Modern reconstructive surgery and its history

Reconstructive surgery- one of the most complex and versatile branches of medicine. The essence of reconstructive medicine is the restoration of a lost or deformed (as a result of injury or from birth) part of the human body, not only anatomically, but also functionally. Of course, the restored organ should look as natural as possible, which is why reconstruction is closely related to aesthetic plastic surgery (surgery). It is worth noting that this branch of medicine has begun to develop at a particularly rapid pace over the last 50 years. This is largely due to the deep study of human microscopic anatomy and the development medical equipment. Since microsurgical optics and instruments were created, surgeons have been able to operate on the thinnest vessels and nerves. We can say that at the same time a new branch of medicine appeared - microsurgery. A revolutionary leap has been made from simple skin grafting to complex flap transplantation, organ and limb reconstruction. Until now, surgical methods and optical instruments continue to be improved; every year operations become more complex and their efficiency increases.

Historical stages in the development of reconstructive surgery

1st century AD - separate references to attempts at surgical corrections of the nose, ears, and facial skeleton;
XVI century - in 1597 the first treatise on it appeared under the authorship of Tagliacozzi (Italy)
XIX century - as before, operations (surgery) are aimed more at aesthetic correction than at the full restoration of all physiological functions. Positive results single.
XIX-XX centuries - anesthesia is used during operations, the doctrine of asepsis and antiseptics is being developed - this allows for more complex operations and exclude complications such as pain and septic shock. Skin grafting operations are performed using free flaps and pedicled flaps. The introduction of bone grafting operations is beginning, which makes it possible to restore deep defects. In the early 70s. Transplants of complex tissue complexes began to be carried out, the blood flow of which was restored by connecting the thinnest vessels with a diameter of up to 1 mm. Subsequently, such microanastomoses began to be applied to nerves.
Currently, any movement of tissue occurs taking into account the anatomy of the blood supply and innervation of the flap, as well as the biomechanics (features of muscle and tendon movement) of the donor area. During manipulations it is used
microsurgical instruments, magnifying optics, ultra-thin suture material.

Main directions of reconstructive surgery

• Surgery for skin defects:
  • Extensive burns
  • Disfiguring scars and cicatrices
  • Extensive pigment and vascular benign formations
• Tendon surgery:
  • Primary injury
  • Scar changes in tendons, contractures
• Surgery for muscle defects:
  • Muscle injury
  • Disturbance of muscle innervation
  • Impaired blood supply to muscles

Areas of application of reconstructive surgery

• Post-traumatic and postoperative dysfunction and shape of various parts of the body and limbs (hands, feet, chest, ears, nose, mammary gland, etc.)
• Congenital defects of any localization (absence or underdevelopment)
• correction of unsatisfactory results after .

The use of autografts (materials obtained from the patient himself) allows us to minimize the possibility of rejection of the transplanted tissue. Now doctors have the opportunity to take for transplantation and reconstruction not only a flap of skin, but also complex grafts consisting of several tissues - skin, muscles, bones.
The choice of graft is the art of the surgeon and will determine the successful outcome of the operation. Correct selection carried out on an individual basis only during an in-person examination. Not only the initial state of the existing defect and the capabilities of the donor areas are taken into account, but also the patient’s requirements for the future appearance of the donor areas and the transplant area. The size of the flap is selected so that when correcting the defect there is no excessive tension along the edges of the skin, which can lead to necrosis of the graft. Typically, the size of the graft is slightly larger than the area of ​​the defect.

General principles of reconstructive operations

• Taking a graft on a vascular pedicle
• Graft transplant
• Adaptation of the transplanted flap to the new bed
• The period of rehabilitation and restoration of organ function

Evaluation of the results of the operation

Evaluation of the results of reconstructive operations should be carried out in a multi-stage manner. At the first stage, the engraftment of the graft to the bed is assessed. It should be borne in mind that even with a very experienced surgeon, the failure rate is 1-5%. At further stages, the gradual restoration of the functions of a particular zone is assessed.

Reconstructive surgery originates from ancient centuries. Still in excavations Ancient Egypt, Peru and Urartu, skulls with devices for osteosynthesis of bones were discovered. Modern reconstructive facial surgery is a relatively young field that deals with the restoration and treatment of damaged tissues of the human body after severe injuries, burns, oncological operations, and for correction congenital pathology development. After many congenital and acquired pathologies, a person experiences serious violations vital functions: swallowing, nasal breathing, chewing. As a rule, such violations are accompanied by a violation of facial aesthetics, which clearly leads to loss vital activity human and mental disorders.

Recovery operations V maxillofacial surgery are carried out to eliminate defects by recreating lost (partially or completely) organs or tissues of the face and neck with the subsequent restoration of their function and integrity. Why is the technology of moving one’s own tissues used or microsurgical technique for transplanting a large complex of tissues?

Reconstructive surgery is aimed at eliminating deformations caused by trauma or post-traumatic process.

Indications for use reconstructive operations - these are congenital and acquired defects and deformations:

• soft tissues and bones of the face (jaw, eye sockets, frontal bone, oral cavity, nasal and zygomatic areas, nasal cartilage);
• violation of facial aesthetics and facial expressions;
• chewing dysfunction;
• difficulty or inability to speak;
• difficulty breathing;
• complete or partial absence of the bones of the facial skeleton and adjacent soft tissues (eyeballs, ears, eyelids, etc.);
• damage to tissue and bones as a result of operations for tumors and radiation therapy.

Contraindications restorative and reconstructive operations include mental disorders, infectious diseases, skin pyoderma, ulcerative stomatitis, inflammatory processes in the lymph nodes, sinuses, pharynx, general malaise and age of the patient.

In the Federal State Budgetary Institution Scientific Center of Otorhinolaryngology, Federal Medical and Biological Agency of Russia, reconstructive operations are carried out qualified specialists Scientific and Clinical Department of Maxillofacial Surgery under the leadership of Doctor of Medical Sciences, Professor A.S. Karayan.

Operations performed on the face, oral cavity, neck, and limbs are complex jewelry art that requires not only the special professional skills of the surgeon, but also special tools, special suture material, surgical equipment, operating rooms. Our Center has the most modern clinical facilities to perform such complex operations, including diagnostic equipment and its own laboratory (the only laboratory in Russia) for the production of ectoprostheses necessary for patients. All department employees have scientific degrees and big practical experience in maxillofacial surgery, actively use not only the best domestic and foreign techniques, but also apply their own developments and methods in their work. All this allows for a comprehensive examination of the patient, necessary treatment and provide highly qualified assistance.

To carry out restorative and reconstructive operations, the Center’s specialists conduct a thorough study of the nature of the injury, associated pathological changes using radiography, CT or MRI. The patient undergoes examination and consultation with doctors of related specialties - a neurosurgeon, an otolaryngologist and an ophthalmologist.

Patients undergo a detailed examination and study of the features bone tissue in the defect area using 3D modeling, which is necessary for the production of an individual stereolithographic model when modeling the transplant. In the non-profit organization of maxillofacial surgery, developed and implemented clinical practice some unique techniques for the restoration and reconstruction of the face and neck in patients who have suffered complex oncological diseases, injuries, burns, gunshot wounds.

Only A complex approach to the assessment of all positions makes it possible to accurately determine the size of damage, identify the boundaries of preservation of areas of bones and soft tissues, and develop tactics further treatment and patient recovery.

Post-traumatic deformities of the zygomatico-orbital complex– the most common in the practice of maxillofacial surgeons. Fractures of the walls of the orbit can be isolated and in combination with fractures of the zygomatic, maxillary, frontal, temporal bones, and often with the bone base of the nose. Considering that the above bones partially or completely form the walls of the orbit, their fracture involves an orbital fracture. Therefore, a displaced fracture of the zygomatic bone is always a zygomaticoorbital fracture.

As for isolated fractures of the bones of the orbit, in this case its bottom and medial wall, which are “ weak points", limiting the orbit from the paranasal sinuses, and having the thinnest bone wall; Such fractures are called “blowout” or “blowout” fractures. The cause of such fractures is most often a blow to the eyeball with a blunt object. According to the laws of physics, an impact causes elastic deformation of the eyeball due to a short-term change in hydraulic pressure in it. In turn, the resulting elastic deformation causes mechanical stress in the surrounding soft tissues, which causes destruction of the orbital walls. With this type of fracture, the edges of the orbit remain intact, and the soft tissue component can displace and penetrate into the paranasal sinuses. Isolated orbital fractures occur in 16.1% of cases of fractures involving the orbit.

Zygomatic-orbital fractures occur quite often (in 64% of patients with injuries to the upper and middle zones of the face) as a result of motor vehicle injuries, impacts and falls from a height, while the zygomatic bone breaks more often along the zygomatic-maxillary, zygomatic-frontal, zygomatic-temporal buttresses and shifts, involving a fracture of the lower, less often the medial, walls of the orbit.

Since orbital trauma is combined with neurotrauma in 30% of cases, the diagnosis and treatment of orbital fractures are often relegated to the background when monitoring patients in neurosurgical departments. Late contact with specialized medical institution may also cause the formation of post-traumatic deformities.

Within 2–3 weeks after injury, in the absence of treatment, bone and fibrous adhesions occur between bone fragments. From this period, the process of resorption of displaced bone fragments of the walls of the orbit begins, and in their place, rough scar tissue is formed, which is not capable of performing the function of a bone frame. By the end of the third month, the deformity that arose after an injury in the absence of treatment is considered to be formed, that is pathological processes in the affected area fully manifested themselves with the appearance of persistent aesthetic and functional disorders.

Defects in the walls of the orbit can arise as a result of resorption of displaced fragments of the lower and medial walls of the orbit, sometimes having a thickness of no more than a paper plate, and involving changes in the soft tissue contents, leading to its atrophy, scar changes or prolapse in the sinus cavity. The resulting enophthalmos and/or hypophthalmos leads, in turn, to aesthetic and functional disorders. Restoration of atrophied soft tissue contents surrounding eyeball, especially behind the orbital cellular space, is still very complex and actual problem reconstructive surgery, which does not have a unified concept optimal treatment. We came to the conclusion that to eliminate post-traumatic volume deficit of the soft tissues of the orbit, the optimal material is a prepared mixture of bone chips and platelet-rich autoplasma (PRP).

Any bone reconstruction requires repositioning of displaced bone fragments, their fixation to intact bones, to each other, and replacement of bone tissue defects. Restoring the lower and inner walls of the orbit requires a special approach. Small bone fragments that form during fractures cannot be compared and consolidated; moreover, over time they resolve, forming a defect.

When repositioning incorrectly fused bone fragments zygomatico-orbital complex, the intraoperative occurrence of a bone tissue defect is, as a rule, inevitable. Therefore in practice we're talking about about replacing lost bone base grafts or implants. In this capacity, a variety of materials have been and are still used: titanium meshes, plates, silicone implants, auto- and allografts, etc. Since the walls of the orbit directly border paranasal sinuses nose, the use of synthetic material has a certain risk due to infection of the latter with the development of inflammatory complications; in addition, as practice shows, over time it can occur scar change tissues surrounding the implant. Optimal material in in this case may be a bone graft. The outer plate of the parietal bone and the wing crest are used as donor material. ilium or rib. A bone autograft is required as a donor material, with the help of which it is possible to obtain thin bone plates that make it possible to recreate the lost orbital wall, while the bone material should be minimally susceptible to resorption, convenient for collection and relatively painless for the patient in the postoperative period.

Bone autografts are classified according to their structure: cortical – cranial vault, chin and body lower jaw; spongy – tibia and iliac crest; cortical-spongy or mixed - iliac crest. By embryonic origin: intramembranous type - mesenchymal origin: skull bones and enchondral type - ectomesenchymal origin: iliac crest and tibia. Cortical grafts of membranous origin are characterized by high mechanical strength and resistance to resorption. We have successful experience in using cortical parietal autografts for reconstruction of defects of the medial and inferior walls of the orbit in isolated fractures.

Our experts came to the conclusion that for reconstruction of the floor or medial wall of the orbit, with isolated fractures that caused a defect in one wall, in cases where the patient, for one reason or another (religious considerations, concomitant alopecia, etc.) refuses coronary access, with enophthalmos ≤ 3.5 mm, it is possible to do without coronary access, using cortical autografts taken from the branch of the mandible, which are similar in their properties and origin to the parietal ones, as a donor material for the reconstruction of defects in the orbital walls.

It is very important to understand that a bicoronal or, in other words, coronal incision is necessary when it comes to eliminating the reconstruction of the zygomatic-orbital complex, zygomatic arch, frontal bone, since the incision simultaneously serves as an access that allows you to get to the desired areas without damaging the neurovascular bundles and the site of collection of donor material. The coronal incision does not leave visible scars as it passes through the scalp.

Features of membranous mandibular cortical autografts

Like parietal cortical bone grafts, chin and ramus grafts are of intramembranous origin and therefore are less resorbed than those of an enchondral nature. This feature is explained by osteologists by rapid revascularization and slow resorption of bones of intramembranous origin.

Compared to other methods of bone reconstruction, when using autografts from the lower jaw, the quality of bone tissue in the area of ​​grafting improves and the healing time is reduced. The body of the mandible embryologically develops as rectangular membranous bone, while the condylar processes develop from an enchondral bone precursor. Experiments have shown that autografts from membranous bone undergo less resorption than bones of endochondral origin (from hyaline cartilage). Although cancellous blocks revascularize faster than cortical ones, cortical membranous autografts revascularize faster than autografts of endochondral origin, even with a more pronounced cancellous layer. It is the early revascularization of the bone block of membranous origin that is most likely the reason for the preservation of the volume of the autograft. This explains why bone autografts of the lower jaw, which are mainly a cortical plate and contain a large number of osteogenic cells, lose little volume and quickly take root in the recipient’s bed. There is another hypothesis that states that bones of ectomesenchymal origin (for example, the mandible) have a better potential for engraftment into the maxillofacial area. facial area due to the biochemical similarity between the protocollagen of the donor site and the recipient site.

Some researchers have suggested that better engraftment of membranous autografts is associated with a preferred three-dimensional structure. Marx pointed out that autografts of the calvarial bones, for example, have a developed vascular system spongy substance and a large number of Haversian canals and Volkmann canals, which contribute to rapid and complete revascularization. In addition, autografts of membranous origin have a more pronounced cortical layer, due to which they resolve much more slowly. The advantages also include: the absence of aesthetic disturbances due to intraoral access for sampling, minor postoperative pain and, most importantly, it is always easy to obtain the patient’s consent for this manipulation.

Operation scheme

To access the lower and medial walls of the orbit, we often use the subciliary approach. To do this, the incision is made 1.5-2 mm below the ciliary edge. The preparation plane is either superficially above m. orbicularis oculi - with the creation of a skin flap, or deeper under the muscle - with the formation of a musculocutaneous flap. When forming a musculocutaneous flap, variations are possible: the muscle can be cut at a level 1 mm lower than the skin incision. The orbicularis muscle is incised and the periosteum in the area of ​​the lower orbital margin is dissected. The approach allows visualization of the medial and inferior walls of the orbit.

Next, a graft taken from the ramus of the mandible or the parietal region is installed in the area of ​​the defect in the lower orbital wall (or medial orbital wall). Also, the bone graft is crushed in a bone mill, the resulting shavings are mixed with platelet-rich autoplasma (PRP) and placed in the retroocular tissue space to eliminate the deficit in soft tissue volume with hypercorrection in the form of exophthalmos in a relatively healthy eye.

Example 1

Before surgery

CT scan before surgery

After operation

Example 2

Reconstructive surgery is used to restore the shape and function of body parts and various organs due to birth defects, illness or injury. These are unusually complex operations from a technical point of view, because they involve skin grafting, implantation, restoring the normal functioning of damaged tissue, or even reattaching limbs.

What are the features of reconstructive surgery?

Reconstructive surgery differs from cosmetic surgery in that cosmetic surgery does not correct abnormalities. Reconstructive surgery, even if chosen for aesthetic reasons, is usually done to correct certain anomalies. Although both oral and maxillofacial surgery and plastic surgery sometimes deal with facial reconstructive surgery after trauma and head and neck reconstruction after cancer, other branches of surgery (e.g. general surgery, gynecological surgery) some reconstructive procedures are also performed.

The common feature is that the goal of any of these surgeries is to restore normal anatomy and function of body parts. Reconstructive surgery can also be used to improve a person's appearance, especially in cases of injury or birth defects. Reconstructive plastic surgeons use the concept of the "reconstructive ladder" to rank the complexity of reconstruction procedures after injury and trauma. This rate ranges from very simple methods used such as primary closure and dressings, to more complex ones - transplantation of skin, tissue, etc.

What types of reconstructive surgery are there?

Some examples of circumstances that call for the use of reconstructive surgery:

• Restoration of tissue from burns or other injuries (skin grafts or other reconstructive methods are performed).
• Getting rid of scars.
• Correction of cleft lip.
• Eliminate breathing problems or even snoring.
• Breast reduction and breast reconstruction after mastectomy. These procedures are available for women who have undergone a mastectomy or for women who have abnormally large breasts that lead to back problems. Men also sometimes undergo breast reduction surgery.
• Operations on the legs and arms after various diseases, including tumors (cancerous and non-cancerous).
• Correction of birth defects. Webbed fingers, extra fingers or toes, treatment of carpal tunnel syndrome.
• Reconstruction of knees or elbows after sports injuries.
• Facial reconstruction after injuries (nose, lips, ears).
• Correction of protruding ears, too large or deformed ears.
• Sewing on fingers.
• Restoration of crushed bones.
• Microsurgery or flap procedures. These surgeries may be performed to replace body parts damaged by injury or disease such as cancer.

The use of reconstructive surgery in professional sports. Contact views sports, such as football, often lead to various injuries in athletes. Reconstructive surgery can effectively cope with their consequences.

Injuries to the knee, shoulder, and broken facial bones are usually corrected by reconstructive surgeons. One of the most unusual uses of reconstructive surgery is gender reassignment surgery. This is the last radical step for the patient in a long process that includes months of preparation before surgery. Gender reassignment surgeries are extremely complex and can only be performed by a relatively small number of doctors.

The concepts of “plastic surgery”, “ reconstructive surgery“In recent years, they have appeared more and more often on television and in the media. What do they have in common and how do they differ? Few people really understand this, but if you have decided to undergo any kind of surgery, then you need to know exactly what will be done to your body.

What is reconstructive surgery

Reconstructive surgery deals with creating or restoring the shape and function of an organ or body part. The need for such an operation arises most often with congenital changes, consequences traumas suffered and operations. Reconstructive surgery is carried out by transferring plastic material from other places taken from the same person, implanting organs and tissues of another person, or implanting special devices - implants.

Reconstructive surgeries can be performed in any part human body, which means surgeons of any specialty (plastic surgeons, urologists, gynecologists, otolaryngologists, ophthalmologists, etc.).

In turn, plastic surgery was conditionally divided into aesthetic surgery, when improvement of the shape of the face and body occurs at the request of the patient, and reconstructive surgery, when restoration and improvement of appearance and function occurs according to medical indications. In most cases, reconstructive operations are carried out in several stages. But there is no clear distinction between aesthetic and reconstructive operations in plastic surgery: reconstructive operations almost always include aesthetic elements and vice versa.

Reconstructive plastic surgery on the face

After injuries, burns, operations on the face (for example, for a tumor), various birth defects, restoration of one or another organ or tissue on the face is required. For example, skin grafting after burns: skin is taken from the same person from another part of the body and transplanted onto the face. Rhinoplasty is also performed - restoration of the normal shape of the nose, which simultaneously restores its function, otoplasty - restoration of shape auricle, lip plastic surgery - restoration of their size and shape after a burn or injury.

Eyelid surgery (blepharoplasty) is a concept that includes various ways eyelid corrections, allowing you to change the shape and shape of the eyes, eliminate various eyelid imperfections, including age-related changes(elimination of excess skin and fatty tissue in the upper and lower eyelids), consequences of injuries and paralysis.

Reconstructive plastic surgery in the breast area

Plastic surgery in the breast area is carried out both cosmetic and medicinal purposes. Thus, for congenital (funnel-shaped, keeled breasts, etc.) and acquired defects of the chest (after injuries, operations), bone and musculoskeletal breast plastic surgery is performed , which normalizes the activity of respiratory and of cardio-vascular system, restores the correct contours of the body.

After breast removal for malignant tumor breast plastic surgery is performed with its complete restoration (mammoplasty).

Reconstructive plastic surgery in the abdominal area

Abdominoplasty or tummy tuck is a reconstruction of the anterior abdominal wall(removing excess fat, restoring the appearance and tone of the skin), which is one of the methods surgical correction figures. The need for abdominoplasty occurs in cases of stretching of the abdominal muscles and skin after pregnancy or sudden weight loss, as well as after removal of tumors of the anterior abdominal wall or large hernias.

Gynecological and urological reconstructive plastic surgery

Gynecological reconstructive surgeries are plastic surgical interventions, the purpose of which is to restore the structure and function of the female genital organs. Reconstructive operations may be required for various congenital anomalies, for example, various anomalies of the vagina, up to its fusion, external genitalia, prolapse and prolapse of the female genital organs, which may occur after childbirth, etc.

Such operations are most often performed using vaginal access, without damaging the skin of the anterior abdominal wall. In this case it is restored as appearance, so correct work female genital organs. For example, during surgery for prolapse pelvic organs uterus, vaginal walls, perineal muscles, bladder and the rectum is returned to its normal anatomical position. The latter has not only aesthetic significance, but also improves the functions of the pelvic organs (urination, defecation), and also has a beneficial effect on the quality of sexual life.

Urological plastic surgery restores function urinary tract, as well as the appearance and function of the male genital organs.

Reconstructive surgery on the limbs

Reconstructive plastic surgery is one of the most necessary and sought-after branches of medicine. Sometimes, due to injuries received by a person or congenital features bodies, a person’s face is far from aesthetic norms, causing him discomfort and rejection of his appearance.

In such cases, it is customary to seek help from plastic surgeons, which are capable of restoring damaged soft fabrics and even individual organs. In addition, not only the appearance is restored, but also the natural anatomical functionality of organs and skin.

Types of plastic surgery

What is the difference between reconstructive and ordinary plastic surgery? Reconstructive plastic surgery returns damaged organs to their functionality and can even partially or completely restore them if they are completely absent.

Alison Pontius

plastic surgeon

Facial reconstructive surgery includes various interventions that involve the restoration of a specific facial area. With their help, you can eliminate the consequences of burns, deformations, injuries, and also cope with congenital anomalies. I would like to note that often after surgery there is numbness for several weeks to several months. Because the nerves in the area become injured and then experience temporary neuropraxia (temporary loss of nerve conduction). This usually occurs over the next 6-12 weeks. This depends on the procedure being performed, sometimes much longer. If numbness has been present for more than a year, go to the doctor.

What and how to do with your body is a personal matter for each person. However, in some cases, a person needs to seek help from a surgeon who will restore damaged tissues, organs or correct a congenital defect.

Such a change will improve not only a person’s appearance, but also raise his self-esteem, and also eliminate psychological discomfort. Therefore, if you suffer from identical problems, we advise you to seek help from an appropriate specialist.