GC192 I Want To Look Better Plastic And Reconstructive Surgery
Plastic and reconstructive surgery is a surgical specialty focused on restoring form and function to body structures affected by congenital defects, trauma, burns, or disease, as well as enhancing aesthetic appearance through elective cosmetic procedures.
Plastic & Reconstructive Surgery — "I Want to Look Better"
This GC 192 lecture by Dr. Joseph HP Chung (HKU Division of Plastic and Reconstructive Surgery, Queen Mary Hospital) provides a panoramic introduction to plastic surgery — not just cosmetics, but the full spectrum from congenital deformities to cancer reconstruction to burns to aesthetic procedures. The lecture is structured around principles first (wound healing, skin anatomy, flap design, reconstruction ladder) and then clinical applications (congenital, cancer, trauma, breast, hand, microsurgery, aesthetics). It culminates with the critical concept of patient selection and the ethical balance between benefit and harm in elective surgery. [1]
Learning objectives (directly from slide 2): [1]
- Introduction to Plastic and Reconstructive Surgery
- Understand basic principles of surgical techniques in Plastic Surgery
- Illustrate common diseases and management principles
- Appreciate the importance of patient selection and total patient care of form (cosmesis), function, and feeling (psychological) and how to achieve the best outcomes
The three Fs — Form, Function, Feeling — are the philosophical backbone of plastic surgery. Every management decision should be justified by improvement in at least one of these domains. [1]
Core Concepts & First-Principles Explanations
- "Plastic" derives from the ancient Greek "Plastikos" — meaning "to mould" or "to form." [1]
- It covers surgical operations from head to toe — the unifying theme is optimal tissue handling, design, transfer, and reshaping for form and function with enhanced psychosocial feeling. [1]
- Two main streams:
- Plastic and Reconstructive Surgery — restoring defects from congenital abnormalities, trauma, cancer, burns
- Aesthetic / Cosmetic Surgery — elective procedures to enhance appearance
Why does this distinction matter for exams? Because reconstructive surgery is medically indicated (e.g., post-mastectomy breast reconstruction), while aesthetic surgery is elective and patient-driven. The ethical, medicolegal, and patient selection considerations differ enormously.
| Period | Key Development | Significance |
|---|---|---|
| 600 BC, Sushruta, India | Nose reconstruction with forehead flap | Earliest recorded reconstructive surgery; punishment of nose amputation led to innovation [1] |
| 17th century Italy, Tagliacozzi | Nose reconstruction with arm flap | Distant flap concept during wartime [1] |
| Modern era | Development of microvascular surgery | Free autologous tissue transfer to distant areas — revolutionized cancer reconstruction [1] |
| Contemporary | Emergence of aesthetic surgery | Driven by cultural demand, technology, and commercial pressure [1] |
Basic Principles in Plastic Surgery
Three types of wound closure are fundamental and repeatedly tested: [1]
| Type | Mechanism | Indication | Key Features |
|---|---|---|---|
| Primary closure | Approximation of wound edges surgically | Clean surgical wounds | Best cosmesis, fastest healing |
| Delayed primary closure | Wound left open for a few days, then closed | Contaminated wounds (e.g., dog bite) | Allows drainage and cleansing → reduces infection risk |
| Secondary closure (secondary intention) | Granulation → epithelialization → contraction | Infected/contaminated wounds (e.g., abscess) | Prolonged inflammatory phase → increased scarring and contracture |
Why delayed primary closure for dog bites? Dog bites are polymicrobial (Pasteurella, anaerobes). Closing immediately traps bacteria → abscess. Leaving open allows wound toilet and surveillance for 3–5 days before definitive closure. [1]
Why secondary intention causes more scarring: The wound must fill from the bottom up with granulation tissue, which contracts as myofibroblasts pull edges together. The prolonged inflammatory phase upregulates collagen deposition beyond what's needed, leading to hypertrophic scarring. [1] [2]
The lecture lists these specific technical principles: [1]
- Ensure haemostasis — haematoma separates wound edges and is a culture medium for bacteria
- Ensure viability of tissue — non-viable tissue becomes necrotic → infection
- Obliterate dead space — prevents seroma/haematoma formation
- Good approximation of tissue in layers — anatomical repair reduces distortion
- Use subcuticular closure or fine dermal interrupted suturing — minimizes scar and stitch marks
- Avoid tension or pressure on wound — tension → ischaemia → wound breakdown → wider scar
- Appropriate timing for suture removal — too early = wound dehiscence; too late = suture marks ("railroad tracks")
High Yield
Suture removal timing varies by body region: face 3–5 days, trunk/extremities 7–10 days, over joints 10–14 days. Earlier removal on face because rich blood supply → faster healing, and prolonged sutures leave worse stitch marks on cosmetically sensitive areas.
Three layers of skin with their vascular architecture: [1]
- Epidermis — avascular, nourished by diffusion from dermis
- Dermis — contains vascular plexuses (subepidermal plexus and subdermal plexus)
- Subdermis (hypodermis) — fat, fascia, and deeper structures
Skin composition: The epidermis constitutes approximately 5% of total skin thickness, while the dermis constitutes approximately 95%. The dermis contains sebaceous glands, hair follicles, and sweat glands. [1]
STSG sub-thicknesses: Split-thickness skin grafts can be harvested at thin, medium, or thick depths within the dermis, affecting graft properties and donor site healing. [1]
Blood supply to skin: [1]
- Fasciocutaneous vessels — run along fascial septae between muscles
- Perforating branches through muscles (musculocutaneous perforators) — pierce muscle to supply overlying skin
- Subdermal plexus — horizontal network feeding the dermis
- Subepidermal plexus — finest terminal network
"Importance of identification and preservation of perforators during flap reconstruction" — if you ligate the perforator that feeds the skin paddle of your flap, the flap dies. [1]
An angiosome is a composite unit of skin and underlying tissue supplied by a source vessel. [1]
Why this matters: Flaps are designed based on angiosome territories. A flap that includes one or more angiosomes supplied by a known vessel will have reliable perfusion. Tissue outside the angiosome territory will NOT be reliably supplied — this is why flaps have size limits. [1]
Named flap examples from the lecture: [1]
- Radial forearm flap — based on radial artery angiosome
- TRAM flap (Transverse Rectus Abdominis Myocutaneous flap) — based on superior/inferior epigastric artery angiosomes
The four zones of the lower abdominal (TRAM) flap: [1]
- Zone I: directly over the perforator — most reliable
- Zone II–IV: progressively further from the perforator — less reliable blood supply
- In a pedicled TRAM (based on superior epigastric artery), Zone IV is the least reliable and often discarded
- In a free TRAM (based on deep inferior epigastric vessels), the zonal perfusion pattern shifts
What the TRAM blood-supply slide shows: superior vs inferior epigastric inflow relative to the umbilicus, with red labels for pedicle flap design vs free flap design, and the abdomen divided into perfusion zones I–IV — Zone IV is the far side you discard when reliability is poor. [1]
4. Skin Graft vs. Skin Flap
Skin graft = transfer of tissue WITHOUT its usual source of blood supply (depends on recipient bed) [1] Skin flap = transfer of tissue WITH preservation of its original blood supply [1]
| Feature | Skin Graft | Skin Flap |
|---|---|---|
| Blood supply | From recipient bed (imbibition → inosculation → revascularization) | Carries its own blood supply |
| Complexity | Simpler | More complex |
| Reliability | Needs well-vascularized, uninfected bed | Can cover avascular beds (bone, tendon, hardware) |
| Donor morbidity | Variable | Higher (larger donor defect) |
| Type | Definition | Example |
|---|---|---|
| Autograft | From same individual | STSG, FTSG |
| Allograft | From same species | Cadaveric liver/kidney transplant |
| Xenograft | From another species | Porcine skin graft (temporary wound cover in burns) |
This is an extremely high-yield comparison table for exams: [1]
| Feature | STSG (Split Thickness) | FTSG (Full Thickness) |
|---|---|---|
| Includes | Epidermis + partial dermis | Epidermis + entire dermis |
| Take rate | Easier take (thinner → needs less vascular supply) | More demanding recipient bed |
| Contraction | Greater contraction | Less contraction |
| Cosmesis | Poorer (shiny, discolored) | Improved cosmesis (better color, texture match) |
| Donor site healing | Re-epithelialization (heals by secondary intention) | Must be closed primarily (donor site cannot re-epithelialize if full dermis removed) |
| Size available | Larger area of donor site | Limited size (needs primary closure) |
| Preferred use | Large wound coverage (burns, large defects) | Facial defects, hands, over joints |
Why FTSG for face and joints?
The face demands color/texture match and minimal contraction (contraction → ectropion, lip eversion). Joints need flexibility — STSG contraction over joints → contracture → loss of motion. FTSG contracts less because the intact dermis provides a collagen scaffold that resists myofibroblast contraction.
The lecture classifies flaps by four systems: [1]
A. By Blood Supply:
| Type | Description |
|---|---|
| Random | No named vessel; depends on subdermal plexus; limited length-to-width ratio |
| Axial | Based on a named source artery running along the flap axis; can be longer |
| Reverse flow | Based on retrograde flow through an axial vessel (e.g., reverse radial forearm flap) |
Slide subtypes under random vs axial [1]:
| Pattern | Subtypes shown |
|---|---|
| Random | Random cutaneous flap (dermal–subdermal plexus); myocutaneous random flap (skin + muscle) |
| Axial (direct cutaneous a. & v.) | Peninsular axial (skin bridge/pedicle remains); island axial (skin island on vascular pedicle); free flap (completely detached, vessels anastomosed) |
B. By Design:
| Type | Movement |
|---|---|
| Advancement | Slides forward in one direction |
| Transposition | Pivots over intervening normal skin |
| Rotation | Arcs around a pivot point |
| Interpolation | Pedicle crosses over or under intervening tissue (e.g., forehead flap for nose) |
C. By Proximity:
| Type | Example |
|---|---|
| Local | Nasolabial flap |
| Regional | Forehead flap |
| Distant | LD (latissimus dorsi) flap |
| Free | Free ALT (anterolateral thigh) flap |
D. By Tissue Transferred:
| Type | Contents | Example |
|---|---|---|
| Cutaneous | Skin only | Skin flap |
| Fasciocutaneous | Skin + fascia | Radial forearm flap |
| Myocutaneous | Skin + muscle | TRAM flap |
| Osteomyocutaneous | Skin + muscle + bone | Fibula free flap |
The lecture notes that flap survival depends on preserved vasculature and vascularized tissue captured and transferred. [1]
- Mathes and Nahai classification (Types I–V) categorizes muscles by their vascular pattern
- Common examples from the lecture:
- Rectus abdominis — Type III (two dominant pedicles: superior and inferior epigastric arteries)
- Pectoralis major — Type V (one dominant + secondary segmental pedicles)
Mathes and Nahai Classification — All Five Types (HIGH YIELD): [1]
| Type | Vascular Pattern | Example |
|---|---|---|
| I | Single vascular pedicle | Tensor fascia lata |
| II | Dominant pedicle(s) + minor pedicle(s) | Gracilis |
| III | Two dominant pedicles | Gluteus maximus, Rectus abdominis |
| IV | Segmental vascular pedicles | Sartorius |
| V | Single dominant pedicle + secondary segmental pedicles | Latissimus dorsi, Pectoralis major |
Z-plasty is a fundamental technique tested in exams. [1]
Mechanism: Based on skin elasticity and undermining of surrounding tissue. Two additional limbs are drawn at 60° angles to the original scar, creating two triangular flaps that are transposed.
Advantages: [1]
- Lengthening of scar (theoretical gain of ~75% with 60° angles)
- Change direction of scar (aligns scar with relaxed skin tension lines)
- Break pulling effect on scar (redistributes tension vectors)
Flap Design Considerations: [1]
- Elasticity and vascularity of skin are critical for vector changes in flap design
- Design is affected by aging skin and scar tissue in the surrounding area — both reduce tissue mobility and vascularity
Disadvantages: [1]
- Creates new scars
Modifications: Multiple Z-plasty, W-plasty [1]
Why 60° angles? At 60°, the theoretical length gain is maximum (~75%). Smaller angles give less lengthening; larger angles create flaps that are too broad and difficult to close.
"Area to be resected is determined primarily by the pathology — reconstruction comes second." [1]
This is a critical philosophical point: never compromise oncological clearance to make reconstruction easier.
Resection margins by pathology (HIGH YIELD): [1]
| Pathology | Margin |
|---|---|
| BCC (Basal Cell Carcinoma) | 2–3 mm (lecture slide p21) or 3–5 mm (slide p31) |
| SCC (Squamous Cell Carcinoma) | 1–2 cm |
| Melanoma / Sarcoma | 2–3 cm |
Exam Trap: BCC Margin
The lecture gives slightly different BCC margins on different slides (2–3 mm on p21, 3–5 mm on p31). For exam purposes, know that BCC requires the smallest margin of the three. The standard teaching is 3–5 mm for most BCC (some guidelines say as low as 2 mm for well-defined nodular BCC). Mohs micrographic surgery allows narrower margins with intraoperative frozen section control.
Intraoperative frozen section guidance for margin clearance in selected cases. [1]
Surgical approaches for resection: [1]
- Open surgery
- Minimally invasive surgery (minimize scar)
- Non-incisional destructive modalities: cauterization, cryosurgery, topical agents, laser ablation, radiofrequency, focused ultrasound
The reconstruction ladder moves from simple to complex procedures: [1]
Free flap (top — most complex)
↑
Pedicle flap
↑
Local flap
↑
Skin graft
↑
Secondary intention
↑
Primary closure (bottom — simplest)The choice is balanced by: [1]
- Amount of tissue loss
- Availability of surrounding donor tissue
- Complexity of procedures
- Expertise available
- Cosmetic and functional outcomes
Modern plastic surgery sometimes uses a "reconstruction elevator" rather than ladder — jumping directly to a free flap if it gives the best functional/cosmetic outcome, even if simpler options exist. But for the HKU exam, the traditional ladder is what's tested. [1] [2]
This comparison is directly testable: [1]
| Feature | Autogenous Tissue | Implants |
|---|---|---|
| Availability | Depends on donor tissue | Readily available |
| Donor morbidity | Present | None (no donor site) |
| Infection risk | Less once taken | Higher (foreign body) |
| Longevity | Lifelong | Material fatigue/breakage |
| Healing | Living tissue — can heal | Cannot self-repair |
| Complications | Donor site issues | Capsular fibrosis/pain, extrusion, foreign body reaction |
| Examples | TRAM flap, fat graft, cartilage graft | Breast implants, nose implant, Medpor, metal implants |
Clinical Applications — Common Diseases
A. Congenital Deformities
Key timing and multidisciplinary principles (HIGH YIELD): [1]
- Unilateral or bilateral, incomplete or complete
- May involve cleft lip, cleft palate, or combination ± cleft nose deformity
| Procedure | Timing | Details |
|---|---|---|
| Repair of cleft lip | 3 months | Surgical correction of muscle, mucosa, and skin |
| Repair of cleft palate | 9 months | Surgical closure of hard and soft palate |
Mnemonic: "Rule of 10s" — cleft lip repair at ~10 weeks (≈3 months), 10 lbs weight, 10 g/dL hemoglobin.
Multidisciplinary approach addresses: [1]
- Appearance
- Speech and articulation
- Hearing and middle ear effusion (Eustachian tube dysfunction → OME)
- Small maxilla and dental malocclusion
- Facial growth and facial appearance
Why cleft palate causes middle ear effusion
The tensor veli palatini muscle (which opens the Eustachian tube) inserts into the soft palate. In cleft palate, this muscle is abnormally positioned → Eustachian tube dysfunction → negative middle ear pressure → middle ear effusion → conductive hearing loss. This is why an ENT team is essential in the multidisciplinary cleft team.
- Microtia (small ear)
- Prominent ears (bat ears)
- Cryptotia (cartilage framework partially buried under skin)
- Corrected by rearranging tissue or adding cartilage framework (single or staged procedures)
- Soft tissue tumours such as neurofibromatosis
- Haemangioma and vascular malformation — e.g., primary excision of haemangioma with FTSG reconstruction (eyelid lesions)
- Melanocytic lesions and pigmentation — congenital naevi may require excision with local flap reconstruction
- Small lesions → excision and primary closure
- Large lesions → resection and reconstruction (skin graft / flaps)
- Non-surgical options: laser, sclerotherapy, interventional radiology with embolization
- Based on photo-selective properties targeting hemoglobin (vascular) or melanin (pigmented)
- Repeated multiple sessions required
- Variable effect; not effective for deep lesions
- Examples: port wine stain, facial freckles, telangiectasia of nose, nevus of Ota
Visual recognition: the laser slide pairs each target with a face photo — purple periocular port-wine stain (haemoglobin chromophore), brown freckles, bluish-grey nevus of Ota, and nasal telangiectasia. Deep dermal pigment responds poorly; expect multiple sessions and variable clearance. [1]
Resection margins (as above) followed by reconstruction per the reconstruction ladder. [1]
Key principles: [1]
- Different pathology/differentiation determines the margin
- Intraoperative frozen section for clearance in selected cases
Skin graft for facial defects: [1]
- Primary closure may be impossible → deformities
- FTSG preferred for face — better colour matching, contour, and texture
Common local flaps for nose reconstruction: [1]
- Nasolabial flap — based on facial artery perforators; good for alar defects
- Bilobed flap — transposition flap; good for small nasal tip/dorsum defects
- Forehead flap — the "workhorse" for large nasal defects; interpolation flap based on supratrochlear artery
Hypertrophic Scars and Keloids
This distinction is a perennial exam favourite: [1]
| Feature | Hypertrophic Scar | Keloid |
|---|---|---|
| Boundary | Does NOT extend beyond wound | Extends beyond wound and grows with time |
| Timing | Develops within weeks, may regress | Develops months later, does NOT regress |
| Recurrence after excision | Less common | Common |
| Genetics | Less genetic predilection | More common in certain ethnicities (African, Asian) |
Problems: unsightliness, pain, recurrent infection [1]
Treatment: [1]
- Observation
- Corticosteroid injection (intralesional triamcinolone — reduces collagen synthesis)
- Pressure therapy (compression garments)
- Surgical excision / debulking / Radiotherapy
- Recurrence common with keloids — adjuvant radiotherapy or steroid injection post-excision reduces recurrence
- Recovery depends on depth (degree) and extent (% TBSA)
- Superficial burns heal well with minimal scarring
- Infection and poor wound care deepen the wound → adversely affects healing
- Deep dermal injury → scar formation and contracture → poor cosmetic and functional outcomes
Principles of burn reconstruction: [1]
- Prevention and management of scar — pressure garments, mobilization
- Correction of contractures — scar release, local plasties, flaps, skin graft (FTSG for ectropion of eyelids, correction of microstomia, eversion of lip, neck scar release)
- Skin and dermal replacement — skin graft ± dermal substitutes, flap reconstruction
- Adjuvant therapy — hair/eyebrow transplant, CO₂ resurfacing of skin
D. Facial Trauma [1]
Priority: Treat life-threatening conditions first (ATLS principles — airway, breathing, circulation).
- Good haemostasis
- Adequate cleansing and removal of foreign bodies
- Ensure viability (especially avulsed tissue)
- Layered closure, tension-free, accurate apposition
- Reconstruction ladder for tissue loss
- Late secondary revision of scar
Imaging:
- Plain X-ray
- CT scan ± 3D reconstruction (gold standard for facial fractures)
Problems with facial fractures: [1]
- Bleeding from open fractures
- Airway obstruction from mucosal bleeding
- Deformities affecting facial appearance
- Blow-out fracture → entrapment of inferior rectus → diplopia (inability of upward gaze)
- Fracture of zygomatic arch/condyle of mandible → malocclusion
- Instability of fragments → malunion → loss of function and pain
Management approaches:
| Fracture | Treatment |
|---|---|
| Nasal fracture | Closed reduction under GA/IVS/LA; aim to achieve alignment of dorsum and septum and restore central prominence of nasal pyramid; postoperative nasal packing + nasal splint for protection and temporary support [1] |
| Orbital floor blow-out | Open reduction via conjunctival approach, release entrapment, ± reconstruction with Medpor (synthetic bone) [1] |
Clinical photograph teaching: diplopia with inability of right upward gaze → inferior rectus/orbital soft-tissue entrapment until proven otherwise; the operative sequence is release through a conjunctival approach, then floor reconstruction as needed. [1] | Displaced facial fractures | ORIF — open reduction internal fixation with plates/screws/wire; anatomical reduction; release soft tissue entrapment; regain occlusion of upper and lower jaw; bone graft for tissue loss [1] |
"Replacement of tissue with alike" — the nose has three layers that must all be reconstructed:
- Nasal lining (mucosa)
- Bone and cartilage support (structural framework)
- Skin / soft tissue coverage (external envelope)
Aesthetic subunits of the nose (9 subunits): [1]
- Dorsum
- Two lateral side walls
- Tip
- Columella
- Two alar
- Two soft triangles
If > 50% of a subunit is lost, it is better to excise the remaining subunit and reconstruct the entire subunit — this gives a more natural result because scars fall along subunit borders.
- A free composite graft (e.g., helical cartilage and skin from the ear) can reconstruct small alar defects
- The graft includes both auricular skin and underlying helical cartilage, providing structural support and skin coverage in a single stage
- Scar revision of healed facial wounds
- Rhinoplasty of deformed nose
- Restoration of lost tissue with cartilage graft for structural support
E. Breast and Trunk Reconstruction [1]
Indications:
- Post-cancer reconstruction
- Augmentation / reduction mammoplasty
- Post-bariatric body contouring
- Gynecomastia, congenital asymmetry (e.g., Poland syndrome)
Timing: [1]
- Primary (Immediate) — at the time of mastectomy
- Secondary (Delayed) — later; often chosen if adjuvant radiotherapy planned (RT damages reconstructed tissue)
Options: [1]
| Type | Flap/Method | Details |
|---|---|---|
| Autogenous — TRAM | Pedicled or Free | Lower abdomen skin/fat/muscle; tunneled to chest for breast mound |
| Autogenous — DIEP | Free flap | Deep inferior epigastric perforator; muscle-sparing modification of TRAM |
| Autogenous — LD | Pedicled | Latissimus dorsi myocutaneous flap from back; often combined with implant |
| Implants | ± muscle flap (e.g., LD) | Silicone or saline; may need tissue expander first |
| Nipple/areola | Reconstruction + tattooing | Staged after breast mound creation; local flaps for nipple, tattoo for areola |
| Fat grafting | Contouring | Fine-tuning shape after primary reconstruction |
TRAM flap details: [1]
- Based on lower abdominal skin, fat, muscle, and supplying vessels (superior epigastric for pedicled, deep inferior epigastric for free)
- Tissue removed and transposed via subcutaneous tunnel to form new breast mound
- Can be transferred as free tissue transfer with microvascular anastomosis
- Modification: muscle-sparing or DIEP flap (preserves rectus muscle → less donor morbidity)
Other indications for chest wall flaps: osteoradionecrosis, large defects after cancer resection [1]
Uses:
- Augmentation (increase breast size for body contouring)
- Reconstruction after mastectomy (especially after skin-sparing mastectomy ± flaps)
Types: gel implants, saline implants [1]
Complications of breast implants (HIGH YIELD): [1]
| Complication | Explanation |
|---|---|
| Capsular contracture | Foreign body reaction → fibrous capsule forms around implant → squeezes → deformity and pain (Baker grade I–IV) |
| Disruption and leakage | Silicone gel leak → local inflammation, distant migration |
| Infection | May require implant removal |
| Skin ulceration | Pressure necrosis of overlying skin |
| Implant extrusion | Implant erodes through skin |
| Need for replacement | Implants are NOT lifelong — may need revision surgery every 10–15 years |
| BIA-ALCL | Breast Implant-Associated Anaplastic Large Cell Lymphoma — a rare T-cell lymphoma; higher risk with textured implants |
BIA-ALCL — High Yield for Exams
BIA-ALCL is a rare but important complication specifically associated with textured breast implants. It presents as a late seroma (> 1 year post-implant), capsular mass, or lymphadenopathy. Diagnosed by cytology of periprosthetic fluid showing CD30+ large cells. Treatment: capsulectomy and implant removal. It is NOT a breast carcinoma — it is a lymphoma of the capsule.
- Congenital (e.g., extra digit/polydactyly)
- Trauma
- Scar release (e.g., burn scar release of web space with Z-plasty)
- Tissue hypertrophy and lymphedema (e.g., free lymph node transfer)
- Allows free tissue transfer from distant site
- Common in head and neck reconstruction
- Re-anastomosis of artery and vein using microscope
- Applications: replantation surgery, complex reconstruction (e.g., pedicle PM flap + STSG for buccal cancer resection, free ALT flap for recurrent buccal cancer) [1]
Facial reshaping:
- Blepharoplasty (eyelid surgery)
- Rhinoplasty (nose reshaping)
- Face and brow lift
- Fillers and injectables
- Botox (botulinum toxin)
Body reshaping:
- Breast augmentation
- Liposuction
- Body sculpture
Anti-aging procedures and skin tightening: [1]
- Laser
- Surgical procedures (minimal or conventional)
- Botox
- Chemical peels
- Fillers / fat graft
- Energy modulation: CO₂ fractionation, Radiofrequency (Thermage), Focused ultrasound (HIFU)
- Hair transplant
HIFU treatment depths: Focused ultrasound targets tissue at 1.5 mm, 3.0 mm, and 4.5 mm depths, reaching from the dermis through subcutaneous fat to the SMAS (superficial musculoaponeurotic system) layer. [1]
Hyaluronic acid dermal fillers: Gel is injected into the dermis/subdermis to restore volume; commonly used for nasolabial folds, lips, and facial contouring. [1]
Mechanisms of action: [1]
| Mechanism | Examples |
|---|---|
| Restore volume and fullness | Fillers, fat graft |
| Increase skin tightness and texture | Facelift, Thermage |
| Alter shape by augmentation/reduction | Blepharoplasty, rhinoplasty, breast/nose implants, mandible angle reduction |
| Reduce muscle activity | Botox (reduces wrinkling by blocking ACh release at NMJ → muscle relaxation) |
Balance between effects and complications: [1]
- Immediate effect vs. long-term complications
- Some treatments require repeated sessions
- General surgical complications (infection, fibrosis, migration, deformity, scarring)
- Risks of fake products with impurities
- Over-exaggeration of effects by advertisements/companies
- Evidence base is important
"Facial Overfilled Syndrome" — a recognized pattern of over-treatment with fillers/injectables leading to characteristic distortions including broad/avatar nose, pillow face, sunset eyes, duck/sausage lips, and witch/dagger chin. [1]
Safety alerts: Cases of iatrogenic botulism after botulinum toxin injection for cosmetic purposes have been reported (Hospital Authority Poisoning Alert, 2016). This underscores the importance of using regulated products and qualified practitioners. [1]
This is arguably the most exam-relevant conceptual slide in the deck. [1]
Factors to consider: [1]
- Medical contraindications — unfit for anaesthesia, bleeding disorders, active infection
- Realistic understanding and expectation of outcomes — patients must understand limitations
- Psychological or emotional interference — body dysmorphic disorder (BDD), depression, unrealistic expectations
- Technical expertise and artistic judgment of surgeon
- Balance between risks and benefits (short-term and long-term)
The ideal patient has a HIGH degree of deformity and LOW patient concern (realistic). A patient with LOW deformity but HIGH concern is NOT a suitable surgical candidate — this suggests BDD or psychological issues. [1]
The lecture specifically references a real case: "Woman dies after receiving liposuction at hair treatment centre" (SCMP, 2014) — highlighting the dangers of unregulated cosmetic procedures at non-medical facilities. [1]
Philosophical Closure
"Primary goal is to cure, to relieve and to support. Be careful to treat diseases, not to create illnesses. First do no harm. Not to be driven by money, materials and madness." [1]
Balancing values: [1]
- Life and death
- Form and function
- Benefit and risk
- Beauty and nature
- Donor and recipient
- Cultural norm, community and individual expectation
| Related Lecture | Connection |
|---|---|
| GC 190 Burns | Depth classification, %TBSA, fluid resuscitation → plastic surgery manages burn reconstruction [1] |
| GC 201 Skin Cancer | BCC/SCC/melanoma margins; when to use Mohs vs wide excision |
| GC 187 Head & Neck Cancer | Free flap reconstruction after cancer resection (ALT, fibula, radial forearm) [3] |
| GC 181 Breast Cancer | Post-mastectomy breast reconstruction options; oncoplastic surgery [4] |
| CFB OT04 Reconstruction | Reconstruction ladder in detail |
| CFB WCS27 Surgical Infection | Wound infection prevention; delayed primary closure rationale |
| Cleft Lip and Palate (Dr. M Wong) | Detailed cleft management; Millard rotation-advancement technique |
Common Exam Traps
-
STSG vs. FTSG: Students confuse which contracts more. Remember: STSG contracts MORE (less dermis = less scaffold). FTSG contracts LESS (intact dermis resists contraction).
-
Hypertrophic scar vs. Keloid: The discriminator is whether it extends beyond the original wound boundary. Hypertrophic scar does NOT; keloid DOES.
-
Reconstruction ladder direction: Always start from the simplest appropriate option. Don't jump to free flap when primary closure would suffice — unless the simplest option would compromise function/cosmesis significantly.
-
Resection margins: BCC has the smallest margin (3–5 mm). Melanoma/sarcoma has the largest (2–3 cm). SCC is intermediate (1–2 cm). Students sometimes reverse BCC and SCC margins.
-
Patient selection for cosmetic surgery: The patient with minimal deformity but extreme concern is the worst candidate. This is a common MCQ discriminator.
-
Cleft lip vs. palate repair timing: Lip at 3 months, palate at 9 months. Don't mix them up.
-
TRAM vs. DIEP: DIEP is a muscle-sparing perforator flap — it takes the skin/fat paddle on the deep inferior epigastric perforators WITHOUT the rectus muscle. TRAM takes the muscle too → higher donor morbidity (hernia risk).
High Yield Summary
- Plastic surgery = Form + Function + Feeling.
- Key principles: (1) Three types of wound closure — primary, delayed primary, secondary intention. (2) STSG vs. FTSG — STSG contracts more, takes easier, larger donor; FTSG has better cosmesis, less contraction, preferred for face/joints. (3) Flaps carry their own blood supply; grafts depend on recipient bed. (4) Angiosomes define flap territory — tissue outside the angiosome is unreliable. (5) Reconstruction ladder: primary closure → secondary intention → skin graft → local flap → pedicle flap → free flap. (6) Cancer resection margins: BCC 3–5 mm, SCC 1–2 cm, melanoma/sarcoma 2–3 cm. (7) Cleft lip repair at 3 months, palate at 9 months. (8) Hypertrophic scar stays within wound borders; keloid extends beyond and recurs after excision. (9) Breast reconstruction: autogenous (TRAM/DIEP/LD) vs. implants; BIA-ALCL is a rare implant complication. (10) Patient selection for cosmetic surgery: the ideal candidate has a real deformity with realistic expectations; low deformity + high concern = NOT suitable (possible BDD).
Active Recall - Plastic & Reconstructive Surgery
[1] Lecture slides: GC 192. I want to look better Plastic and reconstructive surgery.pdf [2] Senior notes: Maksim Surgery Notes.pdf (Section 4.1 Wound healing and reconstruction, p.343–344) [3] Lecture slides: GC 187. Head and neck cancer problems Function and shape.pdf [4] Senior notes: Maksim Surgery Notes.pdf (Breast reconstruction, p.186–187)
GC190 I Have A Scald Burn
A scald burn is a thermal injury to the skin and underlying tissues caused by contact with hot liquids or steam, commonly classified by depth as superficial, partial-thickness, or full-thickness.
GC193 Inguinal And Scrotal Swelling Different Types Of Hernia
Inguinal and scrotal swellings encompass various hernia types—indirect inguinal (through the deep ring), direct inguinal (through the posterior wall of the inguinal canal), and femoral (through the femoral canal)—as well as non-hernia causes such as hydrocele, varicocele, and undescended testis, each distinguished by anatomical location and clinical characteristics.