Author : Dr Satish H V,

Plastic Surgery is always a mystery to the public.

The word plastic denotes the ability of the plastic surgeon to mould tissues the way plastic can be moulded to various shapes. There is no better word for this and therefore the name. Plastic Surgeons use many of the ‘normal’ surgery instruments. The difference however, is in the planning of the steps, the meticulous care and utmost skill in execution of the surgical procedure and the patience and perseverance to try and achieve perfection each and every time. Unlike public perception, Plastic surgery is more than skin surgery. Plastic surgeons deal with skin, fat, muscles, arteries, nerves and a few bones too. And with all parts of the human body! There is no regional limitation (head/ chest/hand etc.) unlike other branches eg. ENT, Eye surgeon, Head and neck, Gyneacology etc As our understanding has increased and diagnostic modalities have become more accurate and sophisticated; plastic surgery today is vastly different from what it was earlier. Using knowledge and technology, the scope of Plastic surgery is truly varied and wide.

Sub specialties of Plastic Surgery are:

1. Reconstructive surgery:

This deals with replacement of lost tissue or function, often by using body parts for overcoming the problem. Loss of tissue may occur following trauma (injury) or cancer etc. The challenge is to tailor the treatment and surgery to suit the need of the patient – restore shape, restore movement etc. It can range from repairing a damaged fingertip to restoring its form, repairing a badly injured hand and replacing skin, tendon etc; repairing blood vessels, nerves etc . Diabetic wounds leading to loss of tissue may also be corrected in this way. This constitutes 40% of a plastic surgeon’s work.

2. Paediatric plastic surgery:

Deals with correction of defects that a new born may be born with. The commonest is cleft of the lip and palate. Abnormalities in the hand (fused or extra fingers etc), blood vessel tumours in the face, birth marks, large swellings, deformed ears etc can all be corrected.

3. Cosmetic surgery:

Deals with a voluntary need for a change in external appearance in a healthy patient. Most people believe plastic surgery means only this! But this makes up for only 20% of a plastic surgeon’s practice. It might be the navel, breast, nose…and any other part of the body that catches the fancy of people who think they want it changed! This is hence an expanding branch which moves forward with public imagination!

4. Burns :

When a patient who has suffered burns escapes out of the horror alive, his/her skin is as scarred as the psyche! One of the main problem in burns is loss of skin with subsequent scarring . Correcting this and replacing the skin (skin grafting) is the solution.

5. Microvascular surgery:

Many a times, we get patients who have had an accident and a finger or even a limb has been cut off. Attempting to suture the severed organs is a challenging and time consuming surgery, not to mention the technical finesses involved in it. Small blood vessels of 1-2 mm and small nerves must be aligned and sutured together so that life and function is restored to the severed organ. These are repaired using a microscope. Tissues in our body can also be shifted from place to place using this technique.

You need to know that: Plastic surgeons do not use ‘plastic’ during surgery as some people imagine! We try to use the body’s own tissues as much as possible as we believe nothing can replace the natural tissues in our body! Sometimes we may use ‘implants’ which are made of different materials. Plastic surgeons cannot perform scar less surgeries. Nobody can. Scars will always occur when skin is cut. It is nature’s way of healing a wound. Plastic surgeons can only try to hide it or make it as inconspicuous as possible so that the scar does not look ugly. The final results of such also depends on the ability of the body to heal normally and hence may vary from person to person. Plastic surgeons cannot and have never ‘changed faces’ by putting skin from the thighs! The skin on the thigh is dark, grows hair and has different patterns as compared to facial skin. How could an aesthetic surgeon imagine such a blatant disregard of tissue nature? In fact, even on the face the nature of skin differs from forehead to nose to cheek to chin! Skin graft to the face is a last choice, if at all! Plastic surgeons even stitch the skin with utmost care and love! We use fine suture materials that will not leave any mark. We also sometimes use ‘gum’ or ‘tapes’ Plastic surgery is not always expensive. The experience, skill, duration and the special materials contribute to the cost. Some surgeries take 8- 10 hours to perform. They require a high amount of skill. Patients expect only the best results from us and will not accept any problems easily. All these are needed to meet the expectations of the patient! There are 2100 plastic surgeons in India. Compared to the need for this speciality, there is a severe shortage of Plastic surgeons especially in all non tier 1 cities.

What you need to ask when you meet a plastic surgeon

  1. What is the diagnosis or the problem in this person?
  2. What is your solution for this?
  3. What are the alternatives to this?

How do the results of different methods compare in terms of Time for healing/ Final outcome/ Cost In which method are you most sure that the result will be good? Can you show me photographs of similar problems and their outcomes? What if the outcome is not as expected? Are there any ways to salvage the situation? These are exactly the same issues that we focus our modalities of treatment on. P.S: A plastic surgeon is a super-specialist. His basic training of MBBS is followed with specialization in General Surgery (MS) and then the super-specialization in Plastic surgery (M Ch) Thus the plastic surgeon may have trained for 12 years before acquiring a Plastic surgery degree. Author : Dr Satish H V - MS. DNB, M Ch, DNB. Nose reconstruction following a injury using a ‘Indian forehead flap’

This is the first plastic surgery procedure described in the world. It was described more than 2000 years ago by Sushrutha, the eminent surgeon.
Ptosis – sleepy eye - correction
Some people have weak muscles in their upper lids and their lids droop. This can be corrected by a surgery. Filling up depressions with fat.

When there are depressions in the face, such as in this lady who had it from birth, her own fat was used to fill it up. The color too improved, bringing a
smile in addition! Cleft lip –before and after…
A common birth defect that leaves the parents in shock. Surgery can restore a ‘normal’ appearance to these kids. Correction of prominent ears

When the ears are more prominent, it attract comments . This can be easily corrected and a better position achieved. Surgical Management of Facial lesions.

Case 5: Digital nerve neuroma

This vendor has severe pain in his palm and had eaten tablets for months. He had a old nerve injury that had healed badly leading to severe apin whenever he gripped any object. Using microsurgical techniques, this nerve was identified, trimmed and repaired. This not only treated his pain, but partly restored his sensation also. Doctor can you change my face? Every Plastic surgeon has faced this query. The answer is yes and no! What makes people happy/unhappy about their face? Is it the color, the shape or glow etc? A major factor is the symmetry of the face. Facial proportions play a large role in making a face acceptable. In a crowd we always tend to glance a second time at people with blemishes. A prominent jaw, unequal eyes, large nose are instant magnets for the eyes. This manifests itself as ‘something is wrong, your lips are big, you don’t have a nose’ comments. We also have what is called a ‘body image’. The mental image is the picture of our face we see, when we close our eyes. If the mirror does not show our ‘mental image’ we feel uncomfortable. Sometimes other problems (career or relationship failures) get linked to this perception and dissatisfaction multiplies. What does the Plastic surgeon see? We look for overall proportion of the face first. We look for structural problems like large bones, bones that are not in place or bones that are displaced. We then look for the covering tissue – muscle/ fat and skin. We then have to decide which of these may be causing the dissatisfaction and then offer solutions.

Can we actually change the full face?

Technically-NO. The face has a combination of tissues which are themselves different. Such as: skin of different textures/ characters – forehead : horizontal lines; nose: thick and oily; eyes : thin and fine lines, differing fat content - lots on the cheek , less elsewhere, nil in lids Muscles (thick on the jaw and thin elsewhere). These are not replaceable with tissues from elsewhere in the body. Bones which are multiple pieces that are linked to each other -The eyes are supported by the bones; the nose shape is largely dependent on this; the teeth are fixed to bone and any change in bone will have an impact on chewing. Any surgery will have to take all this into consideration.

What can be changed?

The nose: its height, projection and the shape of the tip can be changed. Changes to the width of the lower part of the nose are more difficult in the typical Indian skin that is thick and oily. The ears – projection can be decreased if prominent. The eyes – wrinkles can be removed, sleepy eyes can be corrected, bulges reduced. The lips – can be made thicker or thinner The jaw and chin - can be made more or less prominent by moving the bones. They can also be changed by adding tissues or implants. The lower half of the face can also be changed by reducing muscle thickness. Forehead wrinkles, age relate wrinkles, skin sagging and drooping eyebrows can be corrected Dimples can be created on the cheeks, moles removed and scars reduced. Thus many changes are possible and a combination of these will change the face! Psychological issues Any facial surgery carries the risk of long term psychological problems. If the request for change is made by a person on whims, that person is likely to be unhappy after the change. In case a Plastic surgeon feels that the request is not rational, he/she may ask for a psychiatric evaluation. None of these surgeries are instant magic. After every surgery, we have to wait for a minimum of 3 months for the results as the swelling reduces, scars become softer and skin shrinkage occurs. Poor results Not every surgery will lead to full patient satisfaction. Studies in USA have shown that 25% of those who undergo nose surgery are unhappy with the results. A patient must be mentally prepared for this. Also, some people are unhappy even with a good result, because their colleagues/friends did not approve of the result (you were better before!)

What you need to clarify before surgery?

Write down your desires/ requests and make sure the surgeon has understood them. Poor communication can lead to unwanted changes! Ask for results of similar procedures. Remember that you may not get the same results as shown to you. Make sure you have discussed all alternatives and risks. This will help you prepare for the surgery What of the result is not good? What will the surgeon plan then? Remember, every surgeon tries 100%, but the result may not always be perfect. Repeat surgery cannot be free and you must be aware of this. What is the recovery period? Some operations will lead to more swelling/black eye and may take a month to resolve. FINALLY Cosmetic surgery is a fine balance between changing what should/can be changed and what should be left alone. The surgeon’s skills, the reaction of the body and the perception of the patient should all synchronize for a good result. That’s the art and science of Cosmetic surgery Author : Dr Satish H V

car that was deforming the eyes was revised and reduced . The eyes are back in position . Scar remov l operations donotexist . We can reduce and manipulate scars for
betterresultsThe nose shape has been
changed from a low and depressed to a prominent one with a shaper tip . This adds a new dimension to the face and loads of confidence too !
When the ear projection is reduced
the face seems more harmonious .
The lips thickness
can bevaried . In this person , who felt the upper lip was too thick it was reduced . If it i stoothin , then it can be made thicker with injections of fat or of other safe material . Hand surgery Our hands are our source of daily bread. Yet they do not get the recognition of the heart, the brain or the kidney. They are marvels of engineering and as of today no one has been able to replicate even a part of the functions we effortlessly perform. When we pick up food with our hands,we are actually doing a complex job. As we touch the food, we are assessing temperature and softness. As we tear a piece of chapatti, we are stabilizing one side, and pulling on another side( opposite movements) in a controlled way, with one hand. As we gather it we are squeezing the fingers depending on the amount of liquidity. As we lift up the hand we don’t ‘see’ our mouth, but our hand heads straight for it. 30 bones, more than 20 joints, 50 muscles and 3 nerves work in seamless harmony to provide a movement in multiple axis. What a wonderful symphony! The part of the hand beyond our wrist, is the most complex area. The skin is thick on the front, and yet is among the most sensitive in the body. It has separate sensors for heat, touch, vibration and pain. It has sweat glands but does not have oil glands. It has special layer to keep it firmly anchored so that we can grip well. As we move to the tip, the number of sensors ,increase, especially in the thumb.+ The bones in the hand are narrow and are meant for mobility and suppleness. The joints are strong and allow movements easily. Take a look at your thumb. It can move in 3 different axis – in and out, up and down and rotate to face the fingers. Yet it is strong enough to resist pull and delicate enough to pick up a hair! There are 12 long muscles to fold your fingers, 11 long muscles to straighten them. In addition there are 4 short muscles for your thumb, 3 for the little finger and 12 for the 4 fingers. The total is an amazing 42 muscles. Yet they are superbly co ordinated. When you fold your fingers , the straightening muscles relax synchronously . Signals at the speed of light fly back and forth controlling the muscles and providing feedback. And yet we do it ‘effortlessly’! When we have such a complex structure, leading our effort to work, they are more prone to injuries and disease than most other parts of the body. They actually contribute to 40 % of all injuries to the human body. Yet, many people are not sure whom to approach when they have a hand injury. Orthopedic surgeons are often a natural choice. By nature a majority of them are focused on the bony part and may not focus adequately on the other structures. Thus was born HAND SURGERY.
A hand surgeon , in India , is more likely to be a Plastic Surgeon. Equipped to deal with all challenges a Hand surgeon can with equal ease fix the small bones, re align joints, repair nerves and arteries using a microscope, stitch cut tendons and ensure good function, stitch or replace lost skin to allow for fast healing and achieve the goal of ‘ functional restoration’. Finger tips are often injured in a closing door or with a running motor. Skin is lost, bone may be crushed and the nail may be ripped off. Dressings are only occasionally the answer. A precise repositioning of the nail tissue, shifting skin from a less important part or from an adjacent fingers , may be needed. The goal is to enable a finger tip that can painlessly grip objects. Industrial injuries and sharp objects damage multiple structures at the same time. It is easiest to repair them the first time. Knowledge and experience will ensure that this happens. The complex repair is however only the beginning of the journey. Often, the repaired fingers are stiff and immobile. A good surgeon will guide the patient in physiotherapy. The result is gauged more by the function and less by appearance. Replantation is another area of great importance. When a part of the limb is cut off, it can be re attached. This depends on the level of the injury , the amount of damage to the part and the time interval. There is no universal rule and this is a judgment of the surgeon involved. Return of function can take time, but this procedure is undoubtedly a revolution in managing amputations. Even ‘small’ problems in the hand can cause major inconvenience. A swelling can be attached to an important nerve. It is then important to separate the two and not damage the nerve. Numbness in the hand in software companies, stiffness in elderly people, deformity with arthritis, disability in children with spasticity are all areas that can be improved with surgery. Hand surgery is a growing speciality and one with practical application to the society. Restoring a working hand is an invaluable contribution to the family of these bread winners. This is a role not commonly associated with Plastic surgeons!

Patient experience is a priority..
Complexities of finger injuries.
This is an injury caused during
sports – Mallet finger. Unable to straighten the tip of the finger, but can fold with pain. Result of an accurate repair of this tendon showing ‘normal’ movement.
Nerve repair needs high magnification for accurate repair. Only the outer covering layer of the nerve can be held or stitched. The stitches are much thinner than human hair. This is a nerve in the wrist area – Median Nerve.
A combination of extra fingers and fused fingers.
The surgery is ideally done before 1 year of age, so that the child can use the hands ‘normally’ from 1 year of age. It is more than just splitting the fingers. Often structures are missing/ fused and blood supply may be insufficient. Yet it is an ‘essential ‘ surgery. This is a child with polysyndactyly. The child 6 years later. She can separate all fingers and write well too…