Plastic surgery

Skin grafting is one of the most well-known procedures in plastic surgery. In this procedure, bits of skin are taken from one part of the body and used to cover a damaged area in another part. The area from which the skin is taken is called the donor area. Skin grafting is usually performed to treat skin wounds, like those created due to burns, injuries, or cancer. It can also be done to treat pressure sores and diabetic ulcers.

The graft can be of one of the following types:

• Autograft: This refers to a graft taken from one part of the person’s body to mend another part.
• Isograft: Graft taken from a genetically identical person such as an identical twin.
• Allograft: Graft taken from another person who may not be genetically identical to the patient. This type of graft is considered as a temporary treatment of individuals with severe burns. However, allografts are often rejected by the immune system.
• Xenograft: This type of graft is taken from an organism belonging to another species, usually pig but also cattle or horse, sometimes fish. These grafts are also temporary like the allograft and give the skin underneath some time to heal.
• Synthetic graft: A number of synthetic substitutes are now available to be used as grafts. They allow better control of the properties of the graft. However, their structure usually does not resemble a person’s skin. Synthetic grafts are more commonly employed as dressings in burn wounds.

Skin grafting is of the following three types, depending on what all parts of the skin the graft includes:

• Full-thickness skin graft: This graft contains both the epidermis (the top layer of skin) and the dermis (the layer of skin right below the epidermis). This type of graft is the best and leaves almost no scars. It is used to mend smaller areas (less than 1 cm) that do not have blood vessels and large areas with deep-set wounds with blood vessels in them.
• Split thickness skin graft: This type of graft contains the epidermis and only the upper part of the dermis. The graft is often of a different colour than the surrounding skin, is susceptible to trauma and is also associated with contracture (shortening of a muscle of a joint). Split thickness skin grafts are used to mend large areas without blood supply where a full-thickness graft won’t be effective. Most commonly, split-thickness grafts are used to treat areas near the skin surface like burns.
• Composite grafts: Composite grafts contain skin along with other tissues—cartilage and fat, for example. This type of graft is most commonly used in the nose or ear where a cartilage graft is also needed.

Contraindications of skin grafting

Skin grafting is generally not indicated in infections and where there is controlled bleeding.

The procedure is done with caution in smokers, malnourished people, those with bleeding disorders and people on anticoagulant medications.

Risks of skin grafting

The following are some of the most common risks associated with skin grafting:

• Infection of the site
• Discolouration of the area 
• Numbness or pain in the area
• Scar formation
• Hematoma
• Slow healing

Graft failure

Graft failure is one of the most common risks of a skin grafting procedure. The graft is very loosely attached to the underlying skin, hence any movement of the limb or the area may cause the graft to dislodge. A graft may also fail due to conditions like hematoma, seroma (fluid build-up under the skin), infection, blood vessels not growing into it, or a technical error.

If a graft starts to look white or black a week or two after the procedure, it means graft failure has occurred in the upper layer only. In such cases, only the affected part is removed. However, if the whole graft gets rejected, the surgery has to be redone.

Graft rejection

Graft rejection occurs in cases of an allograft or a xenograft usually. This is because the tissues for these grafts are taken from another person or animal. The person’s immune system sees the graft as foreign and potentially harmful and will hence make antibodies against the graft. This leads to the rejection of the graft.

Tissue expansion is a process by which surgeons create the conditions for your body to grow extra skin—this skin is transplanted to the affected area later. The procedure uses one of the most basic properties of skin, to stretch under pressure. For this, the surgeon puts a small tissue expander under the skin near the damaged tissue. The expander has a pouch that the doctor will slowly fill with a saline solution to allow the patient’s skin to stretch. A tube connected to the pouch is used to fill it up. 

Tissue expanders are usually constructed to fit perfectly over the area and fill up to various volumes of the liquid. Most of the expanders can take up to 200 mL of saline. More than one expander is sometimes inserted if more skin is needed. The size of the expander is selected on the basis of the size of the wound, size of the donor site, and the possible increase in the size of the tissue. Some experts suggest that the size of the expander should be the same as that of the wound site. In this way, when the expander doubles the skin tissue, it can be used to cover the whole wound along with the donor area. Others suggest that the base of expander should be twice or thrice the size of the wound. 

Breast reconstruction is the most common type of tissue expansion surgery. This procedure is also used to treat extensive burns. Tissue expansion is difficult and is hence not generally recommended in thicker-skinned areas like the back or torso. The patient would have temporary disfigurement of the part of their body that the expander is applied to. 

Once the surgeon thinks that the patient's skin has expanded enough, he/she will stop adding more saline to it and will let it sit for up to 14 days so that the skin can stay stretched. After this, the expanded area will be taken off and the grown skin pulled over the damaged area to replace the affected skin. In the case of breast reconstruction, breast implants are put under the expanded skin.

Risks and complications of tissue expansion

Tissue expansion has been associated with some of the following risks and possible complications:

• Minor risks: These include hematoma, inadequate tissue expansion, seroma, 
• Major risks: These include:
  • Deflation of the balloon: This was more common in the previous generation of expanders where instead of a tube to fill in the saline, the port for expansion was located right over the expander. Deflation occurred due to needle injuries while putting in the saline. In modern expanders, deflation may occur if the injector port somehow gets detached from the main expander and causes leakage of saline.
  • Necrosis (death) of the skin above the balloon: Death of the expanding tissue may occur when the expander is put under fragile or thin skin. To avoid this, surgeons usually consider tissue expansion, pain and blanching of the skin as endpoints for expansion.
  • Cellulitis or infection: This could be from the port, an abscess in the skin or folliculitis. An infection can cause the skin to harden. This may, in turn, make it difficult for the skin to expand. Exposure of the balloon may occur when the skin over the expander is thin or not strong enough, if the incision (through which the expander was inserted) tears or if somehow the skin over the implant gets eroded.
  • Nerve dysfunction: This occurs when the expander is placed near a big nerve in the body. It manifests in the form of motor (movement) issues, numbness or sensory problems associated with the said nerve. However, if recognised on time, the problem can be resolved quickly. 
  • Bone resorption: This occurs more commonly in the elderly and children and when the expander balloon is placed on the scalp. The bone under the balloon starts to get resorbed and new bone formation occurs around the balloon. However, all of this is usually temporary and heals itself within three to six months after the balloon is removed. 

Flap surgery involves cutting off a flap of skin from one area and replanting it in another area of the body that has lost muscle, fat and/or skin. The flap has its own blood supply, which is what makes it different from a skin graft which usually does not have its own blood vessels. So, unlike the skin grafts that need to regain blood vessel connections from the underlying skin to survive, a flap can survive on its own blood supply.

Flap surgeries can be of various types, depending on where the flap is taken from and what all the flap includes. Here are some of the types of flaps:

• Local flap: In this type of flap, tissue from an area near the damage site is moved to cover the affected area. The flap stays connected at its base to the blood vessels of the body throughout the procedure. Local flaps are more commonly used on face lesions. A local flap can be of the following types:
  • Rotational flap: This flap just needs to be rotated around a point to be put over an adjacent damaged area.
  • Advancement flap: This flap is used to cover a site slightly forward from the donor site.
  • Transposition flap: This flap moves sideways from the donor site. 
  • Interpolation flap: The flap moves around a pivot point to be placed on a nearby site which is not really adjacent to the donor site.
• Regional flap: The flap is obtained from an area very close to the damaged area, for example, a forehead flap for a problem on the nose. 
• Distant flaps: The flap is obtained from an area far away from the damaged area. Distant flaps may include: 
  • Microvascular free flap: The flap is cut from a far off area to the damage site and then blood vessels are reattached to the flap through microsurgery.
  • Pedicled flap: The flap remains connected to its blood supply and is just twisted so that it covers the damaged area. For example, taking a flap from the abdomen or back for breast reconstruction.
• Muscle or mucocutaneous flaps: These flaps include both muscles and skin. The most common type of muscle flaps are those used in breast augmentation.
• Bone and soft tissue flap: This type of flap is used when a bone along with the soft tissue needs to be re-planted to another site. 

Risks and complications of flap surgery

Flap surgery, like every procedure, has its own set of risks and complications. Flap loss is one of the most common risks in free flap surgery. As long as the flap has adequate blood flow, it will survive. However, any signs of ischemia (lack of blood supply and hence oxygen) may damage the flap.

Other risks include that of infection and slow wound healing. 

Laser plastic surgery is a cosmetic procedure that is mostly used for the treatment of wrinkles, pigmented and uneven skin, scars, sun spots, acne and vascular issues of the skin. Laser treatment can also be used to remove skin tattoos.

Read more: Causes and home remedies for wrinkles on the face 

Various types of lasers, with varying wavelengths, are used in this kind of plastic surgery. According to an article published in Seminars in Plastic Surgery, the five types of dermatological lasers include: 

• Ablative: Lasers that remove the upper layer of the skin and promote collagen formation in the inner layers so it can heal and regenerate. Collagen is a protein that is responsible for the structural integrity of the skin. This type of laser surgery is good for removing wrinkles. Carbon dioxide lasers are a type of ablative laser.
• Non-ablative: These lasers do not really harm the upper layer of the skin, instead they generate heat that can prompt the skin to form collagen and start to tighten. Non-ablative lasers are used for wrinkle removal as well as for the removal of minor scars and brown spots. 
• Fractionated lasers: These types of lasers break down laser energy into microbeams to spread them evenly on the surface of the skin. These lasers can be ablative or non-ablative.
• Unfractional lasers: These lasers use all of the laser energy in one area instead of breaking it. 
• Radiofrequency systems: These are not really lasers—they are heating systems, more like microwaves. Radiofrequency systems are non-ablative, have a deeper penetration capacity than other lasers and use a comparatively low temperature. These systems function similar to laser therapy by stimulating the production of new collagen and tightening the skin.

Risks of laser surgery

Laser surgery has some of the following risks:

• Reactivation of herpes
• Discolouration of the skin such as skin darkening or lightening
• Scarring may happen in some patients who have had radiotherapy in the area before.
• Itching or redness in the area
• Infection

Experts suggest that ablative laser surgery has more side effects than the non-ablative one, especially in those with darker skin. On the other hand, non-ablative surgeries show results slowly.

Endoscopic surgery involves the use of a small tube-like instrument with an attached camera (endoscope) that is put into the skin through tiny incisions. The surgeon uses the camera to see the images of the inner tissues on a screen to conduct a procedure. Although endoscopy has been used for various purposes for a long time, it is relatively new in the field of plastic surgery. 

Endoscopic surgery is used for various purposes including a deep facelift and a forehead lift. It is also employed in breast augmentation and abdominoplasty (tummy tuck). 

Additionally, muscle flaps can be picked up and replaced with the use of an endoscope without needing a big incision on the skin. 

One of the benefits of endoscopic surgery is that it does not leave big scars. More often than not, the scars are hidden. It is also easier to manage the pain and swelling associated with the surgery site. 

Risks of endoscopic surgery

Endoscopic surgery has some of the same risks as other types of plastic surgery which involve infection, hematoma, seroma (fluid build-up), damage to the nerves or blood vessels in the area or an injury in the surrounding skin.