Plastic surgery is surgery to repair and reconstruct damaged skin and tissue. The damage may be the result of:

• a congenital disease (a disease that is present from birth),
• a disease or illness that develops later in life, or
• an injury.

The main aim of plastic surgery is to restore the functioning of skin and tissue to a level that is as close to normal as possible. Improving the appearance of the skin is an important, secondary objective of plastic surgery.

Plastic surgery differs from cosmetic surgery

Cosmetic surgery is not the same as plastic surgery. Cosmetic surgery is surgery that is carried out by choice (elective) and is undertaken for the sole purpose of improving a person’s physical appearance.

Cosmetic surgery includes procedures such as:

• face-lifts,
• nose reshaping,
• tummy tucks,
• liposuction (excess fat removal),
• female breast enlargement, and
• breast reduction (male and female).

Examples of plastic surgery include:

• correcting congenital defects, such as a cleft lip and palate (a birth defect that affects the top lip and the roof of the mouth),
• reconstructing skin and tissue following an illness that has affected a particular part of the body - for example, reconstructive breast surgery following a mastectomy (breast removal) due to breast cancer, and
• repairing skin and tissue that has been damaged by fire, or other serious injuries, such as those sustained during motor vehicle accidents.

Below are some examples of situations where plastic surgery is often used. For each category - congenital defects, illness, and injury - a common procedure is explained in-depth.

Congenital defects

Plastic surgery can be used to correct congenital defects such as those listed below.

• Haemangiomas - where small blood vessels collect together to produce a raised, red mark on the skin that is commonly known as a ‘naevus’.
• Birthmarks and port wine stains - which occur as a result of malformations of capillaries, veins, and arteries.
• Hypospadias - where the opening of the urethra (the tube that carries urine from the bladder to the penis) is on the underside of the penis.
• Craniofacial defects - abnormalities of the head and face which may affect the eyes, ears, or nose.
• Cleft lip and palate - a birth defect that affects the top lip and the roof of the mouth (palate).

Cleft lip and palate

A cleft lip and palate is the most common form of birth defect in the UK. The care and treatment of babies who are born with a cleft lip and palate is provided by a number of different healthcare professionals, including orthodontists (specialist dentists who can help correct the function and appearance of crooked teeth), ear, nose, and throat (ENT) specialists, speech therapists, and plastic surgeons.

Surgery to repair the lip is usually carried out when your child is three months old. The procedure involves making an incision (cut) on either side of the lip so that the lip can be pulled down and rotated in order to produce a more normal looking appearance, before being stitched into place.

After surgery, a small scar is usually apparent, although the surgeon will try to line up the scar with the natural lines of the face in order to make it less noticeable.

Surgery to repair the palate is usually carried out when your child is six months old. The surgeon will take tissue from either side of the mouth and use it to rebuild the palate and  join the muscles together. In some cases, additional surgery may be required to improve the function and appearance of the lips and mouth.

Skin and tissue damage caused by illness

Plastic surgery can be used to repair and reconstruct damaged tissue resulting from illness or disease. For example, it may be used in the following circumstances.

• Breast reconstruction - following an illness that affects the breast, such as breast cancer, the breast is reconstructed using either prosthetic (man-made material), or tissue from another part of the body.
• Chest wall abnormalities - surgery may be used in cases where the breast bone is concave (bowed inward), a condition that is known as pectus excavatum, or where the breast bone is convex (bowed outwards) - a condition known as pectus carinata.
• Hand and upper limb - plastic surgery may be required in some cases where the joints of the fingers, shoulders, elbows, or wrists are damaged by conditions such as rheumatoid arthritis and osteoarthritis.

Breast reconstruction

Following breast cancer, about 40% of women decide to have a mastectomy in order to prevent further cancer developing in the future. A mastectomy is a surgical procedure where the whole breast is removed.

After having a mastectomy, many women decide to have reconstructive breast surgery. The aim of reconstructive breast surgery is to recreate a breast mound that matches the other, remaining breast. The procedure is performed by a reconstructive plastic surgeon, either at the same time as the mastectomy, or at a later date.

There are two main types of reconstructive breast surgery:

• prosthetic - where artificial implants are used to replace some, or all, of your breast tissue, and
• autogenous - where a new breast is created using tissue taken from another part of your body.

A combination of implant and body tissue are sometimes also used to create a new breast. The type of procedure that is best suited to you will depend on a number of factors, such as the size and shape of your remaining breast, and which procedure you prefer.

If you decide to have prosthetic breast reconstruction, the surgeon will make an incision (cut) in your skin between your ribcage and your pectoral (chest) muscle. The implant will be inserted through the incision, and the surgeon will move it into position.

Once the implant is in position, the incision will be closed using stitches. The implants that are used are sometimes expandable and can be enlarged over 3-6 months to produce a breast of a specific shape and size.

If you decide to have autogenous breast reconstruction, tissue will be removed from your back, buttocks, or abdomen (stomach) and used to create a new breast mound.

The advantage of autogenous breast reconstruction is that a full-sized breast is created immediately. However, it will probably change shape and size slightly during the first few months after surgery.

The other benefit of the autogenous procedure is that it uses natural tissue, giving the breast a natural shape and feel. The obvious downside is that the procedure creates scars in the areas of your body where the tissue is taken from.

Once the newly created breast has had time to settle down, and it has reached its final shape and size, the last stage of the process is to reconstruct and reposition the nipple.

Skin and tissue damage caused by injury

Plastic surgery can be used to repair and reconstruct skin and tissue that is damaged in a range of injuries including:

• Lower limb injuries - for example, fractures and soft tissue injuries to the legs, ankles, and feet.
• Facial injuries - for example, severe lacerations to the face that are caused by an animal bite.
• Burns - people with extensive burns (more than 15% of the body’s surface for adults, and more than 10% for children) may require treatment, including plastic surgery, at a specialist burns centre.

Skin grafts

Skin damage and skin loss can occur following surgical procedures, burns, or other serious injuries. A skin graft is a surgical procedure that involves removing healthy skin from an unaffected area of the body and using it to cover an area where the skin has been damaged or lost.

There are two types of skin graft which are described below.

• Full thickness skin graft - where the epidermis (top layer of skin) and the dermis (the layers of skin underneath) are removed, and the area is closed with stitches. Only a small area of skin will be removed, usually from the neck, behind the ear, or the inner side of the upper arm.
• Partial or split thickness skin graft - where the epidermis and part of the dermis are removed and the area is left to heal over without being closed by stitches. The skin is usually taken from the thigh, buttock, or the upper arm.

If you need to have a skin graft, you may be able to go home on the same day as the procedure, or you may need to stay in hospital. This will depend on the size and location of the affected area.

Before the procedure, you will be given either a general, or a local, anaesthetic. Again, this will depend on the area being treated. The surgeon will remove the skin from the donor site and position it over the affected area. If the skin graft is covering a small area, stitches will usually be used to hold it in place.

For larger areas, the skin graft will either be laid over the area, or secured using clips or stitches. The area will be covered with a sterile dressing until it has healed and has connected with the surrounding blood supply. This will usually take between 5-7 days.

A dressing will also be placed over the donor site to help protect it from infection. The donor area of partial thickness skin grafts will usually take about two weeks to heal. For full thickness skin grafts, the donor area will take about five days to heal.

After having a skin graft, you may experience more discomfort in the area of the donor site than in the area of the skin graft. Painkillers may be recommended to help ease any pain and discomfort.

On returning home, you will be advised to rest the affected area as much as possible in order to let it heal properly. Depending on where the skin graft is on your body, and the type of work that you do, you may be advised to take some time off work.

As with any type of surgery, plastic surgery is not without its risks and complications. The degree of risk depends on the nature of the procedure being carried out - for example, whether the surgery is to a small, or large, area - the level of experience of the surgeon, and the overall health of the person having the procedure.

You should contact your surgeon, GP, or healthcare team immediately if you have any concerns regarding your recovery from a surgical procedure, such as pain, swelling, discharge, or any other unexpected side effects.

Below are some common complications that can occur following cleft lip and palate surgery, breast reconstruction, and skin grafts.

Cleft lip and palate

A cleft lip and palate can have a psychological impact on a young child, particularly as they get older and start to mix with other children. As treatment for the problem can be ongoing and last for many years, you need to be realistic about the possible outcomes of treatment, and ensure that you have a supportive and positive attitude towards your child.

In the long-term, most children who have a cleft lip and palate grow up into well-adjusted adults, and there is no evidence that they experience any more psychological problems than the general population at large.

Children with clefts have an increased risk of developing tooth decay. This is partly due to abnormalities in their tooth development that make it difficult for them to keep their teeth properly cleaned. Children with clefts are recommended to have a dental check-up at least once every six months.

Breast reconstruction

Over the last decade, breast reconstruction surgery has improved significantly. However, there are a number of possible problems that can occur either immediately after the procedure or some time afterwards.

Immediate problems

Problems that can occur immediately after breast reconstruction surgery include:

• infection,
• fluid under the wound,
• flap failure, and
• pain and discomfort.

If the area around the breast implant becomes infected, you will need to have antibiotics. The infection should clear up in around a week. However, if infection reoccurs, you may need to have the implant removed, and you will have to wait for about three months before having another one fitted.

Following surgery, it is normal for fluid to be produced. Any fluid that is produced can usually be drained away through a tube. However, any excess fluid build up may need to be removed using a needle and syringe. If fluid keeps building up, you may need to have your implant temporarily removed.

Sometimes, the flap of tissue that is used to make a new breast can die. This is less likely to happen if the flap that is used is connected to its original blood supply. This is known as a pedicled flap.

There is a small chance (a 3-5% risk) that the flap will fail completely and die. If this happens, you will need to have surgery to remove it. You will then need to wait between 6-12 months before having reconstructive surgery again.

Following breast surgery, you may experience some pain and discomfort. If you have severe pain and discomfort, you may need to have a painkilling injection for the first 24 hours after the operation. Less severe pain can be treated with painkilling tablets.

Long-term problems

Long-term problems that can develop after breast reconstruction surgery include:

• the implant hardens and changes shape,
• fluid leaks from the implant,
• unequal sized breasts due to changes in your weight, and
• the implant needs to be replaced.

Sometimes, following breast implant surgery, a fibrous (tough) capsule can form around the implant. The materials that implants are made from are safe, but the implant itself is still a foreign object which your body may react adversely to.

It is also possible that over several years, the capsule may shrink and put pressure on the implant. This occurs in around 16% of cases, making the breast hard and painful. If this happens, you may need to have the implant removed.

The risk of implants leaking is fairly low because the liquid inside them is quite thick. A leak will usually only occur if you have a serious injury to your breast. Minor knocks to your breast, or travelling in a plane, will not cause a problem. In the unlikely situation that a leak does occur, the lymph glands under your arms may swell up.

If you lose or gain weight after having a breast reconstruction, the size of your breasts may appear uneven. It is not always possible for surgeons to get a perfect match when performing a breast reconstruction, but they may be able to make them more even by carrying out further surgery. Alternatively, they could put in a larger, or smaller, implant.

It is possible that your breast implant may need to be replaced at some stage. It is not known exactly how long modern breast implants last for. However, it is estimated that they should last at least 10-15 years, although they may last longer.

Skin grafts

After having a skin graft, you may experience bleeding, or the skin graft may become infected. Contact your GP, or healthcare team, if your skin graft is painful, red, or inflamed (swollen).

If you smoke, your risk of developing problems with your skin graft is increased.

Following a skin graft, you will have scars, both at the site of the skin graft and at the place where the skin was taken from. However, over time, these will gradually start to fade. Using an emollient (moisturiser) may help to keep the skin around the scars soft and supple.

There is likely to be a difference in the colour of your grafted skin and the skin surrounding the graft. If you feel uncomfortable about this, special camouflage make-up is available to help minimise the differences in skin colour.