PLASTIC SURGERY
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struction of the radical pelvic cancer surgery defects with flaps
transferred into the pelvis. This procedure was originated by UofL
Plastic Surgery, which maintains international recognition as a
center for these reconstructions. Another set of pioneering cancer
reconstructions coming from UofL Plastic Surgery is reconstruction
of head and neck cancer resections by microvascular flap transfers,
in which Louisville again remains a center.
CONGENITAL DEFECT AND CRANIOFACIAL RECON-
STRUCTION
Among the most common birth defects are clefts of the lip and
palate. Procedures developed in past centuries attempted to ad-
dress these problems, but with limited success. A significant step
forward occurred in the 1950s when plastic surgeon Ralph Millard,
MD, of Miami devised a cleft lip repair which gave a significantly
more normal appearance. Severe congenital deformities such as
misshapen faces and skulls remained vexing unresolved problems
until plastic surgeon Paul Tessier, MD, of Paris made major break-
throughs in the 1960s. He almost singlehandedly created the field
of craniofacial surgery.
BURN CARE AND RECONSTRUCTION
Thermal burns represent a substantial source of mortality, principally
secondary to high vulnerability to infection in the devitalized skin
of full thickness (third degree) burns. A significant step forward
occurred in the 1960s, with recognition of the value of excising the
dead tissue shortly after the injury and before infection could set
in, a process called “early excision.” An effective component of this
strategy was layered removal of the burned tissue with skin graft
knives that could shave burned tissue in thin layers until a precise
interface with living tissue was defined, followed by prompt skin
grafting. This technique was developed in 1970 by Yugoslavian
plastic surgeon Zona Janzekovic, MD. In the late 1970s, UofL plastic
surgeons at the burn care unit of Norton Children’s Hospital became
among the first American users and proponents of this technique,
with demonstrably superior mortality and functional outcomes.
It has now become a mainstay of therapy internationally and is
skillfully practiced at the UofL Hospital Burn Unit, where plastic
surgeons and general surgeons collaborate to bring excellence in
burn care to Kentucky and beyond. Plastic surgeons associated with
burn units also encounter substantial challenges in addressing the
scar deformities and contractures affecting limb joints and facial
features.
HAND SURGERY
Hand surgery draws practitioners from plastic surgery, orthopedic
surgery and general surgery. Major improvements in hand injury
care came out of World War II. Subsequently, Louisville surgeons
Harold Kleinert, MD, and Joseph Kutz, MD, made a significant
breakthrough in flexor tendon repair that captured international
acclaim. Another breakthrough occurred with the development of
28
LOUISVILLE MEDICINE
microvascular techniques that allowed small upper extremity vessel
repairs and replantation of traumatic amputations. Louisville became
a leader in this arena, with Kleinert, Kutz and Associates creating a
major replantation center at Jewish Hospital, and with pioneering
instruments and training techniques that were developed by Dr.
Robert Acland in the Plastic Surgery Laboratory at UofL. These
activities provided key infrastructure for achieving hand and face
transplantations. As described elsewhere in this volume, the world’s
first long-term success in transplantation of skin-bearing structures,
a hand transplant, occurred here twenty years ago. This established
a field called “Vascular Composite Allotransplantation” that has be-
come one of the most exciting activities in contemporary medicine.
RECONSTRUCTION OF TRAUMA
Reconstruction of traumatic injuries is a mainstay of plastic sur-
gery. In addition to replantation of severed limbs, repair of facial
fractures is a major activity, with significant numbers coming from
motor vehicle accidents. This field draws practitioners from plastic
surgery, oral and maxillofacial surgery, and otolaryngology. These
specialties often work together in teams where the most severe
injuries are brought, such as the UofL Hospital Level One Trauma
Center. A major advance in this field was development of rigid
internal fixation devices, which are small strong frames attached to
fractured bones with screws to solidly immobilize healing fractures
of the craniofacial skeleton, hands and feet.
BODY CONTOURING
Contemporary nutrition habits have generated more people with a
greater body mass index than in previous eras. This situation gave
rise to bariatric surgery and non-surgical programs that produce
massive weight loss. However, afterwards, patients are usually left
with substantial amounts of excess skin. Body contouring surgery
has been developed to address this, with large excisions of excess
skin in affected body areas. Along with body contouring, chal-
lenging hernias and defects of the abdominal wall must often be
addressed. These create major technical challenges for involved
plastic and general surgeons, and their repair is a substantial focus
of current activity.
FRONTIER OF PLASTIC SURGERY
Today, there are many promising frontiers for plastic surgery. These
include the transplantation of hands, faces and other body parts.
Also, intensive laboratory investigation is developing tissue engi-
neering of organs and body parts. Although just entering clinical
application, this will likely become the next exciting frontier of
plastic surgery. As long as human needs call, the field of plastic
surgery will surely respond with creative ingenuity and dedicated
commitment.
Dr. Tobin is a professor at the University of Louisville School of Medicine,
Department of Surgery, Division of Plastic and Reconstructive Surgery.
He practices with UofL Physicians-Plastic and Reconstructive Surgery.