5.7 Plastic & Microsurgical Instruments

The Plastic Surgery Instrument Profile

Plastic surgery works on skin, soft tissue, small vessels and nerves, and bone of the face and hand. The instruments are correspondingly short, fine, lightweight, and low-glare, and a plastics tray is one of the most damage-prone sets in the department.

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Soft-Tissue Instruments

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Hand Surgery

Hand sets add small bone instrumentation on the same delicate scale: mini-plating systems with tiny screws in caddies, K-wires and drivers, small rongeurs, bone-holding clamps, tendon passers and retrievers, and tendon and nerve micro-instruments. The mini screw caddy is counted position by position exactly like a trauma caddy — and the screws are small enough that a single loss is easy to overlook.

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Graft Harvesting Instruments

The mesher and carrier must match. A carrier of the wrong ratio produces a graft that does not expand as the surgeon expects. The mesher rollers are inspected for damage and for free rotation, and the drive mechanism is tested through full travel.

The dermatome's depth setting is a calibrated function: a dermatome whose depth mechanism is loose, whose indicator is illegible, or whose width plate does not seat squarely cannot be relied upon to harvest a graft of the intended thickness, and it is routed for vendor calibration rather than released.

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Microsurgical Instruments

Microsurgery — replantation, free flaps, nerve repair, and micro-vascular anastomosis — uses instruments whose working dimensions are measured in tenths of a millimetre.

Materials and finish

Micro-instruments are frequently titanium — lighter, non-magnetic, and less fatiguing during long anastomoses — and are finished in satin or ebonized surfaces to eliminate glare under the operating microscope. That combination is diagnostic: a light, dull-grey, very fine instrument is almost certainly titanium micro-instrumentation, and it must not be scrubbed with abrasives.

Inspection under magnification

At these dimensions the naked eye is not an acceptable inspection tool. Requirements:

1. Inspect every tip under a magnifying lamp or microscope.
2. Confirm tips meet precisely with no gap, no overlap, and no lateral deviation.
3. Confirm spring return is brisk and complete.
4. Confirm micro-scissor blades close cleanly along their whole length.
5. Confirm micro-clamp spring force is adequate — an approximator that no longer holds a vessel is useless.
6. Confirm no burrs anywhere that will contact intima or nerve.
7. Confirm insulated micro-bipolars pass insulation testing.

Storage and handling

Micro-instruments live in dedicated racks, silicone holders, or tip-protected cases. They are never placed loose in a general tray, never processed in a basket with heavy instruments, and never brushed with a stiff brush. A single retractor lying on a set of jeweler's forceps in a washer basket will bend every one of them, and the damage is invisible until someone looks under magnification.

Counting and Protecting Spring-Handled Micro Instruments

Microsurgical instruments are spring-handled rather than ringed, which changes both how they fail and how they must be assembled.

A spring handle works by elastic deflection of the shafts. Its failure mode is loss of spring tension: the instrument no longer opens fully on release, or it opens but no longer closes with even tip pressure. Test it by compressing the handle fully and releasing it, watching that the tips separate cleanly and return to their rest position without lag. Compare against a known-good instrument of the same pattern, because absolute tension is hard to judge in isolation.

Tips must be assessed under magnification, every time. Micro-forceps tips must meet exactly at the very end with no crossing, no gap, and no burr; micro-scissors must show intact, unrolled edges; micro needle holders are checked for the same insert wear as their full-size counterparts. A tip bent by a fraction of a millimetre is functionally destroyed while looking perfectly normal to the unaided eye.

Protection is not optional. Every micro instrument gets a tip protector or an individual bracket, and these instruments are placed in the tray last, in a dedicated level or case, never under anything. Silicone finger mats and slotted micro-cases exist precisely because a single heavy instrument shifting during transport will destroy a tray's worth of micro tips.

Skin Graft Equipment and Its Consumables

Graft harvesting is instrument-heavy and consumable-heavy, and the two must be distinguished.

A dermatome — powered or the manual Weck or Goulian pattern — harvests split-thickness skin at a set depth. The powered dermatome has a depth-setting mechanism and a width plate, both of which must be present, and its blades are single-use. A mesh graft dermatome or skin mesher expands the graft using a carrier board with a defined expansion ratio; the carriers are typically single-use and ratio-specific.

At inspection, confirm the depth-setting gauge moves and reads correctly, confirm the width plates and screws named on the count sheet are present, and confirm the powered handpiece runs smoothly. Do not attempt to sharpen or reuse dermatome blades.

Facial, Rhinoplasty and Hand Sets

Rhinoplasty trays add osteotomes in graduated widths, rasps, and fine elevators; the osteotome sizes are a graduated family and must be complete. Hand sets add small bone-holding clamps, K-wire drivers and wire cutters, and fine tendon instruments. Skin hooks in single, double, and multi-prong patterns are sharps requiring point protection.