Plastic Surgery Has Many Faces

From reconstructive surgeries that fix congenital defects in children to cosmetic surgeries that help make older people look younger, plastic surgery treats or plays a role in treating a vast number of medical conditions.

The Medical College of Wisconsin Department of Plastic Surgery is testament to that fact. Its faculty surgeons offer the full range of plastic surgery applications to thousands of patients a year through Children's Hospital of Wisconsin, the reconstructive surgery clinic, a center specializing in the treatment of hands, the Cascadia MediSpa center, and other venues.

"Plastic surgery has nothing to do with plastic, as you might imagine it would, because plastic surgery predates plastic," said David L. Larson, MD, FACS, Medical College Professor and Chairman of the Department of Plastic Surgery and Cascadia MediSpa. "It comes from the Greek word plastique, which means 'to shape or form'.

"The Department of Plastic Surgery annually sees about 16,000 patient visits. That includes the Hand Center as well as the reconstructive clinic that we have here, in addition to the MediSpa where we see our cosmetic patients. There are essentially two sides to the field, the reconstructive side and the cosmetic side.

"Reconstructive surgery is taking a defect that's created by disease, cancer, infection, congenital abnormality, trauma and burns, whatever the cause, and trying to restore the form and sometimes the function of that part of the body, anywhere from the top of the head to the bottom of the foot."

A Very Personal Process
Whether reconstructive or cosmetic, plastic surgery often involves treatment decisions by the surgeon and the patient of the most personal sort, Dr. Larson said.

"Cosmetic surgery is an attempt to take the norm, let's say of a 65-year-old woman who has wrinkles and excess skin under her chin and jowls, and do a face and neck lift and give her a more youthful appearance but not to make her look like she's 35," said Dr. Larson.

"We also do reconstruction related to congenital deformities. That's done at Children's Hospital, where we have three surgeons for that. Reconstruction for the adult population could be related to trauma, where there's significant facial or abdominal trauma or something like that; it could be related to tumor resection, for example removal of a jaw that has cancer or a piece of bone in the leg that has a tumor, and then reconstruction of the defect; it could be related to breast surgery.

"Obviously, breast reconstruction is an important aspect of restoring body image and body form to a woman who has lost a breast. That's a very personal thing related to the indications for reconstruction. The other big thing that we do in our department is hand surgery, reconstructing the hand after trauma including accidents, primarily industrial accidents and home accidents like those involving electric saws."

GAP Flaps a Breakthrough
Plastic surgeons are now able to use tissue from nearly anywhere on the body without harming the function of the "vessel" [the area of the body] from which the tissue was taken, Dr. Larson said, which has opened new treatment doors as limits on what tissue can be used elsewhere on the body are far less restrictive.

"Probably the most important recent development in plastic surgery that you'll be hearing a lot more about is the procedure called 'perforator flaps'," said Dr. Larson. "With this procedure, a piece of tissue based on a vessel on some part of the body is taken and moved from one part of the body to another, not limited by any anatomy other than the vessel itself as it goes into the flap of surgery.

"What it means is that we can take a piece of tissue from just about any part of the body and move it to any other part of the body and we're not restricted by rules of anatomy as we have been in the past. It's only within recent years that we've been able to pay attention to that anatomy and get down to that level of blood supply of the skin. We've been dealing on larger levels in the past. That's a very exciting thing. As an example, we can actually take a part of the abdomen or a part of the buttocks of a woman, and without violating any of the muscle associated with that tissue we can move a portion of that up to reconstruct a breast.

"It's called a GAP flap, a gluteal artery perforator flap, and that's actually going to be the next big method of breast reconstruction. There's nobody else in the upper Midwest that does it. We're developing the procedure. We have two new faculty members that have joined us and this is an area of their expertise. The procedure is based on better knowledge of anatomy plus refined surgical technique; it has nothing to do with technology. We're not robbing Peter to pay Paul, we're just sort of borrowing from Peter; Peter can well afford it, and Paul needs it."

Cosmetic Developments
"In the cosmetic world, there are a lot of new methods of facial rejuvenation," said Dr. Larson. "Another thing that's exciting is a new form of liposuction called ultrasonic liposuction, which melts the fat, and then it is suctioned out. This is a safer, less painful method of reconstruction and it gives more predictable results with less recovery time.

"Another development may be a renaissance of the gel-filled implant for augmentation mammoplasty. We have been able to use the gel-filled implant all along for breast reconstruction, but not for purely cosmetic procedures. The new kind of gel that they're talking about, the silicone gel, is much, much different than the gel that we knew of ten years ago. The new gel doesn't separate, doesn't flow anyplace, doesn't go anywhere."

The new silicone gel may help assuage the fears of women considering breast augmentation that stemmed from the controversy over whether "leaking" breast implants caused serious medical problems, Dr. Larson said.

Medical College plastic surgeons are also involved in research on several fronts. Current or recent research activities include aesthetics, nerve surgery, micro-hand surgery and breast reconstruction.

"Our department is one of the largest in the Midwest and one of the few 'free standing' departments of plastic surgery in the country," said Dr. Larson. "Most others are divisions within the departments of surgery. This is well known around the country, and because of that we feel we're able to attract higher-quality residents and faculty.

"We have nine full-time faculty plastic surgeons and two psychologists. We're the only department in plastic surgery in the country that even has one, much less two psychologists on the faculty full time. They work to rehabilitate - psychological rehabilitation if you will - patients following significant trauma to the upper extremity, loss of limb related to cancer or trauma, and in dealing with the psychological issues of body image. They are absolutely invaluable to us."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.