Editorial
More Caveats for Plastic Surgeons
Donald A. Hudson, F.R.C.S.
Cape Town, South Africa
Plastic surgery is a rapidly growing and evolv-
ing specialty. Newer techniques are described,
newer flaps are performed, and variations of ex-
isting techniques are applied. This rapidly evolv-
ing surgical specialty also allows for originality.
It is imperative that, as the discipline evolves,
principles and caveats are established. These
are necessary to minimize complications and
yield satisfactory results. These principles also
serve as building blocks for those beginning
their careers in plastic surgery.
10 CAVEATS
Caveat 1: When Marking a Proposed Incision, Never
Draw a Straight Line Unless it Lies in the Relaxed Skin
Tension Lines
All plastic surgery operations are pre-
planned. Usually this means marking the skin
before making the incisions. A major factor
affecting the quality of the scar is the direction
of the incision. It is a plastic surgery caveat that,
where possible, the incision should be placed
in a relaxed skin tension line. This is not always
possible, however, in which case, the incision
should assume a sinusoid or wavy pattern or a
series of Z-plasties should be used.
It must also be remembered that all scars
contract. This may have aesthetic (and func-
tional) consequences on a convex surface, for
example. A wavy scar, when it contracts, has
less effect on the surrounding tissue than a
linear scar. It seems strange in retrospect that
the bicoronal incision was performed as a
straight line for decades. Only relatively re-
cently has it been recognized that this would
not yield the best possible scar.1
Caveat 2: Caveats to Consider When Using Prosthetic
Tissue
It is a recognized principle that autologous
tissue should always be used in preference to
prosthetic materials. However, the former in-
volves donor-site morbidity and the latter are
becoming more biocompatible.
If prosthetic tissue is used, the following ca-
veats apply, whether the substance is simply
injected (e.g., for lip augmentation) or in-
serted in a formal operation:
1. The incision for insertion should be distant
to the site of placement.
2. Two-layer closure of the pocket is required.
3. The soft-tissue cover should have good vas-
cularity. For example, prosthetic material
should not be used where there is poor
vascularity, such as after radiation therapy.
4. The pocket for the prosthetic material must
be big enough to allow it to “sit” with ease.
There should be no tension on the pros-
thetic material or extrusion will occur.
5. The prosthetic material, particularly when
solid, needs to be fixed to prevent migra-
tion. Fixation can be with sutures, wires, or
screws. The greater the degree of fixation,
the less likely migration is to occur.
6. Prosthetic material that cannot be easily re-
moved should not be inserted.
7. Prophylactic antibiotics should always be
given.
Caveat 3: Learn to Classify and Work from the
Classification
Classification is important in working out a
plan of management. A breast with mild ptosis is
managed differently than one with severe ptosis,
for example. Similarly, it is also important to
Received for publication December 31, 2003; revised February 11, 2004.
DOI: 10.1097/01.PRS.0000128349.08220.24
584
assess one’s results critically. The classification
system should always be as simple but as compre-
hensive as possible. Often in plastic surgery, sur-
geons tend to be so impressed with their results
that critical assessment is not undertaken.
Caveat 4: The Ability to Think, Analyze, and
Understand Is a Surgeon’s Greatest Asset
The surgeon’s greatest faculty is not the dex-
terity of his hands but rather the aptitude and
function of his cerebral cortex. Most surgeons
who are committed to their profession, with
experience and proper teaching, become tech-
nically able and adequate. Of course there will
always be the “gifted,” but these are few and far
between.
It is vital that the surgeon be able to analyze
and think critically. The specialty has grown so
rapidly that we are consumed with learning
how to perform a technique rather than un-
derstanding the mechanics of that technique.
The technique of breast reduction serves as an
example. The surface markings and technique
are often so intricate that the mechanics of
how reduction is actually achieved are lost.
It is also important to assess one’s own work
critically. For example, why did ectropion oc-
cur after blepharoplasty when excessive skin
was not excised? One must also understand
how a new technique achieves its effects before
embarking on the technique.
Caveat 5: Choose a Safe Technique in Cosmetic Surgery
There are now a myriad of surgical techniques
for every cosmetic problem, and choosing a tech-
nique can be difficult. There are many tech-
niques for rhytidectomy, for example, including
subcutaneous dissection, superficial musculoapo-
neurotic system plication, or undermining and
suturing, and deep plane, subperiosteal, mini, or
endoscopic methods, to name but a few. How
does one choose the “best” technique? Further-
more, as time progresses, newer and purportedly
better techniques will be published. The authors
of these articles will usually claim that their tech-
nique is the best available.
It is very difficult to justify a major complica-
tion occurring for a purely cosmetic indication.
Thus, before embarking on a new rhytidectomy
technique, for example, in which the facial nerve
is more at risk, one must ensure that the (poten-
tial) result is so much better that it is worth the
risk. Liposuction combined with abdominoplasty
may enhance the cosmetic result, but it is also
fraught with complications. Choose a safe proce-
dure that yields a satisfactory result rather than a
potentially “spectacular” procedure with horrific
complications. In almost anyone, carefully
planned aesthetic surgery should lead to some
improvement in appearance.
Caveat 6: There are Complications in Cosmetic
Surgery
If you develop a complication, particularly in
cosmetic surgery, wear the patient out (not vice
versa).
We all have complications. Some occur de-
spite what we do, others occur because of us.
Complications embarrass us and we tend to
want to wash our hands of them—and the pa-
tient. This is a medicolegal time bomb. It is
better to see the patient whenever he or she
requests and to always be supportive and help-
ful. In fact, arrange to see the patient in your
office so often that you wear the patient out!
This is one very good way to prevent the stress
and heartache of a legal proceeding. Also bear
in mind that the patient, not the surgeon, is
“suffering” the complication.
Caveat 7: A Triangle is a Plastic Surgeon’s Best Friend
In this specialty, we frequently work with
“lines” or tissues of different lengths. A good way
to attain equal length in this situation is to add or
excise a triangle of tissue. This principle has been
applied in cleft lip repair,2 where one side of the
lip is larger than the other side. A Z-plasty is an
example of two triangles that are transposed.
A triangle interposed into a straight line
breaks up the long scar and inhibits scar retrac-
tion.3 It may also confer aesthetic advantages.
Caveat 8: There Are Other Ways to Deal with Lines
of Unequal Length
Often in plastic surgery an ellipse is de-
signed, but because of the configuration of the
lesion, the limbs of the ellipse have different
lengths. A triangle of tissue (as described
above) is one solution, but there are occasions
where this is not desirable.
If the discrepancy between the limbs is not too
big, differential suturing (“stealing stitches”) is all
that is required. When there is a greater discrep-
ancy in length, in principle, one line can be
made longer or the other can be made shorter,
or both methods can be used (Fig. 1).
Remember, dog-ears commonly arise from two
situations: the angle of the ellipse is too obtuse,
or the length discrepancy between the two limbs
is too great to allow for a “stealing” stitch.
Vol. 114, No. 2 / EDITORIAL 585
Caveat 9: In Plastic Surgery, Always Think Blood
Supply
Almost all plastic surgical procedures involve
a flap of some sort. It is critical in any proce-
dure to be fully aware of the blood supply of a
flap. Flap failure occurs for the following rea-
sons: poor design, hematoma, and infection.
The most common factor in poor design is
excessive tension, which leads to ischemia and
subsequently necrosis (blood supply is im-
paired). Hematoma also causes tension to the
flap, leading to ischemia and infarction (indi-
rect injury to blood supply). In infection, the
inflammatory process leads to vessel infarction
and hence flap necrosis (loss of blood supply).
Flap failure serves to emphasize the impor-
tance of always considering blood supply. In
abdominoplasty, for example, the upper ab-
dominal flap is depleted of its usual main
blood supply from the perforators of the supe-
rior epigastric systems. The flap now relies on
perforators from the lateral intercostal vessels.
This is the reason why a “minor” insult to the
blood supply (caused by liposuction or tension
on the flap) is hazardous.
Caveat 10: Put Function before Form and Form
before Scarring
I claim no originality in this regard. This
caveat has apparently been known for decades,
yet I have not seen it highlighted in any plastic
surgery textbooks. It is a crucial caveat, partic-
ularly in reconstruction, and it has particular
relevance to reconstruction after major burn
injuries and severe and extensive trauma.
THE HAND: TWO IMPORTANT CAVEATS
Because plastic surgeons are also involved in
hand surgery, two important caveats deserve to
be emphasized.
First, flexion is more important than exten-
sion. It has been said that finger extension is a
cosmetic action. Most of the activities of daily
living, for example, holding a cup or a pen and
buttoning clothing, involve flexion. Hence, in
principle, it is our policy in the surgical treat-
ment for Dupuytren’s disease, for example, to
splint the hand in extension after release of a
contracture. However, at the 1-week postoper-
ative visit, physiotherapy is arranged to ensure
that full finger flexion is achieved before finger
extension is tended to.
Second, one pump of the hand is worth 24
hours of elevation. This caveat is to stress that
“active” works better than “passive.” When the
patient makes a fist, not only is edematous fluid
mobilized but also the joints of the hand are
mobilized, thereby inhibiting periarticular fi-
brosis and the potential for stiff joints.
Prof. Don A. Hudson, F.R.C.S.
Department of Plastic Reconstructive Surgery
Groote Schuur Hospital
H53 OMB
Observatory 7925
Cape Town, South Africa
hudsond@uctgsh1.uct.ac.za
REFERENCES
1. Munro, I. R., and Fearon, J. A. The coronal incision
revisited. Plast. Reconstr. Surg. 93: 185, 1994.
2. Randall, P. A. Triangular flap operation for the primary
repair of unilateral clefts of the lip. Plast. Reconstr. Surg.
23: 331, 1959.
3. Hudson, D. A. Maximising the use of tissue expanded
flaps. Br. J. Plast. Surg. 56: 784, 2003.
FIG. 1. (Above) Line ab is longer than line cd. (Center) The
surgeon can make line ab shorter (original line ab is shown as
a dashed line). (Below) The surgeon can make line ab shorter
and line cd longer by lowering the apex point db.
586 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004