Plastic surgery - How plastic surgery is performed

Plastic surgery can involve a number of different techniques to move and manipulate body tissue.

Before having plastic surgery, you should have a consultation with a plastic surgeon. They will explain in detail what will happen before, during and after surgery. You may also be given a psychological assessment.

Plastic surgery used to be confined to a procedure called a skin graft, but newer techniques such as tissue expansion and flap surgery are often used these days. These techniques are discussed in more detail below.

Skin grafts

A skin graft is a surgical procedure that removes healthy skin from an unaffected area of the body and covers the lost or damaged skin.

Skin grafts may be used for bone fractures that break the skin (open fractures), large wounds, surgical removal of an area of the skin (for example, due to cancer), burns and cleft lip and palates.

There are two main types of skin graft:

• a full thickness skin graft – where the top layer of skin (epidermis) and all the layers of skin underneath (dermis) 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
• a partial or split thickness skin graft – where the epidermis and a smaller part of the dermis are removed, and the area is left to heal without being closed by stitches; the skin is usually taken from the thigh, buttock or upper arm

Before the procedure, you'll be given a general anaesthetic or a local anaesthetic, depending on the area being treated. 

You may be able to go home on the same day as the procedure, or you may need to stay in hospital. It will depend on the size and location of the affected area.

The skin graft will usually be held in place using stitches, staples, clips or special glue. 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 five to seven days.

A dressing will also be placed over the area where the skin has been taken from (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 takes about five days to heal.

After having a skin graft, it's common to feel more discomfort in the area that the skin was taken from rather than in the skin graft. Painkillers may be recommended to help ease any pain and discomfort.

When you return home, you'll be advised to rest affected areas as much as possible to help them heal properly. Depending on the location of the skin graft and the type of work you do, you may be advised to take time off work.

Tissue expansion

Tissue expansion is a procedure that enables the body to 'grow' extra skin by stretching surrounding tissue. This extra skin can then be used to help reconstruct the nearby area.

Examples of when tissue expansion may be used include breast reconstruction and repairing large wounds.

The technique involves inserting a balloon-like device called an expander under the skin near the area to be repaired. This is then gradually filled with salt water, causing the skin to stretch and grow over time.

The operation to insert the expander can be carried out under general or local anaesthetic.

The time involved in tissue expansion can vary, and largely depends on the size of the area to be repaired. If a large area of skin is involved, it can take as long as three or four months for the skin to grow enough. During this time, the expander will create a bulge in the skin.

Once the skin has expanded sufficiently, a second operation is needed to remove the expander and reposition the new tissue.

This technique ensures that the repaired area of skin has a similar colour and texture to the surrounding area. There is also a lower chance of the repair failing (see complications of plastic surgery for more information) because the blood supply to the skin remains connected.

Flap surgery

Flap surgery involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessels that keep it alive.

Flap surgery may be used for a variety of reasons, including breast reconstruction, open fractures, large wounds and improving cleft lip and palates.

In most cases, the skin remains partially attached to the body, creating a 'flap'. The flap is then repositioned and stitched over the damaged area.

Occasionally, a technique called a free flap is used. This is where a piece of skin, and the blood vessels supplying it, are entirely disconnected from the original blood supply and then reconnected at a new site. A technique called microsurgery (surgery using a microscope) is used to connect the tiny blood vessels at the new site.

Depending on the location and size of the flap, the operation can be carried out under general or local anaesthetic.

As flap surgery allows the blood supply to the repaired area to be maintained, there is a lower risk of the repair failing compared to a skin graft.