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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_612_Библиотеки_им_академика_М_И_Перельмана
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Video 91.2. Visible nodularity and catching of the
flexor tendon in the A1 pulley during
trigger release
Chapter 104. Upper Limb Amputations and Prosthetics
Travis J. Miller and Erin A. Miller
Video 104.1. Patient utilizing a myoelectric prosthetic
to write with a pen
Video 104.2. Utilization of the myoelectric prosthetic
to open and close the fingers
PART IX. TRUNK AND LOWER EXTREMITY
Chapter 109. Abdominal Wall Reconstruction
Ibrahim Khansa and Jeffrey E. Janis
Video 109.1. Percutaneous transfascial suture fixation
using laparoscopic suture passer
Chapter 114. Gender-Affirming Chest Surgery
Monica Llado-Farrulla and Jens Urs Berli
Video 114.1. Markings for double incision gender-
affirming mastectomy
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PART I
PRINCIPLES, TECHNIQUES, AND BASIC
SCIENCE
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CHAPTER 1 Fundamental Principles of
Plastic Surgery
Sarah E. Sasor and Kevin C. Chung
KEY POINTS
Plastic surgery is a diverse surgical specialty guided by a
set of fundamental principles.
Understand the patient’s goals and set expectations
before surgery.
Optimize modifiable patient factors when possible.
Understand and correct the etiology of a problem before
offering surgery.
Plan the surgery preoperatively and have a backup plan.
Be intentional and precise with intraoperative maneuvers.
Plastic surgery is a unique and exciting specialty that defies
definition and is often misunderstood. Unlike other surgical
specialties, plastic surgery has no organ system of its own—it is
based on principles, rather than specific procedures, which enables
surgeons to solve diverse and unusual problems. What is plastic
surgery? In theory, it restores form and function throughout the
human body. The term plastic is derived from the Greek word
plastike, which means to shape or mold.
In practice, it is difficult to describe a specialty whose “turf” was
acquired through a combination of tradition and innovation. Plastic
surgery encompasses reconstructive and esthetic surgery from head
to toe on patients of all ages. Plastic surgeons are known as the
“problem-solvers,” the “surgeon’s surgeons,” and the “finishers.”
Plastic surgery is surgery of the skin and its contents.
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Plastic surgeons rely on an intimate knowledge of anatomy and
understanding of fundamental principles to guide their practice.
Ambroise Paré was the first person to describe a set of five
reconstructive surgical principles in 1564.1 Sir Harold Gillies and D.
Ralph Millard, Jr, published The Principles and Art of Plastic Surgery
in 1950 (Table 1.1).2 Years later, Millard expanded on this to define
33 fundamental tenets in the Principlization of Plastic Surgery,
published in 1986.1 Most of their concepts remain true today.
TABLE 1.1. PRINCIPLES OF PLASTIC SURGERY BY PARÉ
AND MILLARD/GILLES
Paré (1564)
1. Take away what is superfluous.
2. Restore to their places things which are displaced.
3. Separate tissues which are joined together.
4. Join those tissues which are separate.
5. Supply the defects of nature.
Gillies/Millard (1950)
1. Thou shalt make a plan.
2. Thou shalt have a style.
3. Honor that which is normal and return it to normal position.
4. Thou shalt not throw away a living thing.
5. Thou shalt not bear false witness against thy defect.
6. Thou shalt treat thy primary defect before worrying about the
second one.
7. Thou shalt provide thyself with a lifeboat.
8. Thou shalt not do today what thou canst put off until tomorrow.
9. Thou shalt not have a routine.
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10. Thou shalt not cover thy neighbor’s plastic unit, handmaidens,
forehead flaps, Thiersch grafts, ox cartilage nor anything that
is thy neighbor’s.
From Millard DR Jr. Plastic peregrinations. Plast Reconstr Surg (1946). 1950;5:26-
53.
This chapter reviews and updates the fundamental principles of
modern plastic surgery. The remaining chapters in section one
provide additional information on key concepts in our specialty,
including wound healing, scar management, and flap design. Parts
two through nine offer detailed information on the many
subspecialties in our field, including craniofacial surgery, head and
neck reconstruction, esthetic surgery, breast surgery, body
contouring, hand surgery, and lower extremity reconstruction.
GENERAL PRINCIPLES
Understand the Patient’s Goals
Listen carefully to patients and address their needs. Do not make
assumptions. Ask, “What can I help you with?” or “What would make
you happy?” The existence of a deformity is not an indication for
surgery—patients can adapt. Surgical plans must be tailored to each
individual patient. Be honest about the limitations of surgery and
anticipated outcome. Ensure that your operative goals align with the
patient’s goals.
Set Expectations
Discuss the rehabilitation process, timeline for recovery, and
expected outcome before surgery. What is obvious to the surgeon
may not be apparent to the patient. Repeat yourself often. See the
patient multiple times preoperatively to ensure that the expectations
are realistic. If therapy or other treatment is required postoperatively,
arrange for a consultation before surgery.
The goal of surgery is to improve function and appearance.
Function will never be “normal” after surgery. Asymmetry and scars
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will persist. Advise the patient that you cannot guarantee a result and
that revision surgeries may be necessary to achieve the desired
outcome. Honesty is the best policy, and when in doubt, under
promise and over deliver.
Take a Comprehensive History
Some patients may not be surgical candidates or may be better
served with nonoperative management. Be a physician first and a
surgeon second. Understand a patient’s overall health before
offering surgery. The following information must be obtained:
Overall physical and mental health
Life expectancy
Associated medical problems
Previous hospitalizations and surgeries
Medications and allergies to medications
Diet and recent weight changes
Tobacco, alcohol, and recreational drug use
Level of independence, mobility, and ability to comprehend
and cooperate with care
Place of residence
Underlying social and financial support structure
Presence of specific cultural, religious, or ethnic issues
Presence of advanced directives, power of attorney, or
specific preferences regarding care
Optimize Modifiable Patient Factors
Many plastic surgery procedures are elective, which gives us an
opportunity to maximize our chance of success. Identify and manage
modifiable patient risk factors preoperatively. Ensure complete
smoking cessation, manage medical comorbidities, optimize
nutrition, treat infections, and stabilize mental health issues before
surgery. Do not operate until a patient is optimized for healing and all
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social factors have been corrected. There are only so many spare
parts.
Know When to Say “no”
Put patient safety first. Let your training and experience guide you;
do not give into persuasive or manipulative patients. Hesitancy
before surgery is usually a subconscious warning sign of things to
come. When in doubt, do not operate.
Understand the Etiology of a Problem Before
Embarking on Reconstruction
Identify and correct the cause of a problem before proceeding with
surgery. Flaps do not treat infection or conquer the root cause of
wounds. Soft-tissue reconstructions cannot overcome deforming
joint forces. Esthetic surgeries do not treat mental health issues.
Failure to consider underlying issues will result in surgical failure and
recurrence of the problem.
Choose the Best and Most Predictable Surgical
Solution
The concept of the reconstructive ladder was introduced by Mathes
and Nahai in 19823 (Figure 1.1). Higher rungs on the ladder
correspond to more complex solutions. Apply the simplest option that
meets the reconstructive needs—this ensures that a “lifeboat” is
available if the procedure fails. In some situations, a complex
solution is the best surgical option, and in these cases, skipping to a
higher rung is appropriate and encouraged.
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FIGURE 1.1 Reconstructive ladder demonstrating the
concept of planning from simple to complex.
Minimize Donor Site Morbidity
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It is not possible to take something for nothing—a price is always
paid. When donor tissues are required, choose a site with the least
functional and esthetic sacrifice. The donor site is an additional
anatomic area where complications may arise. Weigh the downsides
of tissue harvest against the potential reconstructive benefit. Discuss
any potential donor site morbidity with the patient preoperatively.
Replace Like With Like
Defects should be reconstructed with tissue of the same quality to
optimize functional and esthetic outcomes. Large bony defects are
best reconstructed with autologous bone flaps. When primary
closure is not possible, skin defects are best reconstructed with local
flaps or skin grafts from nearby donor sites—this provides tissue that
is similar in color, thickness, pliability, and elasticity.
If no suitable donor site exists, innovative strategies are used to
create tissue. Distraction osteogenesis is used to lengthen, mold,
and shape bones in craniofacial and extremity surgery. Tissue
expansion is widely used to create additional local tissue through
biological and mechanical creep. Expanders are used to replace
hair-bearing skin for scalp defects, abdominal wall tissue for hernia
reconstruction, and breast skin after mastectomy.
Plan the Procedure Preoperatively
Plan carefully and precisely before surgery. Although some decisions
must be made intraoperatively, there are few indications for
“exploratory” procedures in plastic surgery. Complete all necessary
workup (imaging, biopsies, etc.) before surgery so there are no
surprises intraoperatively. Anticipate possible intraoperative findings
and have a plan (and a backup plan) for each scenario. Discuss the
plan with the surgical team to ensure that all necessary supplies,
instruments, and implants are readily available. Attention to detail
and careful preoperative planning promotes efficiency and improves
patient safety.
Think Ahead
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Consider a patient’s future treatment needs when choosing a
reconstruction and keep the long-term goal in mind. For cancer
patients, select a reconstruction that is durable and will withstand
radiation. For pressure sore patients, use a flap that can be
readvanced. If hardware removal is expected, choose a flap that can
be re-elevated easily. A carefully considered reconstructive plan can
have an excellent, long-lasting outcome.
INTRAOPERATIVE PRINCIPLES
Plastic surgeons take pride in their technical finesse. Be intentional
and precise with all moves and pay attention to the details. The
following section outlines technical principles that apply to all plastic
surgery procedures.
Incise Precisely
Hold the scalpel like a pencil and steady the ulnar aspect of your
hand on the patient. Stretch the skin and incise with the blade at 90°
to the patient. Incise through the epidermis and dermis in one,
controlled cut. Precisely incising the skin minimizes tissue trauma;
avoids step-offs; prevents the need to connect multiple, short,
hesitation cuts; and sets you up for success when closing the
wound.
Respect the Soft Tissue
Always be mindful how you handle soft tissue. Do not crush, stretch,
or tear tissue. Retract gently with skin hooks, sutures, or a carefully
placed self-retaining instrument. Avoid pinching tightly with forceps.
Dissect sharply with a scalpel, and use scissors sparingly to
separate vital structures. Tearing tissue using forceful spreading of
the scissors induces copious edema that results in scar. Find (and
stay in) a safe plane and dissect from known to unknown. Preserve
subcutaneous veins and nerves to reduce edema and prevent
neuromas. Minimizing tissue trauma reduces postoperative pain,
preserves vascularity, and optimizes healing.
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