Reconstruction is the basis of Cosmetic Surgery

Last week I was involved in two paediatric cases, which reminded me of the power of plastic surgery. For the first patient, I was asked to assist a colleague at the Birmingham Children’s Hospital with a thirteen-year old girl who had facial asymmetry due to an excess amount of abnormal skin. This had resulted from a benign childhood tumour called an infantile haemangioma. Small ones are quite common; they are composed of abnormal blood vessels. The overlying skin is usually red and the past they were called strawberry naevi. Initially they appear shortly after birth and grow rapidly, often at an alarming rate. They then gradually shrink and the vast majority have disappeared by the age of ten years. However some large haemangiomas leave varying amounts of loose abnormal skin that may need surgery to improve the appearance. Large or ulcerating haemangiomas can affect the way the whole face grows.

This young girl had loose hanging folds of skin affecting her left cheek and neck. Symmetry of facial features, “normal” proportions, complexion and expression are some of the many elements that allow all of us to remain within the “herd”. For this girl self esteem and teasing were daily problems in her adolescent world. My colleague cut out the abnormal folds of skin. This left a significant defect which could only be closed by using a face lifting technique, thus allowing the remaining skin to be pulled upwards to cover the defect. The non-affected side of her face was entirely normal and beautiful. I was asked to help because of my experience in cosmetic facelifting and rejuvenation. The techniques used in cosmetic surgery have originated from the reconstruction of deformity. To treat this child, the facial tissues needed quite extensive undermining. Both the skin and parts of the deeper element of the face called the SMAS (Superficial Muscular Aponeurotic System) needed tightening. The tension of part of the SMAS layer needed to be increased to allow the skin on top of the SMAS to be repositioned in a much more favourable location so it could be closed with far less tension. A lot of cosmetic operations are in essence “anti-gravity” procedures. Surgery also manipulates tissue to oppose the long-term effect of muscular tension or the forces of developing scars. This will make the results more likely to be long lasting and allow scars to heal without stretching. The incisions used in facelifts are designed to hide in shadows, creases and crevices and run within the hairline if possible, so that they are camouflaged from human gaze. Nature herself has evolved plants and animals to mask the true nature of what they maybe under the surface! The difference in this young girl’s appearance after the operation was startling. For the first time she is happy to wear her hair up and not to hide one half of her face. Time will tell whether the teasing ceases but in my experience, when one’s inner strength is released and is plain for all to see, hostile forces move to weaker pastures and easier targets.

Another aspect of the art of reconstructive plastic surgery is to transfer the laxity of one part of the body to another area which needs reconstruction and where there is no local laxity for direct closure. In general, the main laxity of the face with ageing is actually in the lower half. Surgery transposes this laxity to the upper half so that tension forces are redistributed. The same principles apply to abdominoplasty (tummy tucks). Laxity in the upper part of the abdomen is mobilised and this allows the resection of excess skin in the lower half of the tummy.

The second case last week followed these principles of transferring the laxity from one part of the body to an area of a major defect needing reconstruction. I was asked to help one of my neurosurgical colleagues to operate on a baby born only the day before with a meningomyelocele. This is a congenital central defect on the back. The meningomyelocele arises because there has been a failure of fusion of elements of the spinal cord and the overlying skin. Often there is also blockage of the cerebrospinal fluid circulation in the brain, so that the baby develops hydrocephalus (enlarged cerebrospinal fluid spaces). This has to be treated first by the neurosurgeon with a special shunt in the brain and then the meningomyelocele itself has to be repaired. After this the skin can be directly closed, but sometimes the defect is so large that a flap repair has to be carried out. A ‘flap’ in plastic surgery is defined as skin with varying amounts of subcutaneous tissue, which has been elevated from its bed and rotated, advanced or transposed to an area requiring reconstruction. In this case the laxity present in the newborn in the upper lateral trunk near the arms was used as the basis of two large skin rotation flaps (one from each side of the body). They were used to cover the upper half of the back defect where there is very little laxity. For the remaining defect, two further flaps were rotated using flaps raised from each buttock. This in turn left defects now on both flanks of the baby and these were closed by further mobilisation of the skin at the sides and around to the tummy, so that everything could be closed directly.

The surgery required close teamwork between two major surgical specialties, as well as highly skilled anaesthetic support. Some surgical problems are so complex it requires expertise of many disciplines. However this is only a small part of this baby’s treatment. The future remains uncertain. We do not know yet whether the baby will be able to walk or have control of its bowls and bladder, or even have normal brain function. Although these uncertainties generate many ethical dilemmas, I believe it was the right thing to do to give life a chance. If you are lucky enough to hold a newborn baby, you will be able to feel where the loose skin is distributed and you may start to understand the principles and art of plastic surgery I have been trying to explain.

Fig 1. Illustration of the Menigomyelocele on the baby's back. The green dotted lines are the incision markings which are in essence four rotation flaps

Fig 1. Illustration of the Menigomyelocele on the baby’s back. The green dotted lines are the incision markings which are in essence four rotation flaps

Fig 2. The red dotted lines illustrate the suture lines of all four flaps rotated into position to cover the defect.

Fig 2. The red dotted lines illustrate the suture lines of all four flaps rotated into position to cover the defect.

Fig 3. These schematic diagrams illustrate the triangulation of a circular defect so that a rotation flap can be planned. The meningomyelocele was in fact so large that four triangles and four rotation had to be planned.

Fig 3. These schematic diagrams illustrate the triangulation of a circular defect so that a rotation flap can be planned. The meningomyelocele was in fact so large that four triangles and four rotation had to be planned.