Plastic and Reconstructive Surgery SKIN COVER

Modern surgery is so vast a subject that no man can master it in all its branches. For this reason it has been necessary from time to time to separate, from general surgery, special branches which demanded special training, and better facilities for their full development. After a number of years’ experience in plastic surgery I feel that the time has come for the separation of this branch from the general surgical tree. The object of this paper is to advocate the special development and teaching of plastic and reconstructive surgery by those interested in it and trained for it. I have heard many busy general surgeons say, “I do not like to do plastic cases, as they take too much time and require so much attention.” These men will welcome the advent of the surgeon who is willing to devote his time to plastic work. By plastic and reconstructive surgery I mean that branch of surgery which is distinctly formative or reparative. It deals with the repair of defects and malformations, either congenital or acquired, and with the restoration of function and improvement of appearance.... The healing of large denuded surfaces, and of intractable wounds, should also come under the care of the plastic surgeon. The field of plastic surgery is a broad one; the cases are numerous, and of varied types. Orthopedic and plastic surgery approach each other quite closely in certain cases, but my experience has been that the orthopedic surgeon is glad to turn the plastic cases over to the plastic surgeon, and vice versa. There is no single group of surgical cases which are more consistently “botched” than those requiring plastic and reconstructive surgery. Plastic surgery is done by nearly every general surgeon in his routine work, and is often attempted by eye, ear, nose and throat specialists, and by those physicians who “operate only occasionally.” I do not believe that it should be done as a routine by any one of these groups of operators. It is well known that if any surgeon is interested in a special line of work, and gives his attention to it, he will in time be able to do this work better than the one who operates in these cases only occasionally. It is imperative that the surgeon who expects to do plastic and reconstructive work should have a thorough general surgical training before attempting to specialize in this branch. Above all he must know, and thoroughly appreciate, the principles covered in the healing of tissues, and in the repair of wounds. A special knowledge of the resistance and utility of tissues more or less infiltrated with scar tissue is also necessary, as in many instances normal tissue is unavailable. A knowledge of the surgical handling of children is very important.... The purpose of surgical intervention in any branch of surgery should always be the cure of the patient. The primary consideration, first, last and all the time, must be the patient. This fact is sometimes lost sight of in the desire to operate. If a patient with a certain type of lesion requiring surgical treatment comes to a surgeon who has not had special experience in the operative treatment of that particular trouble, it is the duty of that surgeon to refer the patient to some colleague who is known to be skilled in that treatment. This may not be “good business,” but it is certainly for the best interest of the patient, and furthers true efficiency.... The plastic surgeon, with his special knowledge of tissue transplantation, can be of great use to the general surgeon and to the orthopedic surgeon in repairing the defects left by certain necessarily mutilating operations. This also applies to the gynecologist and genitourinary surgeons, when called on to perform more extensive transplantations than these surgeons are accustomed to undertake. The aim of the plastic surgeon is the relief of pain and deformity, the restoration of function, and, last but not least, of the ability to earn a living. One occasionally hears the term “beauty doctor” applied to those doing plastic surgery. Although this term may have some foundation, as a matter of fact a very small part of legitimate plastic surgery is done for cosmetic reasons only.... ...Is the field of plastic surgery large enough and interesting enough to justify a surgeon in specializing in it? For myself I can answer unqualifiedly that it is. Furthermore, I believe that it is only a matter of time, and that the time is rapidly approaching when there will be created in every large surgical clinic a department of plastic and reconstructive surgery, under men especially fitted and trained for this work. Which clinic will be the pioneer in putting this important branch of surgery on an efficient and progressive basis?

change. If a large area of skin loss needs to be covered the partial thickness graft can be meshed using a machine that permits an expansion in the graft rather like a string vest. Skin grafts can be stored in a domestic fridge if kept moist and used up to three weeks later.
The survival ofa skin graft depends on the recipient site being sufficiently 4X <>; 0 vascular to support the metabolic needs of the graft and free from gross infection. A successful "take" also requires immobilisation and the prevention of seromas and haematomas, which may lift the graft offthe vascular bed. Gross infection mobilises the fibrinolytic system and breaks down the fibrin adhesion between the graft and the recipient bed. Partial thickness grafts may be applied to a wound directly at the time of surgery and the immobilisation and prevention ofseroma obtained by the application of a bolus pressure dressing using proflavine wool or thick foam. Grafts may also be applied 24-28 hours after surgery and left exposed for frequent wound toilet and debridement without any tie-over dressing. The main disadvantages are the cosmetic mismatch between the graft and surrounding normal skin in colour, quality, and contour and the tendency ofthe wound to contract. So called pinch grafts are not favoured by plastic surgeons principally because of the appalling stippled donor site that is produced in harvesting these grafts.

Full thickness grafts
Full thickness (or Wolfe grafts) were first described by a Scottish -P touneuicr ophthalmic surgeon John Wolfe, who in 1875 successfully reconstructed a lower eyelid by removing a full thickness graft from the forearm.

I =Htiwi 't
In this procedure the whole of the epidermis and dermis is t t > 5 t ' s + l a a 4f -.' t e; transferred; sometimes it may include fat, hair, and sebaceous glands. The advantages ofsuch a graft are the improved cosmetic appearance, the V W t s ; w ; P '**!-;*'*;pt.;,v* xsmaller likelihood ofcontracture, and the possible transfer in certain cases ff X-'-'~ofhair. These grafts are often used for facial reconstruction and can be harvested from behind or in front of the ears, from the upper eyelids or from the supraclavicular region. Similarly, grafts for resurfacing the hand may be harvested from either the groin or the instep ofthe foot.
The disadvantages are that the donor site does not regenerate and therefore has to be primarily closed or itself grafted with a partial thickness skin graft, thus limiting the size of the graft. The recipient bed must possess good vasculature and permit adequate immobilisation; these grafts consequently are often applied using a tie-over bolus dressing.
Skin grafts are initially more susceptible to actinic damage and should therefore be protected for six months. Thin partial thickness skin grafts do not have sebaceous glands and therefore tend to be dry and benefit from the application oflanolin cream. After the initial stage of graft contracture there is a secondary phase of growth in the graft, which parallels the rate of growth of the rest of the body. Scars, however, do not follow this secondary phase, and in children additional surgical procedures may therefore be required where skin grafts have been previously applied, particularly on the hand during adolescence.
Composie graft from ear Skin flaps Skin and its subcutaneous tissue can be moved from one part ofthe body _______________________________ to another provided the vascular pedicle is maintained between it and the 4" -" 3; V ,bodyfor nourishment. Most local flaps are raised as random skin flaps and their design is dictated by experience. Their geometric design is only rough, and there are well defined limits to which the length ofa flap can be raised despite increasing its width, which limits the safe transfer ofskin. The skin in these flaps survives on blood vessels from the subdermal skin plexus, which provides a blood supply many times in excess ofthe metabolic requirements ofthe skin. This is because the skin has an important physiological role in Random pattrn skin flop regulating temperature. Once raised these flaps may be moved to an adjacent area ofskin loss by rotation or transposition. W A 4~~~~~~~~~~T he design ofa random flap obviously presents certain disadvantages in reconstruction. There are two ways of increasing the ratio oflength to U~~~~breadth. Firstly, a flap may be "delayed"; the flap is raised and transferred in more than one stage to insure its safety. At the first stage a longer flap than would normally survive is incised and partially raised. Ischaemia is thought to be a stimulus to increasing the blood supply to the dermis, possibly by an effect on the capillaries, the delay preventing the shunting ofblood away from the dermis. At seven to 10 days a second delay or final raising and transfer of the flap is undertaken. Delaying the skin flap permits roughly a 60-100% increase in survival offlap length. At present despite recent reports flaps cannot be manipulated pharmacologically and the exact physiological basis ofdelay is not fully understood.
Secondly, much larger random flaps may be raised by joining two random flaps together, forming a bridge of skin that can be tubed with two pedicles, one at each end. The tube pedicle was introduced in 1916 simultaneously by Sir Harold Gilles in England and Vladimir Filatov, an ophthalmic surgeon, in Russia. At subsequent stages the flap can be divided at one end and inset on to the wrist. At a later stage the other end can be divided, allowing the flap to be transported on the wrist and inset on a distant site on the body. It is, however, a multistage procedure and therefore susceptible to many complications.
ConslMt f~~~~~~~essel With the extended use ofthe previously described random flaps it became evident that on various areas of the body much longer flaps could be raised successfully without delay. McGregor and his colleagues studied such a flap in the groin and were able to raise a flap that was at least four times as long as its base. This was due to there being a constant anatomical blood vessel in the pedicle, in this case the superficial circumflex iliac artery and accompanying veins. It is now known that skin on the anterior chest wall may be raised as a long flap based on perforating branches from the internal mammary artery-the deltopectoral flap. Similarly, the forehead flap, which may be used to resurface areas ofthe face and oral cavity, is based on the anterior branch ofthe superficial temporal artery.

MUSCLE AND MYOCUTANEOUS FLAPS
Having established the anatomical basis ofaxial patterned flaps, plastic surgeons searched around the body for similar flaps. It became apparent that large areas of skin were not supplied on an axial basis but were supplied by perforating vessels coming through from underlying muscles. Muscles usually receive their blood supply via a pedicle at one end, and the other end ofthe muscle may therefore be detached and the muscle isolated on its pedicle with or without the overlying skin. This paddle ofmuscle can then be rotated through an arc, usually of 360 degrees. Ifmuscle is moved alone skin grafts can be applied to its surface. On the other hand, muscles are often moved with the overlying skin as a myocutaneous flap. The commonly used myocutaneous flaps are pectoralis major used in head and neck reconstruction, latissimus dorsi in breast reconstruction, gluteus maximus in closure ofsacral pressure sores, and grastrocnemius in reconstruction around the knee.

FASCIOCUTANEOUS FLAPS
More recently it has become evident that there are further areas ofskin that are supplied by blood vessels issuing between muscles and supplying a rich vascular plexus that lies just above the deep fascia. This in turn supplies the subdermal plexus ofthe skin and is the basis ofthe fasciocutaneous flap that, in certain areas ofthe body, permits long flaps to be raised for local transposition. Such flaps are important for supplying skin cover to the lower leg and can be raised on the medial or lateral aspects ofthe shin and transposed over the tibia. Similarly, flaps may be raised from the upper arm or lateral aspect ofthe thorax for skin cover ofthe axilla.

FREE FLAPS
Despite the wealth offlaps that have become available to us there are certain areas ofthe body that remain extremely difficult to cover, in particular the scalp and the lower leg when there is extensive injury. With the advent ofmicrosurgery, axial pattern flaps, surviving as they do on a single artery and accompanying vein, may be detached from their normal blood supply at the pedicle and the artery and vein anastomosed to a local undamaged artery and vein adjacent to the area ofskin loss; provided the anastomoses remain patent these flaps will survive. Muscle and myocutaneous flaps may be similarly transferred as may the more recently described compound flaps such as the deep circumflex iliac artery flap that supplies the skin ofthe groin, adjacent muscle, and the bone ofthe iliac crest. This can be moved as a compound flap and used particularly in jaw reconstruction and reconstruction of severe injuries ofthe tibia. Development offree flaps has permitted the transfer in one stage oftissue to a hostile environment where routine flaps would normally not survive because ofthe poor vasculature or because ofinfection. Such procedures, which are now becoming far more routine, although they undoubtedly take more operating time and require the surgical technique ofmicrosurgery, permit a safer and more sophisticated reconstruction than was formerly possible and a greatly reduced stay in hospital compared with the original tube pedicles, which could take at least six months to move into the position in which they were required and had a 50% failure rate.
Mr Dai Davies, FRCS, is consultant plastic surgeon, West London Plastic Surgery Centre, West Middlesex University Hospital, Isleworth, and consultant plastic surgeon and honorary senior lecturer, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS.

Needs and Opportunities in Rehabilitation
Rehabilitation after stroke-2: Language and memory training and the requirements of rehabilitation services DAPHNE GLOAG "On the one side of the city was an area marked 'thoughts.' On the other side of the city was an area marked 'speech.' Down the middle was an unscaleable brick wall." So wrote Lord Smith of Marlow of one type of aphasia, a "Berlin Wall" that he himself did eventually scale (Chest, Heart and Stroke Association's magazine Hope, Spring 1983).

Communication problems and speech therapy
Patients who have been without speech often say later how upset they were at being talked about as though they could not understand.' Few staff, even doctors, are trained to communicate with aphasic patients and Mulley lists the simple do's and don'ts that make such a difference-including talking to the patient and avoiding tests and questions that may diminish him.' He urges the referral of all patients with language problems to a speech therapist as soon as possible for a precise diagnosis; different forms of aphasia, which may include poor comprehension, will need different forms of management, and these in turn will differ from the approaches needed for dysarthria and speech dyspraxia-and many patients have more than one type of disturbance.' Besides providing a diagnosis and if possible some form of speech stimulation, the speech therapist is important for general counselling of patients and family, for teaching the use of some communication aid if appropriate (usually in cases of dysarthria), and for advising staff. The broad elements of speech therapy are discussed by Code and British Medical Journal, London WC1H 9JR DAPHNE GLOAG, MA, staff editor Muller2 and alternative methods of communication by Rowley.2 Publications and other materials for those giving therapy are produced by, for example, the Winslow Press, Buckingham, and Action for Dysphasic Adults (ADA).
Develop communication by any means, said a consultant running a rehabilitation centre: any form of communication makes a great difference to the family as well as the afflicted person. Even the sexual relationship is apparently vulnerable in the face of speech loss. ' Coping with Disability,3Help Yourselves,4 and pamphlets by the College of Speech Therapists, ADA, and the Chest, Heart, and Stroke Association are useful. Even if the patient never says a word again speech therapy may help to sort out the "muddle in the head," as this consultant put it. Language and communication generally, and not just speech, are the point. In this respect many studies of speech therapy may have too narrow a perspective.
Nevertheless, speech therapists are not plentiful and therapy as distinct from diagnosis and advice must be justified by hard evidence. Are there improvements that are not due simply to spontaneous recovery and are sufficient to justify all that goes into it? Do different forms of speech therapy have different degrees of success, and is therapy more than general stimulation and support -in other words, are speech therapists essential or can other people provide similar "treatment"? Finally, is timing crucial: should speech therapy coincide with the period of natural recovery (chiefly the first three months5) or take over where nature leaves off; and is it never too late for it to help, as individual cases would suggest? Theories of recovery, methods of treatment, and evaluation are discussed by Miller.6 Among more than 20 studies of speech therapy after stroke reviewed in 1979 most appeared to show benefit.7 Miller, however, reviewing the evidence (for aphasia of different types and causes), argues that there is no convincing evidence so far that speech therapy has a specific effect on aphasia.6 A recent trial suggested that