Skin Reconstructive Surgery

Reconstructive surgery is the mainstay of a plastic surgeon's work.

Most people equate plastic surgery with cosmetic surgery, but this is only a small part of the speciality, and most is reconstructive.

Tagliacozzi aptly described the essence of plastic surgery when he said:

"We restore, rebuild, and make whole those parts which nature hath given, but which fortune has taken away. Not so much that it may delight the eye, but that it might buoy up the spirit, and help the mind of the afflicted."

G Tagliacozzi 1545-1599

What is reconstructive surgery?

From the head to the toes, and from newborn babies to the very elderly, reconstructive surgery is used to treat a wide range of conditions.

Reconstructive surgery aims to repair defects and restore function. It is performed to correct structures affected by birth defects, developmental abnormalities, trauma/injuries, infections, tumours and disease. Additionally, plastic surgery is an effective and neat way to treat minor “lumps and bumps”.

Using a wide range of reconstructive techniques, plastic surgeons mend holes and repair damage primarily through the transfer of tissue from one part of the body to another. The main aim is to restore function of a specific part of the body and heal wounds as quickly as possible.

Reconstructive surgery also aims to improve and restore appearance. Wherever possible we attempt to minimise the visual impact of the initial wound or defect, and the impact of the surgery itself.

Cosmetic surgery is simply an extension of reconstructive surgery in which the main functional gain to be expected is an improvement in appearance.

Why Plastic Surgeons?

The word ‘plastic’, which comes from the Greek ‘plastikos’, meaning to mould or shape, indicates that repair is generally brought about by moving tissues. The scope and range of surgical expertise in plastic surgery has improved dramatically in the last thirty years and it is a constantly evolving speciality which uses cutting edge techniques to achieve the best results.

As a result of a recent surge in knowledge and skills within the speciality, the techniques used by plastic surgeons today are relatively new. Whereas plastic surgeons once dealt mainly in skin grafts, reconstructive surgery now consists of a range of powerful procedures involving the movement of large pieces of tissue, with connective structures, around the body.

The revolution in plastic surgery techniques occurred in the last three decades of the twentieth century, when surgeons applied a new understanding of the blood supply of tissues, or the vascular system, to enable the development of a large number of flap operations. Now, flap surgery and microsurgery have vastly improved plastic surgeons’ abilities to help restore function and form for severely injured or disfigured patients.

What techniques are used?

The main techniques used by plastic surgeons in reconstructive procedures are:


Skin Grafts

A skin graft involves taking a healthy patch of skin from one area of the body, known as the donor site, and using it to cover another area where skin is missing or damaged. The piece of skin that is moved is entirely disconnected and requires blood vessels to grow into it when placed in the ‘recipient site.

There are three basic types of skin grafts. These are:

Split thickness skin graft

Split thickness skin graft

Commonly used to treat burns or other injuries, using only the layers of skin closest to the surface.


In a split thickness skin graft the surface layer of the skin (epidermis) is removed along with a portion of the deeper layer of the skin (dermis). Part of the dermis is left behind on the donor site and this enables the donor site to heal up in the same way as a graze.

Full-thickness skin graft

Full-thickness skin graft

Often used to treat relatively small defects on the face or hand; all layers of skin from the donor site are used. In a full thickness skin graft the entire dermis and its overlying epidermis is removed. The donor site wound is closed with stitches.

Composite graft

Used to treat wounds have a complex shape or contour, such as following removal of a skin cancer from the nose; the graft comprises all layers of skin, fat and sometimes the underlying cartilage from the donor site.


Tissue Expansion

Tissue expansion is a procedure that enables the body to ‘grow’ extra skin by stretching surrounding tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired, and is then gradually filled with salt water, causing the skin to stretch and grow. The time involved in tissue expansion depends on the individual case and the size of the area to be repaired.

Flap Surgery

Flap reconstruction involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessel that keeps it alive. Unlike a skin graft, flaps carry their own blood supply, so can be used to repair more complex defects. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support. There are three main types of flap.

These are:

Local Flap

Local Flap uses a piece of skin and underlying tissue that lie near to the wound. The flap remains attached at one end so that it continues to be nourished by its original blood supply and is repositioned over the wounded area.


Local flap

In the diagram above’s case, a skin cancer has been removed from the nose leaving a defect that cannot simply be stitched up.  A local flap, called a bilobed flap is used to close the defect. The flap consists of skin along with the underling soft tissue and its blood supply.

A local flap like this relies on the fact that the skin has some natural elasticity and uses the lax skin in the bridge of the nose to close a defect near the tip of the nose where the skin is naturally tight.

Regional Flap

Regional flap

Uses a section of tissue that is attached by a specific blood vessel. When the flap is lifted, it needs only a very narrow attachment to the original site to receive its nourishing blood supply from the artery and vein.

This picture shows muscle from the calf being transferred, keeping its blood supply intact to cover an open fracture below the knee.


Images on this page are courtesty of BAPRAS.

Free Flap / Microsurgery

Free flap reconstruction also involves the transfer of living tissue from one part of the body to another, along with the blood vessel that keeps it alive. 

A free flap is a further modification of flap transfer where the flap is entirely disconnected from its original blood supply and then reconnected using microsurgery in the recipient site. The following are two examples of free flaps.

Free flap - microsurgery

In this image, the patient has an open fracture of his right lower leg. A muscle is taken from his inner left thigh and transferred to his right leg. The blood vessels that keep this muscle alive are dissected out of his left thigh along with the flap, divided, and then joined up micro-surgically to blood vessels in his right leg. This keeps the flap alive in its new position. To complete the reconstruction a split skin graft is taken from the left thigh and laid over the free muscle flap. This is called a free gracilis muscle flap.


This procedure involves hooking up the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name microsurgery.

The ability to disconnect and reattach tissue in this way means that the reach of flap is no longer confined by a patient’s anatomy.

More than any other technique, microsurgery has revolutionised plastic surgery as a specialty and is now the definitive treatment option for patients with cancer and major trauma.

Free flap - microsurgery

In this example of a free flap a portion of skin and fat of the patient’s lower abdomen is transferred to the chest to reconstruct a breast. The blood vessels that keep this tissue alive are divided as they emerge from the groin area and rejoined micro-surgically to blood vessels in the chest in order to restore the blood supply to the flap. This is called a free TRAM flap breast reconstruction.