Plastic and reconstructive surgery basics

• Plastic and reconstructive surgery restores form and function after trauma, cancer, congenital differences and burns; it is defined by how you solve a problem, not by one organ or age group.
• The reconstructive ladder arranges closure options from simplest to most complex: primary closure, healing by secondary intention, delayed primary closure, skin graft, local flap, regional or distant flap, free flap; complexity rises as the defect demands.
• A graft survives only if it receives blood from the wound bed; a flap carries its own blood supply, so it is chosen when the bed is bare bone, tendon, nerve or irradiated tissue, or when function or cosmesis demands living tissue.
• Burn and skin-cancer defects are time-critical: in burns we excise and graft early, and in melanoma we set the excision margin by stage before planning any reconstruction.
• Every reconstruction is planned backwards from the defect, not forwards from a favourite operation: the patient's priorities, comorbidities, available donor tissue and the needed function decide the rung of the ladder.
• Written and visual agreement before the operation, and an honest discussion of scars, donor sites and secondary revisions, matter as much as the technical step.

By the end of this page you should be able to:

1. Explain the reconstructive ladder and choose a closure for a simple defect.
2. Distinguish split-thickness from full-thickness skin grafts, and list the conditions for graft take.
3. Describe the main flap types by blood supply and movement, and state when a free flap is needed.
4. Define hypertrophic scar and keloid, and outline prevention and treatment.
5. State the excision margins for melanoma by stage and for basal and squamous cell carcinoma by risk.
6. Outline the sequence, timing principles and team care for cleft lip and palate.
7. Compare the main options, timing and trade-offs of breast reconstruction after mastectomy.
8. Outline early excision and grafting, and late reconstruction, after major burns.

Plastic and reconstructive surgery is the discipline that restores appearance and function when tissue is lost, distorted or absent. It works on every body region and at every age, and most of its patients are not seeking cosmetic change: they have cancer, trauma, burns or congenital differences. The unifying idea is to plan each repair around the defect, the patient's priorities and the available donor tissue, and to move from the simplest adequate solution to the more complex only when the simpler one will not work.

This page is a basics topic, so it covers the principles that recur across procedures rather than any single operation in full. It is written for a first-time reader; regional guidelines and national service configurations differ, so check your local commissioning and multidisciplinary pathway.

There is no absolute organ system that excludes reconstruction, but some states push the decision towards a simpler option or delay. Heavy smoking and uncontrolled diabetes impair flap and graft survival; active infection requires the wound to be clean first; severe comorbidity or poor physiological reserve argues for the shortest operation that achieves a safe seal; and the patient's tolerance for donor-site scars and secondary procedures sets the ceiling of what is sensible. Consent must include the possibility of flap or graft loss, sensory change, donor-site morbidity and revision.

Reconstructive planning rests on knowing the defect in three dimensions: the size and depth of the loss, what lies in the bed (fat, fascia, muscle, bone, tendon, nerve, major vessels), the quality of the surrounding skin (scarred, irradiated, atrophic, oedematous) and the mobility of adjacent tissue. Equally important is the regional blood supply: random-pattern skin flaps depend on the dermal and subdermal plexus, axial flaps depend on a named artery and vein, and perforator flaps depend on a single perforating vessel emerging through muscle or septum. Donor-site anatomy (the anterior and lateral thigh for split-thickness grafts, the post-auricular, supraclavicular or groin skin for full-thickness grafts) determines both what can be taken and what scar is left.

Routine sets include fine dissecting instruments, skin graft knives or dermatomes, meshing devices, bipolar and monopolar diathermy, Loupe magnification of 2.5 to 4 times, and headlight. Flap work needs microsurgical instruments, a microscope for free transfer, a tourniquet for limb cases, and sometimes a handheld Doppler or indocyanine green angiography to mark perforators. Burns surgery needs escharotomy sets and large meshers. No specific device brand is mandated; follow local lists.

Photographs are taken before debridement and after. The patient is marked awake whenever position matters. Donor sites are discussed explicitly. Anticoagulation and antiplatelet decisions follow the joint oncology-plastics or trauma pathway; the ASPS evidence-based guideline on reconstruction after skin cancer resection addresses anticoagulation timing, antibiotics and analgesia as concepts rather than fixed rules. ^[4]

The ladder is a mental framework, not an order that must be climbed. The practical question is always "what is the simplest method that will reliably give a stable, functional, acceptable result?", and if that method is not enough, you move one rung up, not necessarily to the top.

Primary closure is preferred when the wound can be closed without tension and without distorting a free margin or special structure. Undermining, relaxing incisions and local advancement may make it possible. Healing by secondary intention is appropriate for small wounds in cosmetically unimportant areas, or where infection makes closure unsafe; it produces the widest and most unpredictable scar.

A skin graft is tissue completely detached from its blood supply and relying on nourishment from the wound bed: imbibition in the first 24 hours, revascularisation by about 48 to 72 hours, and inosculation. Graft take fails if there is infection, haematoma, shear, a poorly vascular bed (bare cortical bone, bare tendon without paratenon, thick (more than 10 cells) fibrin or necrosis) or poor patient physiology.

Split-thickness skin grafts (STSG) include the epidermis and a variable portion of the dermis. They are harvested with a dermatome, can cover very large areas, are meshed to expand and allow drainage, and survive on less vascular beds. Their disadvantages are contraction, poor colour match, lack of sensation, a shiny surface and a visible donor site. They are the workhorse for acute burns and large soft-tissue defects.

Full-thickness skin grafts (FTSG) include the epidermis and the whole dermis. They contract little, give the best colour and texture match and are used on the face, hand and flexures, but they need a well-vascularised bed and a donor site that can be closed primarily, which limits their size.

A flap is tissue transferred with its own blood supply. It is needed when the recipient bed cannot support a graft, when bulk or contour is missing, or when sensation or movement must be preserved. Flaps are described by blood supply (random pattern, axial, perforator), by tissue carried (fasciocutaneous, muscle, myocutaneous, osteocutaneous) and by method of movement or transfer (advancement, rotation, transposition, interpolation, microvascular free transfer).

Random-pattern flaps rely on the dermal and subdermal plexus. Their length is limited by perfusion (classically a length to width ratio of about 2 to 1 on the trunk, more generous on the face where vascular density is higher), and they are the type seen in most local repairs. Axial flaps include a named artery and vein along their long axis, so they can be longer and more reliable. Free flaps are completely detached and reconnected with microsurgery; they allow tissue to be moved from any donor site to any defect and are the routine answer for large post-oncological and post-traumatic defects of the head, neck, breast and lower limb.

The "reconstructive elevator" (or ladder turned sideways) is the idea that you should choose the best method for the defect rather than the simplest possible; in practice the ladder is the safer teaching frame for a student, and the choice between local and free flaps is set by defect size, site and the availability of microsurgical expertise.

Tissue expansion slowly stretches adjacent skin to create donor tissue for like-with-like repair, most often on the scalp, neck and trunk. Dermal regeneration templates give a vascularised dermal layer that can later accept a thin graft, widening the options in complex wounds, irradiated beds and burns. Modern adjuncts (negative-pressure wound therapy, hyperbaric oxygen) are used to prepare beds and stabilise grafts, but they do not replace sound flap design.

Grafts are dressed and immobilised for about five days, with the first wound check timed to avoid disturbing the early circulation. Flaps are monitored by colour, warmth, capillary refill, turgor and, for buried or free flaps, by Doppler or tissue oximetry; signs of venous congestion (blue, swollen, brisk capillary return) and arterial insufficiency (pale, cool, slow refill) are taught as an emergency recognition task. Donor sites are dressed as partial-thickness wounds. Physiotherapy, splintage and scar therapy (silicone, massage, pressure garments) start once healing is secure.

Universal complications are bleeding, infection, dehiscence, haematoma and seroma. Graft-specific: failure to take, contraction (especially in the hand, neck and flexures), pigment change, unstable epithelium and hypertrophic scarring. Flap-specific: partial or total necrosis, thrombosis of the pedicle, venous congestion, donor-site morbidity and the need for secondary thinning, debulking or refinement. Many problems are late and are solved in the revision phase, which is integral to reconstruction rather than a sign of failure.

A scar is the visible result of wound repair. Its appearance depends on the mechanism of injury, tension across the wound, the time taken to heal, infection, the patient's skin type and age, and site. Hypertrophic scars are raised, red and may itch or be tender, but stay within the original wound boundaries and often soften over 12 to 18 months. Keloids extend beyond the original wound, rarely regress, occur more often in darker skin types and at sites such as the earlobes, chest, shoulders and upper back, and have a tendency to recur after simple excision.

Prevention is more effective than treatment. Principles: close wounds without tension, evert edges, avoid infection, immobilise flexures and delay heavy exercise, and use pressure or silicone once the epithelium is intact. For treatment, silicone sheets or gel and pressure garments are first-line for raised scars; intralesional corticosteroid (triamcinolone) is the commonest first-line injection for keloids; 5-fluorouracil, cryotherapy and radiotherapy are used as adjuncts; and surgical revision is reserved for specific situations and is combined with a prophylactic measure such as steroid injection or pressure, because surgery alone has a high recurrence rate for keloids. ^{[5] [7]}

Skin cancer work is the commonest reconstructive caseload outside of burns. Excision margins are set by tumour type and risk; reconstruction is planned only after the oncological plan is fixed.

Melanoma. NICE guideline NG14 (published 29 July 2015, last updated 27 July 2022) recommends a clinical margin of at least 0.5 cm for stage 0 melanoma, 1 cm for stage I melanoma (or when a 2 cm margin would cause unacceptable disfigurement or morbidity), and 2 cm for stage II melanoma, measured around the biopsy scar and taking into account the original primary margin. ^[1] A review of surgical margin practice summarises UK practice as an initial excision with a small margin and further excision with a 1 to 2 cm margin for invasive melanoma. ^[2] Sentinel lymph node biopsy is considered from pT1b with high-risk features and from pT2a, and margins and nodal staging decisions are made in the multidisciplinary team.

Basal cell carcinoma (BCC). For low-risk BCC, excision with a 2 to 4 mm clinical margin (or curettage and cautery in selected low-risk lesions) is used; high-risk BCC needs a 5 to 10 mm margin or Mohs micrographic surgery, which examines 100% of the margin and is the gold standard for high-risk and cosmetically sensitive sites. ^[2]

Squamous cell carcinoma (SCC). Low-risk SCC is excised with a 4 to 6 mm margin; high-risk and very-high-risk disease needs multidisciplinary discussion and a 5 to 10 mm margin or Mohs surgery. ^[2] Perineural invasion, depth beyond 6 mm and immunosuppression all increase risk category. ^[2]

Reconstruction after oncological excision is commonly staged (excision first, await histology, then reconstruct) for high-risk lesions and Mohs defects, particularly on the face. ASPS evidence-based guidelines (skin cancer reconstruction revised 2021, reaffirmed 2026) frame the peri-operative concepts (timing, anticoagulation, antibiotics, pain control, follow-up) and BAPRAS publishes Mohs micrographic surgery UK surgical standards (December 2019) alongside oncology service guidance. ^{[3] [4]}

Cleft lip and palate (CLP) is the commonest congenital craniofacial difference and is managed by an interdisciplinary team from birth. It arises from failure of fusion of the medial nasal, maxillary and palatal shelves during embryonic development; the exact spectrum (unilateral or bilateral, complete or incomplete, isolated cleft palate) determines severity and functional impact. ACPA's Parameters of Care for Evaluation and Treatment of Individuals with Cleft Lip/Palate (CL/P) (2024 edition) set out the timing and coordination of team care. ^[6]

Key functional issues are feeding in the neonatal period (specialised bottles and feeding technique; oronasal communication), airway and hearing (chronic otitis media with effusion and conductive hearing loss are common after cleft palate), speech (velopharyngeal function), dental and midfacial growth. Feeding support and the fitting of a feeding plate are part of early neonatal care.

Repair is sequenced. Lip repair (cheiloplasty) addresses the lip and, in many pathways, the nasal deformity; palate repair (palatoplasty) closes the hard and soft palate to separate the oral and nasal cavities and to permit normal speech development. Common named techniques include the Millard rotation-advancement for the lip and the von Langenbeck, Furlow double-opposing Z-plasty and intravelar veloplasty approaches for the palate, with choices made by the surgeon and the team. Timing is set by the team according to weight, anaesthetic safety, growth and airway, within a multidisciplinary plan rather than by a single rule; a common pattern is lip repair in early infancy followed by palate closure during the first year, before speech develops. External nasal and maxillary growth continue into adolescence and secondary alveolar bone grafting and orthognathic or rhinoplasty procedures may follow.

Outcome measures include speech and velopharyngeal function, hearing, nasal airway, facial growth and psychosocial well-being; secondary speech surgery (pharyngoplasty or pharyngeal flap) is needed when velopharyngeal insufficiency persists. Genetic assessment and antenatal diagnosis (ultrasound, occasionally fetal MRI) complete the pathway.

Breast reconstruction is offered after mastectomy for breast cancer. ^[5] NICE NG101 (published 18 July 2018, last updated 14 April 2025) recommends that both immediate and delayed reconstruction are discussed with every suitable woman, whether or not all options are available locally, and that immediate reconstruction is offered unless comorbidities rule it out; not every patient chooses reconstruction. ^[5]

Options fall into three groups:

• Implant-based (prosthetic) reconstruction: tissue expander then implant, or direct-to-implant where feasible; simpler, shorter operation, no donor-site scar, but vulnerable to radiotherapy-related contracture and higher rates of revision and loss.
• Autologous (flap) reconstruction: using the patient's own tissue, most often from the abdomen (deep inferior epigastric perforator, DIEP; or pedicled transverse rectus abdominis myocutaneous, TRAM) or other donor sites. ASPS evidence-based guidelines cover autologous reconstruction with DIEP or pedicled TRAM flaps (published 2017), and BAPRAS publishes guidelines for oncoplastic breast reconstruction (best practice, updated June 2018) and for lipomodelling in breast surgery (October 2021). ^{[3] [4]} Flap reconstruction tolerates radiotherapy better and gives a more natural, ageing breast, but is a longer operation with donor-site morbidity and demands microsurgical expertise.
• Combined or secondary procedures: lipomodelling to refine contour, nipple-areolar reconstruction, and contralateral adjustment for symmetry.

Timing. Immediate reconstruction (started in the same operation as mastectomy) keeps the breast footprint, may help body image, and often needs fewer total operations, but compresses decision-making. Delayed reconstruction gives time for weight management, treatment completion and decision-making, and may be needed when adjuvant radiotherapy is planned or comorbidities intervene. The evidence shows no clear difference in satisfaction with the completed reconstruction between the two. ^[5]

Trade-offs include mastectomy skin-sparing or nipple-sparing options where oncologically safe, the effect of radiotherapy (which affects implants more than flaps), the implications for imaging and follow-up, and the possibility of repeated operations for symmetry and refinement. Decisions are made in a dedicated multidisciplinary oncoplastic pathway with a named clinical nurse specialist.

Burns care has two reconstructive phases. Early surgery converts an unstable wound into a stable, healed surface; late surgery releases contractures and restores function and appearance.

Assessment of depth (superficial, superficial partial, deep partial, full thickness) and extent (total body surface area, TBSA) sets urgency and volume status. The ABA burn patient referral criteria include referral or discussion for full-thickness burns, partial-thickness burns of 10% or more TBSA, deep partial or full-thickness burns of the face, hands, genitalia, feet, perineum or over joints, burns with comorbidities or associated trauma, poorly controlled pain, all paediatric burns in children 14 years or younger or under 30 kg, and all chemical and electrical injuries (high-voltage electrical injuries 1000 V or more meet immediate criteria; lower voltage needs consultation). ^[7] Estimation uses the rule of nines in adults (head and neck 9%, each arm 9%, each leg 18%, anterior and posterior trunk 18% each, perineum 1%) or the palmar method (about 1% of TBSA per palm) for burns under 15 to 20% TBSA. ^[7]

Superficial burns heal without scarring. Deep partial and full-thickness burns are managed by early excision (removal of non-viable tissue) and grafting, most often with meshed split-thickness skin grafts, usually within the first days; tangential or fascial excision is chosen by depth. Special areas (face, hands, flexures) may be grafted with sheet grafts for better cosmetic and functional outcome. Escharotomy and fasciotomy are performed for circumferential, constricting injuries. Major burns need coordinated resuscitation, infection control and nutritional support.

After acute healing, the aims are to prevent and release contractures (especially across joints, the neck, axillae and hands), to restore contour and function, and to improve cosmesis. Techniques include pressure garments worn for up to 12 to 18 months, silicone therapy, laser and steroid treatment for hypertrophic scars, surgical release with Z-plasty or local flaps, full-thickness grafts and, for severe defects, free tissue transfer. Secondary revisions are staged and may include fat grafting, tissue expansion and flap refinement. Psychosocial rehabilitation, return to activity and long-term scar surveillance are part of the same pathway.

• The reconstructive ladder is most useful where resources are tight: start with the simplest adequate method and avoid complex flaps that the service cannot support or monitor.
• Skin grafts need only basic instruments; meshing and delayed grafting still close large burns.
• Sterile technique, early excision where staff and blood products permit, and burn-centre referral networks matter as much as operative technique.
• Keloid treatment with intralesional steroid and pressure can be delivered in outpatient clinics.
• Cleft and breast pathways rely on multidisciplinary coordination; where specialised teams are absent, early referral and interim feeding, speech and psychosocial support should be arranged.
• Skin cancer and melanoma management depends on reliable pathology; if histology is unavailable, margins and diagnosis both suffer, and referral is safer.

• Reconstruction is problem-driven: plan from the defect, the patient and the available donor tissue, from simple to complex.
• Grafts need a vascular bed and freedom from infection; flaps bring their own blood and solve problems of bed, bulk and function.
• Split-thickness grafts are the workhorse for large defects and burns; full-thickness grafts give better match for small, important sites.
• Hypertrophic scars stay within wound boundaries and often improve; keloids overgrow them and recur after simple surgery.
• Melanoma margins follow stage: at least 0.5 cm (stage 0), 1 cm (stage I), 2 cm (stage II) as clinical margin around the biopsy scar.
• BCC low risk 2 to 4 mm, high risk 5 to 10 mm or Mohs; SCC low risk 4 to 6 mm, high risk 5 to 10 mm or Mohs.
• Cleft lip and palate care is lifelong and multidisciplinary, beginning with feeding and proceeding through lip and palate repair to speech, hearing, dental and psychosocial support.
• Breast reconstruction is offered after mastectomy, with immediate and delayed options; no clear difference in satisfaction, and implants are more affected by radiotherapy than flaps.
• Burns are treated by early assessment, excision and grafting, followed by long contracture prevention and scar programmes.
• Consent must cover failure, sensory change, donor-site morbidity and staged revision.

Scars and keloids; wound healing and surgical site infection; burn care and emergency care; skin cancer; melanoma; basal cell carcinoma; squamous cell carcinoma; breast disease and breast cancer; cleft lip and palate; breast reconstruction; low-resource surgery. These are written as plain text only, pending the MedGrasp topic catalogue.