Operating Principles for Plastic Surgeons
Principle 1: Plan the procedure preoperatively. Many top sportsmen have a plan in their minds before a stroke is executed—so-called creative visualization. The plastic surgeon should do the same. The planned incisions must be marked preoperatively. In addition, draw “cross-hatching” marks perpendicular to the incision to facilitate accurate tissue apposition.
Principle 2: Preoperative patient position. The patient’s position will affect ease of surgical access (e.g., where the surgeon operates from above the patient, place the patient’s head very close to the top edge of the operating table).
Principle 3: Use of local anaesthetic. It is important to become conversant with regard to local anaesthetics. I have found that commercial preparations such as lignocaine with adrenalin and bupivacaine are painful when injected because of their pH. Thus, mix one’s own local anesthetic solution and include a buffer—which is less painful when injected.1 First, inject subcutaneously; then, inject intradermally along the incision lines. Always add a vasoconstrictor (epinephrine) to the local anesthetic to lengthen local anesthetic time and reduce blood loss.
Principle 4: Precision is a plastic surgery aphorism. This starts with the skin incision. The skin should always be stretched before inflicting the incision. In addition, the scalpel blade must be applied perpendicular to the skin. Hold the scalpel like a pen and steady the hand by extending the little finger as a pivot point of contact with the patient.
Principle 5: Always irrigate before wound closure. There is always some injured tissue after dissection and use of diathermy. Necrotic fat globules will act as foreign bodies, which increases inflammation and predisposes to wound infection. Copious irrigation helps to remove debris.
Principle 6: Always close dead space. Dead space acts as a reservoir for the collection of blood and fluid. This delays tissue apposition, and acts as a potential source of infection. The value of quilting sutures has been shown after, for example, abdominoplasty,2 face lift,3 and latissimus dorsi flap4 harvest.
Principle 7: The dressing is part of the operation in plastic surgery. Immobilize the incision with tape and apply a dressing that absorbs exudate and promotes wound healing.
Principle 8: Reduce postoperative edema. Edema causes pain and delays wound healing. A procedure on the face requires that the patient sit in a semi-Fowler position, for example.
Principle 9: Postoperative analgesia. Start the postoperative analgesia before the local anaesthetic wears off to ensure that the patient’s pulse and blood pressure are not raised because of pain, which may lead to hematoma formation. Similarly, both arterial and venous pressures will increase in a vomiting patient, which also predisposes to a bleed.
Principle 10: Pressure garments and strapping. Tissue can be molded by strapping and pressure garments.
Regular practice of these principles can improve outcome.