国外切口缝合

Editorial More Caveats for Plastic Surgeons Donald A. Hudson, F.R.C.S. Cape Town, South Africa Plastic surgery is a rapidly growing and evolv- ing specialty. Newer techniques are described, newer flaps are performed, and variations of ex- isting techniques are applied. This rapidly evolv- ing surgical specialty also allows for originality. It is imperative that, as the discipline evolves, principles and caveats are established. These are necessary to minimize complications and yield satisfactory results. These principles also serve as building blocks for those beginning their careers in plastic surgery. 10 CAVEATS Caveat 1: When Marking a Proposed Incision, Never Draw a Straight Line Unless it Lies in the Relaxed Skin Tension Lines All plastic surgery operations are pre- planned. Usually this means marking the skin before making the incisions. A major factor affecting the quality of the scar is the direction of the incision. It is a plastic surgery caveat that, where possible, the incision should be placed in a relaxed skin tension line. This is not always possible, however, in which case, the incision should assume a sinusoid or wavy pattern or a series of Z-plasties should be used. It must also be remembered that all scars contract. This may have aesthetic (and func- tional) consequences on a convex surface, for example. A wavy scar, when it contracts, has less effect on the surrounding tissue than a linear scar. It seems strange in retrospect that the bicoronal incision was performed as a straight line for decades. Only relatively re- cently has it been recognized that this would not yield the best possible scar.1 Caveat 2: Caveats to Consider When Using Prosthetic Tissue It is a recognized principle that autologous tissue should always be used in preference to prosthetic materials. However, the former in- volves donor-site morbidity and the latter are becoming more biocompatible. If prosthetic tissue is used, the following ca- veats apply, whether the substance is simply injected (e.g., for lip augmentation) or in- serted in a formal operation: 1. The incision for insertion should be distant to the site of placement. 2. Two-layer closure of the pocket is required. 3. The soft-tissue cover should have good vas- cularity. For example, prosthetic material should not be used where there is poor vascularity, such as after radiation therapy. 4. The pocket for the prosthetic material must be big enough to allow it to “sit” with ease. There should be no tension on the pros- thetic material or extrusion will occur. 5. The prosthetic material, particularly when solid, needs to be fixed to prevent migra- tion. Fixation can be with sutures, wires, or screws. The greater the degree of fixation, the less likely migration is to occur. 6. Prosthetic material that cannot be easily re- moved should not be inserted. 7. Prophylactic antibiotics should always be given. Caveat 3: Learn to Classify and Work from the Classification Classification is important in working out a plan of management. A breast with mild ptosis is managed differently than one with severe ptosis, for example. Similarly, it is also important to Received for publication December 31, 2003; revised February 11, 2004. DOI: 10.1097/01.PRS.0000128349.08220.24 584 assess one’s results critically. The classification system should always be as simple but as compre- hensive as possible. Often in plastic surgery, sur- geons tend to be so impressed with their results that critical assessment is not undertaken. Caveat 4: The Ability to Think, Analyze, and Understand Is a Surgeon’s Greatest Asset The surgeon’s greatest faculty is not the dex- terity of his hands but rather the aptitude and function of his cerebral cortex. Most surgeons who are committed to their profession, with experience and proper teaching, become tech- nically able and adequate. Of course there will always be the “gifted,” but these are few and far between. It is vital that the surgeon be able to analyze and think critically. The specialty has grown so rapidly that we are consumed with learning how to perform a technique rather than un- derstanding the mechanics of that technique. The technique of breast reduction serves as an example. The surface markings and technique are often so intricate that the mechanics of how reduction is actually achieved are lost. It is also important to assess one’s own work critically. For example, why did ectropion oc- cur after blepharoplasty when excessive skin was not excised? One must also understand how a new technique achieves its effects before embarking on the technique. Caveat 5: Choose a Safe Technique in Cosmetic Surgery There are now a myriad of surgical techniques for every cosmetic problem, and choosing a tech- nique can be difficult. There are many tech- niques for rhytidectomy, for example, including subcutaneous dissection, superficial musculoapo- neurotic system plication, or undermining and suturing, and deep plane, subperiosteal, mini, or endoscopic methods, to name but a few. How does one choose the “best” technique? Further- more, as time progresses, newer and purportedly better techniques will be published. The authors of these articles will usually claim that their tech- nique is the best available. It is very difficult to justify a major complica- tion occurring for a purely cosmetic indication. Thus, before embarking on a new rhytidectomy technique, for example, in which the facial nerve is more at risk, one must ensure that the (poten- tial) result is so much better that it is worth the risk. Liposuction combined with abdominoplasty may enhance the cosmetic result, but it is also fraught with complications. Choose a safe proce- dure that yields a satisfactory result rather than a potentially “spectacular” procedure with horrific complications. In almost anyone, carefully planned aesthetic surgery should lead to some improvement in appearance. Caveat 6: There are Complications in Cosmetic Surgery If you develop a complication, particularly in cosmetic surgery, wear the patient out (not vice versa). We all have complications. Some occur de- spite what we do, others occur because of us. Complications embarrass us and we tend to want to wash our hands of them—and the pa- tient. This is a medicolegal time bomb. It is better to see the patient whenever he or she requests and to always be supportive and help- ful. In fact, arrange to see the patient in your office so often that you wear the patient out! This is one very good way to prevent the stress and heartache of a legal proceeding. Also bear in mind that the patient, not the surgeon, is “suffering” the complication. Caveat 7: A Triangle is a Plastic Surgeon’s Best Friend In this specialty, we frequently work with “lines” or tissues of different lengths. A good way to attain equal length in this situation is to add or excise a triangle of tissue. This principle has been applied in cleft lip repair,2 where one side of the lip is larger than the other side. A Z-plasty is an example of two triangles that are transposed. A triangle interposed into a straight line breaks up the long scar and inhibits scar retrac- tion.3 It may also confer aesthetic advantages. Caveat 8: There Are Other Ways to Deal with Lines of Unequal Length Often in plastic surgery an ellipse is de- signed, but because of the configuration of the lesion, the limbs of the ellipse have different lengths. A triangle of tissue (as described above) is one solution, but there are occasions where this is not desirable. If the discrepancy between the limbs is not too big, differential suturing (“stealing stitches”) is all that is required. When there is a greater discrep- ancy in length, in principle, one line can be made longer or the other can be made shorter, or both methods can be used (Fig. 1). Remember, dog-ears commonly arise from two situations: the angle of the ellipse is too obtuse, or the length discrepancy between the two limbs is too great to allow for a “stealing” stitch. Vol. 114, No. 2 / EDITORIAL 585 Caveat 9: In Plastic Surgery, Always Think Blood Supply Almost all plastic surgical procedures involve a flap of some sort. It is critical in any proce- dure to be fully aware of the blood supply of a flap. Flap failure occurs for the following rea- sons: poor design, hematoma, and infection. The most common factor in poor design is excessive tension, which leads to ischemia and subsequently necrosis (blood supply is im- paired). Hematoma also causes tension to the flap, leading to ischemia and infarction (indi- rect injury to blood supply). In infection, the inflammatory process leads to vessel infarction and hence flap necrosis (loss of blood supply). Flap failure serves to emphasize the impor- tance of always considering blood supply. In abdominoplasty, for example, the upper ab- dominal flap is depleted of its usual main blood supply from the perforators of the supe- rior epigastric systems. The flap now relies on perforators from the lateral intercostal vessels. This is the reason why a “minor” insult to the blood supply (caused by liposuction or tension on the flap) is hazardous. Caveat 10: Put Function before Form and Form before Scarring I claim no originality in this regard. This caveat has apparently been known for decades, yet I have not seen it highlighted in any plastic surgery textbooks. It is a crucial caveat, partic- ularly in reconstruction, and it has particular relevance to reconstruction after major burn injuries and severe and extensive trauma. THE HAND: TWO IMPORTANT CAVEATS Because plastic surgeons are also involved in hand surgery, two important caveats deserve to be emphasized. First, flexion is more important than exten- sion. It has been said that finger extension is a cosmetic action. Most of the activities of daily living, for example, holding a cup or a pen and buttoning clothing, involve flexion. Hence, in principle, it is our policy in the surgical treat- ment for Dupuytren’s disease, for example, to splint the hand in extension after release of a contracture. However, at the 1-week postoper- ative visit, physiotherapy is arranged to ensure that full finger flexion is achieved before finger extension is tended to. Second, one pump of the hand is worth 24 hours of elevation. This caveat is to stress that “active” works better than “passive.” When the patient makes a fist, not only is edematous fluid mobilized but also the joints of the hand are mobilized, thereby inhibiting periarticular fi- brosis and the potential for stiff joints. Prof. Don A. Hudson, F.R.C.S. Department of Plastic Reconstructive Surgery Groote Schuur Hospital H53 OMB Observatory 7925 Cape Town, South Africa hudsond@uctgsh1.uct.ac.za REFERENCES 1. Munro, I. R., and Fearon, J. A. The coronal incision revisited. Plast. Reconstr. Surg. 93: 185, 1994. 2. Randall, P. A. Triangular flap operation for the primary repair of unilateral clefts of the lip. Plast. Reconstr. Surg. 23: 331, 1959. 3. Hudson, D. A. Maximising the use of tissue expanded flaps. Br. J. Plast. Surg. 56: 784, 2003. FIG. 1. (Above) Line ab is longer than line cd. (Center) The surgeon can make line ab shorter (original line ab is shown as a dashed line). (Below) The surgeon can make line ab shorter and line cd longer by lowering the apex point db. 586 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004