PLASTIC SURGERY. — Plastic sur gery includes the various measures re quired to correct malformations due to defective embryonal development, harelip, cleft palate, branchial fistula, and kindred conditions,—and deformi ties occurring as the result of cicatricial contraction after burns, ulcers, or other destructive agencies and disorders. Al though plastic operations upon tendons, nerves, and bones are usually included under this head, it has been deemed more advantageous to the reader to con sider the subjects in articles upon the various conditions in which such meas ures are indicated.
Plastic surgery (anaplasty) should not be confused with skin-grafting plantation). The former is limited to operations where the cuticle is merely loosened from the underlying tissues and slid from one point to another, or where pedunculated flaps are employed, while the latter refers to operations in which portions of skin are entirely sev ered from their original connections and used to fill defects elsewhere. The word flap should be confined to plastic sur gery, and the word graft to transplanta tion.
General Considerations.—In repairing defects the neighboring skin can gener ally be employed by merely stretching it, or by cutting more or less definite flaps and shoving them from one point to an other. Occasionally it is desirable to use flaps with pedicles, obtaining them from the vicinity ("Indian method"), or from an extremity which can be approximated to the seat of operation and held there until union has taken place ("Italian method"). The pedicle is subsequently severed. Considerable twisting of the pedicle is often necessary. Frequently the skin must be extensively undermined in order to increase its mobility.
The applications of plastic surgery are exceedingly numerous. A crural ulcer, for instance, may be covered by a pedun culated flap from the other leg, the limbs being appropriately bound together dur ing the process of healing; the cuticle of the hand may be replaced by flaps from the anterior or posterior surface of the trunk, the skin being sometimes ele vated into a bridge and the hand slipped beneath; defects in•the urethra and ex strophy of the bladder can be repaired with flaps from the scrotum or other adjacent parts; and some of the neatest plastic work is done in connection with cleft palate and repair of the perineum.
Double flaps are sometimes useful. For instance, if a single flap is turned from the neck into a total defect of the cheek, the raw side next the buccal cavity will cicatrize and contract, caus ing much deformity. This can be avoided by using two flaps with their raw sides together: one from the neck and one from the scalp, the hair of the head simulating a beard. In some oper ations it may be advantageous to permit the two flaps to grow together before placing them in position; or the raw surface of a flap may be skin-grafted either before or after sewing it in place. Flaps may be bent upon themselves, rendering them thicker and supplying them with a cuticular covering on both sides; but this requires the sacrifice of so much skin from one region that it is seldom resorted to.
Flaps composed of skin and perios teum, or skin, periosteum, and bone, in undisturbed relation to one another, are often of service. They may be cut and chiseled from adjacent parts and em ployed to fill defects in bone—about the skull, for instance, or following opera tions for osteomyelitis of the tibia. Konig employs, in rhinoplastic work, skin-periosteal-bone flaps obtained from the forehead. Occasionally it is possible to chisel off a flake of bone through a small incision, without cutting a flap at all, and slide it from one spot to another by means of its loose areolar-tissue con nections with the skin.
General Technique. — Asepsis is of prime importance. The avoidance of suppuration diminishes the size of the scar and the amount of cicatricial con traction. and there is less tendency to the cutting of sutures.