the specialist knowledge of a Plastic Surgeon is needed to avert the danger emanating from the infected wound and eventually closing the defect using various reconstructive measures.
The wounds are debrided several times as a first stage procedure, removing all debris and non-vital parts, such as wires and dead bone. This is followed by vacuum therapy (VAC), a special dressing creating a negative pressure over the wound in order to promote wound healing. Using this device has lead to improved healing, reduced mortality and in-patient time even in serious infections. Reconstructing the defect is performed as a second stage procedure, using tissue from the chest (pectoralis muscle), back (latissimus dorsi muscle), of abdomen (rectus abdominis muscle).

Leg ulcers

Ulceration to legs most commonly occurs on the lowest part in association with a circulatory insufficiency, characterized by slow or no progression to heal spontaneously. There are many different types of ulcers with various aetiologies and contributing factors that need to be addressed by vascular surgeons, diabetes specialists and radiologists in order to optimise successful treatment by us Plastic surgeons.
In order to achieve a healthy and clean wound surface, the ulcer is debrided of all dead tissue. In order to accelerate wound healing by increasing blood supply to the wound and draw off unnecessary wound fluid, a vacuum therapy device (VAC) is used to dress the wound. When the wound surface is optimized to allow healing, a split thickness skin graft can be used to close the defect.

Plastic surgery for trauma victims

No matter how complex a wound after mutilating trauma might be, there are a multitude of reconstructive options in the Plastic Surgeon’s armamentarium. While we provide a 24h replantation service for amputated limbs and fingers, we also provide reconstructive surgical expertise in a multi-disciplinary team approach to patients with open wounds after fractures on upper and lower limbs.
Wounds on the lower limb pose a special reconstructive challenge, where the options need to be chosen in a competent way in order to achieve safe wound cover for the patient to regain form and function of the affected limb. Exposed tendons, bone, screws or plates need to be covered by soft tissue. Options include local and regional tissue transfers, and even free tissue transplantations. In our Department, we routinely use microsurgical techniques to transplant tissue (muscles, fat and skin) from the back (Latissimus dorsi flap or parascapular flap), thigh (ALT flap) or forearm (radial forearm flap) to cover defects 

Congenital malformation

We also perform reconstructive procedures for congenital malformations. These involve mostly patients with deformities on hands and feet (eg. syndactyly, polydactyly etc.), but also involving the chest, breast and other anatomical areas. Operative treatment is tailored according to the patient’s individual needs, using reconstructive as well as rehabilitative measures.