Gregory Lakin - Plastic Surgery Review_ a Study Guide for the in-Service, Written Board, And Maintenance of Certification Exams (2014, Thieme)

Plastic Surgery Review A Study Guide for the Written Board, In-Service, and Maintenance of Certification Exams

Gregory E. Lakin, MD Diplomate, American Board of Plastic Surgery Chief, Division of Pediatric Plastic Surgery Director, Craniofacial Center Director, Vascular Anomalies Center University Hospitals Rainbow Babies & Children's Hospital

Assistant Professor, Departments of Plastic Surgery, Neurosurgery, and Pediatrics Case Western Reserve University School of Medicine Cleveland, Ohio

73 illustrations

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Cataloging-in-

Lakin, Gregory E., author. Plastic surgery review: a study guide for the

in-service, written board, and maintenance of certification exams/Gregory E. Lakin. p.; cm. Summary: “Plastic Surgery Review meets the need for a high-yield, compact review book for the plastic surgery in-service, written board, and maintenance of certification examinations. Its 50 chapters are organized into four sections tested by the plastic surgery in-service examination: comprehensive plastic surgery craniomaxillofacial surgery breast and cosmetic surgery hand and lower extremity An outline format with bullet points, tables, figures, mnemonics, and references facilitates review and memorization. Invited expert reviewers ensure the material is accurate and up-to-date”--Provided by publisher. ISBN 978-1-60406-836-8 (paperback) -ISBN 978-1-60406-835-1 (e-book) I. Title. [DNLM: 1. Reconstructive Surgical

Procedures--methods. 2. Certification. WO 18.2] RD119 617.9’52076--dc23 2014035804 © 2015 Thieme Medical Publishers, Inc. Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, [emailprotected] Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, [emailprotected] Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00,

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continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such

examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher's consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

This book is dedicated to Clifford and Arlene Lakin, who have been the best parents anyone could ever ask for. Gregory E. Lakin, MD

Contents Foreword Henry K. Kawamoto Jr.

Preface Reviewers Section I Comprehensive Plastic Surgery Chapter 1 Wound Healing Reviewed by Jeffrey E. Janis

Chapter 2 Local Tissue Rearrangement Reviewed by William Y. Hoffman

Chapter 3 Skin, Bone, and Cartilage Grafts Reviewed by Justine C. Lee

Chapter 4 Flaps and Microsurgery

Reviewed by Kanchwala

Suhail

Khuzema

Chapter 5 Implants and Biomaterials Reviewed by Michael J. Yaremchuk

Chapter 6 Burns Reviewed by Ludwik K. Branski

Chapter 7 Trunk Reconstruction Reviewed by Derek E. Bell

Chapter 8 Tissue Expansion Reviewed by Sara R. Dickie

Chapter 9 Lymphedema and Pressure Sores Reviewed by Reid A. Maclellan

Chapter 10 Skin Lesions and Soft Tissue Tumors Reviewed by Jeffrey H. Kozlow

Chapter 11 Soft Tissue Infection

Reviewed by Andre Yuan Levesque

Chapter 12 Transplantation

Immunology

and

Reviewed by Eduardo D. Rodriguez

Chapter 13 Coding, Medicolegal, and Psychiatric Aspects Reviewed by Kent K. “Kye” Higdon

Section II Craniomaxillofacial Surgery Chapter 14 Head and Neck Anatomy Reviewed by Andrew Wexler

Chapter 15 Cleft Lip and Palate Reviewed by Jesse A. Taylor

Chapter 16 Tessier Clefts Reviewed by Henry K. Kawamoto Jr.

Chapter 17 Orthognathic, Temporomandibular Joint, and Chin

Reviewed by Anand R. Kumar

Chapter 18 Craniosynostosis Craniofacial Syndromes

and

Reviewed by Jeffrey A. Fearon

Chapter 19 Hemangiomas and Vascular Malformations Reviewed by Arin K. Greene

Chapter 20 Facial Paralysis Reviewed by Andre Panossian

Chapter 21 Head and Neck Tumors, Salivary Gland Tumors, Lip, and Scalp Reviewed by Brian T. Andrews

Chapter 22 Maxillofacial Trauma Reviewed by Richard Hopper

Chapter 23 Ear Reconstruction Reviewed by Reza Jarrahy

Chapter 24 Mandible Reconstruction

Reviewed by Nidal Farhan ALDeek and Fu-Chan Wei

Chapter 25 Nasal Reconstruction Reviewed by Robert L. Walton

Chapter 26 Eyelid and Lacrimal System Reconstruction Reviewed by S. Anthony Wolfe

Section III Breast and Cosmetic Surgery Chapter 27 Anesthesia Reviewed by Derek M. Steinbacher

Chapter 28 Breast Augmentation, Mastopexy, and Reduction Reviewed by Luis O. Vasconez

Chapter 29 Breast Reconstruction Reviewed by Stephen Vega

Chapter 30 Body Contouring, Abdominoplasty, and Liposuction Reviewed by Jeffrey A. Gusenoff

Chapter 31 Rejuvenation

Facelift

and

Neck

Reviewed by Val Lambros

Chapter 32 Rhinoplasty Reviewed by Ali Totonchi

Chapter 33 Blepharoplasty and Brow Lift Reviewed by Oren Tepper

Chapter 34 Otoplasty Reviewed by Gaby Doumit

Chapter 35 Chemical Peels Reviewed by David J. Rowe

Chapter 36 Fillers and Injectables Reviewed by Ivona Percec

Chapter 37 Hair Transplantation Reviewed by Alfonso Barrera

Chapter 38 Lasers Reviewed by David W. Low

Section IV Hand and Lower Extremity Surgery Chapter 39 Congenital Hand Reviewed by Phuong D. Nguyen

Chapter 40 Fingertip Amputations Reviewed by Fernando A. Herrera Jr.

Chapter 41 Mutilating Hand Injuries Reviewed by Ryan Katz

Chapter 42 Dupuytren and Vascular Disease Reviewed by Alexander M. Spiess

Chapter 43 Fractures and Dislocations

Reviewed by Brent M. Egeland

Chapter 44 Nerves and Compartment Syndrome Reviewed by Ida K. Fox

Chapter 45 Tendons Reviewed by Warren C. Hammert

Chapter 46 Hand Tumors Reviewed by Andrew Chen

Chapter 47 Hand Infections Reviewed by Devra Becker

Chapter 48 Wrist Reviewed by Anthony Perrone

Chapter 49 Rheumatology Reviewed by Jennifer F. Waljee

Chapter 50 Lower Extremity Reviewed by Hani Sbitany

Index

Foreword When I completed my residency in general surgery at ColumbiaPresbyterian Medical Center in New York, a naïve thought flashed through my brain: “Frustration would be less now that my attention could be concentrated on a subspecialty with a smaller knowledge base.” Just a few months in to the new residency at the New York University Institute of Reconstructive Plastic Surgery thoroughly exposed my fallacy of thought. Although training in general surgery focuses mainly on the trunk, plastic surgery truly encompasses surgery in general of the entire body. In addition, it

commands far greater attention to minutiae! Heaped upon the needs of trainees to capture basic core knowledge is the explosive nature of the specialty. Practitioners as well need to heed attention because the field has moved beyond the “filling a hole and erasing a defect” phase (restorative surgery) to the incorporation of transplantation (replacement surgery). And right around the corner lies regenerative surgery. The process of acquiring new information, applying it properly, and achieving a successful outcome is the fun part. But recalling information needed to prepare for an examination is another thing. Testing cannot be avoided. It

defines the formal educational process, and public and governmental agencies demand it beyond formal training. Plastic Surgery Review seeks to assist the student who is preparing for testing. Its streamlined format facilitates the recall process. Residents preparing for the In-service Examination, new graduates preparing for the American Board of Plastic Surgery's Written Examination, and veteran practitioners for the Maintenance of Certification Examination will all find great value in this compact book. Henry K. Kawamoto Jr., MD, DDS Clinical Professor Emeritus Department of Surgery Division of Plastic Surgery

University of California at Los Angeles Los Angeles, California

Preface Inspiration • Need for a high-yield, compact review book for the plastic surgery In-Service, Written Board, and Maintenance of Certification Examinations

Audience • Plastic surgeons studying for their American Board of Plastic Surgeons Written Examination and Maintenance of Certification Examination

• Plastic surgery residents preparing for their annual In-Service Examination • Medical students on plastic surgery rotations

Framework • 50 chapters organized into four sections tested by the plastic surgery In-Service Examination Comprehensive Plastic Surgery Craniomaxillofacial Surgery Breast and Cosmetic Surgery Hand and Lower Extremity Surgery • Based on the Content Outline of the American Board of Plastic Surgery Written Examination and

Maintenance of Certification Examination • Outline format with bullet points, tables, figures, mnemonics, and references facilitate review and memorization • Invited expert reviewers ensured the material is accurate and up-to-date

Acknowledgments • Expert reviewers for their leadership in the field and contributions to this book • Thieme Publishers Timothy Hiscock, Elizabeth Palumbo, Natascha Morris, Kenny Chumbley, Chris Malone, Cornelia Schulze, and Emily Ekle for

• • • •

•

sheparding this project to publication Peggy Firth and Thompson Digital for the beautiful illustrations Dr. James Bradley for encouraging me to publish this work Dr. Joseph Serletti for always believing in me Dr. Henry Kawamoto and Dr. Bahman Guyuron for their mentorship Margaret, my beloved wife, for her love and support Gregory E. Lakin, MD

Reviewers Nidal Farhan ALDeek, MSc, MD Chang Gung Memorial Hospital Chang Gung University Medical College Taipai, Taiwan Brian T. Andrews, MD, MA Director of Cleft and Craniofacial Surgery Assistant Professor Department of Plastic Surgery Department of Otolaryngology–Head and Neck Surgery University of Kansas Medical Center Kansas City, Kansas Alfonso Barrera, MD, FACS

Clinical Assistant Professor of Plastic Surgery Baylor College of Medicine Houston, Texas Ludwik K. Branski, MD, MMS Assistant Professor Division of Plastic Surgery Department of Surgery The University of Texas Medical Branch Staff Surgeon Shriners Hospital for Children Galveston, Texas Devra Becker, MD, FACS Assistant Professor Department of Plastic Surgery University Hospitals Case Medical

Center Louis Stokes VA Medical Center Cleveland, Ohio Derek E. Bell, MD Assistant Professor of Plastic and Reconstructive Surgery Burn Program Director The University of Rochester Medical Center Rochester, New York Ludwik K. Branski, MD, MMS Assistant Professor Department of Surgery The University of Texas Medical Branch Staff Surgeon Shriners Hospital for Children

Galveston, Texas Andrew Chen, MD, FACS Associate Professor Department of Surgery Division of Plastic Surgery University of Connecticut Health Center Farmington, Connecticut Sara R. Dickie, MD Clinical Educator Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Hospitals NorthShore University Health System Chicago, Illinois

Gaby Doumit, MD, MSc, FRCSC, FACS Director of Pediatric Plastic and Craniofacial Surgery Dermatology and Plastic Surgery Institute Cleveland Clinic Cleveland, Ohio Brent M. Egeland, MD Plastic Surgeon Institute of Reconstructive Surgery of Central Texas Round Rock, Texas

Plastic

Jeffrey A. Fearon, MD, FACS, FAAP Director The Craniofacial Center

Medical City Children's Hospital Dallas, Texas Ida K. Fox, MD Assistant Professor, Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, Missouri Arin K. Greene, MD, MMSc Associate Professor of Surgery Harvard Medical School Department of Plastic and Oral Surgery Boston Children's Hospital Boston, Massachusetts

Jeffrey A. Gusenoff, MD Associate Professor of Plastic Surgery Co-Director, Life after Weight Loss Program Director, Post-Bariatric Body Contouring Fellowship Department of Plastic Surgery University of Pittsburgh Pittsburgh, Pennsylvania Warren C. Hammert, MD, DDS Professor of Orthopaedic Surgery and Plastic Surgery Chief, Division of Hand Surgery Department of Orthopaedic Surgery and Rehabilitation University of Rochester Medical Center Rochester, New York

Fernando A. Herrera Jr., MD Assistant Professor of Surgery Division of Plastic Surgery Medical University of South Carolina Charleston, South Carolina Kent K. “Kye” Higdon, MD, FACS Associate Program Director Assistant Professor Department of Plastic Surgery Vanderbilt University Medical Center Nashville, Tennessee William Y. Hoffman, MD, FAAP Professor and Chief UCSF Plastic Surgery Stephen J. Mathes Endowed Chair Vice Chair, Department of Surgery

University of California–San Francisco San Francisco, California Richard Hopper, MD Surgical Director, Craniofacial Center Chief, Division of Craniofacial and Plastic Surgery Seattle Children's Hospital University of Washington Seattle Washington Jeffrey E. Janis, MD, FACS Professor and Executive Vice Chairman Chief of Plastic Surgery, University Hospitals Department of Plastic Surgery Ohio State University Wexner Medical Center

Columbus, Ohio Reza Jarrahy, MD, FACS, FAAP Associate Clinical Professor Division of Plastic and Reconstructive Surgery Department of Pediatrics David Geffen School of Medicine at UCLA Co-Director, UCLA Craniofacial Clinic Assistant Chief of Plastic Surgery Olive View-UCLA Medical Center Los Angeles, California Suhail Khuzema Kanchwala, MD Assistant Professor Department of Surgery University of Pennsylvania Hospital

Philadelphia, Pennsylvania Ryan Katz, MD Attending Hand Surgeon Department of Orthopedics The Curtis National Hand Center Medstar Union Memorial Hospital Baltimore, Maryland Henry K. Kawamoto Jr., MD, DDS Clinical Professor Emeritus Department of Surgery Division of Plastic Surgery University of California at Los Angeles Los Angeles, California Jeffrey H. Kozlow, MD, MS Clinical Assistant Professor Section of

Plastic Surgery University of Michigan Health System Ann Arbor, Michigan Anand R. Kumar, MD, FACS, FAAP Director, Center for Pediatric Craniofacial Surgery Associate Professor of Plastic Surgery and Pediatrics Department of Plastic and Reconstructive Surgery The Johns Hopkins University School of Medicine Baltimore, Maryland Val Lambros, MD Clinical Professor of Plastic Surgery University of California–Irvine

Irvine, California Justine C. Lee, MD, PhD Assistant Professor of Surgery Craniofacial Surgery Division of Plastic and Reconstructive Surgery UCLA Medical Center Los Angeles, California Andre Yuan Levesque, MD Assistant Professor Division of Plastic Surgery University of Alabama at Birmingham Birmingham, Alabama David W. Low, MD Professor of Surgery

Division of Plastic Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Reid A. Maclellan, MD, MMSc Instructor Department of Plastic and Oral Surgery Boston Children's Hospital Harvard Medical School Boston, Massachusetts Phuong D. Nguyen, MD Division of Plastic and Reconstructive Surgery The Hospital for Sick Children Toronto, Canada

Andre Panossian, MD Director, Facial Paralysis Center Department of Plastic and Maxillofacial Surgery Children's Hospital Los Angeles Keck School of Medicine University of Southern California Los Angeles, California Ivona Percec, MD, PhD Assistant Professor Division of Plastic Surgery University of Pennsylvania Philadelphia, Pennsylvania Anthony Perrone, MD, MBA, RPh Chief, Plastic Surgery Department of Surgery

Maine General Medical Center Augusta, Maine Eduardo D. Rodriguez, MD, DDS Helen L. Kimmel Professor of Reconstructive Plastic Surgery Chair, Department of Plastic Surgery Director, Institute of Reconstructive Plastic Surgery Department of Plastic Surgery New York University Langone Medical Center New York, New York David J. Rowe, MD, FACS Assistant Professor Department of Plastic Surgery University Hospitals Case Medical

Center Cleveland, Ohio Hani Sbitany, MD, FACS Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery University of California–San Francisco San Francisco, California Alexander M. Spiess, MD Assistant Professor of Plastic Surgery Assistant Professor of Orthopaedic Surgery Department of Plastic Surgery University of Pittsburgh Pittsburgh, Pennsylvania

Derek M. Steinbacher, DMD, MD, FACS Associate Professor of Plastic Surgery Director, Craniomaxillofacial Surgery Yale School of Medicine Yale New Haven Hospital New Haven, Connecticut Jesse A. Taylor, MD Mary Downs Endowed Chair of Pediatric Craniofacial Treatment and Research Director, Penn Craniofacial Fellowship Co-Director, CHOP Cleft Team Department of Plastic, Reconstructive, and Craniofacial Surgery The University of Pennsylvania Children's Hospital of Philadelphia

Philadelphia, Pennsylvania Oren Tepper, MD Assistant Professor of Plastic Surgery Director of Craniofacial Surgery Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York Ali Totonchi, MD Medical Director of Craniofacial Deformity Clinic On-Site Director of Plastic Surgery Residency Department of Surgery MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio

Luis O. Vasconez, MD, FACS Plastic Surgeon The Kirklin Clinic of University of Alabama-Birmingham Hospital Birmingham, Alabama Stephan Vega, MD Plastic Surgeon Vega Plastic Surgery Pittsford, New York Jennifer F. Waljee, MD, MS Assistant Professor Department of Surgery University of Michigan Ann Arbor, Michigan Robert L. Walton, MD, FACS

Professor of Surgery Department of Surgery Division of Plastic Surgery Northwestern University School of Medicine Chicago, Illinois

Feinberg

Fu-Chan Wei, MD, FACS Distinguished Chair Professor Department of Plastic Surgery Chang Gung Memorial Hospital Chang Gung University Medical College Taipei, Taiwan Andrew Wexler, MD, MA Chief, Plastic Surgery Regional Director of Craniofacial Services

Southern California Kaiser Permanente Clinical Professor Plastic Surgery University of Southern California Los Angeles, California S. Anthony Wolfe, MD, FACS, FAAP Chief, Division of Plastic Surgery Miami Children's Hospital Miami, Florida Michael J. Yaremchuk, MD Professor of Surgery Department of Surgery Harvard Medical School Boston, Massachusetts

Section I Comprehensive Plastic Surgery

1 Wound Healing Reviewed by Jeffrey E. Janis

Phases of Wound Healing (Table 1.1) • Peak tensile strength: 80% at 60 days • Epithelial cell migration in healing wound Occurs in first 48 to 72 hours Initiates by loss of contact inhibition Mitosis occurs at wound margin to replace migrated cells Contact inhibition reestablished

Collagen • Ratios type I:III (Table 1.2) Normal skin: 4:1 Early scar: 2:1 Fetal scar: 1:3

Table 1.2 Types of collagen

Type

Characteristics

Skin, bone, tendon, arteries, uterus, dentin, fascia

Eye, cartilage

III

Skin, arteries, bowel wall, uterus

Basement membrane

Similar to type IV, widespread

• Amino acid composition Glycine Proline Hydroxyproline: vitamin C hydroxylates proline to form hydroxyproline Hydroxylysine: vitamin C hydroxylates lysine to form hydroxylysine

Synthesis • Tropocollagen • Filament • Fibril • Fiber • Bundle: crosslinked–strongest • Procollagen: secreted from cell • Collagen: formed when amino and carboxy ends cleaved off procollagen

Impaired Wound Healing • Smoking Increases microvascular vasoconstriction Increases carboxyhemoglobin

Carbon monoxide by-product competitively inhibits carbon dioxide and hemoglobin hypoxia erythropoiesis blood viscosity platelet aggregation, collagen deposition, and thrombogenesis • Steroids: decreases inflammatory reaction • Organ transplantation immunosuppressants: antilymphocytes do not impair wound healing • Radiation therapy Increases blood vessel thrombosis Decreases acute inflammatory response, neutrophil function, cytokines, growth factors, wound healing, and tissue oxygenation

• Infection: culture of 1 × 105 bacteria/g of tissue diagnoses infection

Excessive Wound Healing • Keloids Characterized by: excess scarring beyond borders of original wound, common among patients with dark skin color, seen in face, neck, chest, deltoid region Histology: no myofibroblasts, decreased blood vessels, collagen in large disorganized bundles Treatment excision alone: 45 to 100% recurrence Treatment excision combined with

something else is more successful than excision alone: excision with steroid injections (20 to 40% recurrence), excision with pressure (induces local tissue hypoxia), excision with radiation therapy (25% recurrence), silicone tape Do not cause contractures, do not regress Ear keloid: treat with excision, steroid, pressure therapy, and radiation therapy (if recurrent), electronegative charge, increase in skin surface temperature to decrease recurrence rates • Hypertrophic scars Characterized by: elevated scar

within borders of original wound, seen in flexor regions Usually caused by tension Histology: myofibroblasts, collagen in organized bundles Cause contractures, can regress

Wound Care • Negative pressure wound therapy: avoid putting on open blood vessels • Alginate: absorbent, for exudative wounds • Silver ion impregnated: antimicrobial–bacteriocidal • Hydrogels: waterproof, prevent bacterial contamination • Films/transparent dressings:

waterproof, impermeable to bacterial contamination • Silicone sheeting: occlusive, acts through hydration, electronegative charge, increase in skin surface temperature • Zinc: cofactor for metalloproteinases • Folate and Vitamin B6 (pyridoxine): for DNA synthesis, cell proliferation • Vitamin E: antioxidant, immune modulator • Vitamin A: restores steroid effects • Isotretinoin (Accutane): related to vitamin A, for cystic acne, impairs epithelialization, decreases activity of sebaceous glands • Tretinoin (Retin-A, Ortho-McNeilJanssen Pharmaceuticals, Titusville,

NJ): promotes epithelialization, skin resurfacing • Mechanical debridement: scrub brush to remove embedded dirt prevents tattoo • Scar revision surgery: wait for > 12 months postop, do routine scar management therapy until then (massage, sunscreen)

Suggested Reading Broughton G, Rohrich RJ. Wounds and Scars. Dallas TX: Selected Readings in Plastic Surgery, Inc.; 2005:5–7. Selected Readings in Plastic Surgery; vol 10, issue 7 Gurtner GC. Wound healing: normal and

abnormal. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:15–22 Janis JE, Kwon RK, Lalonde DH. A practical guide to wound healing. Plast Reconstr Surg 2010;125(6):230e–244e Levenson SM, Geever EF, Crowley LV, Oates JF III, Berard CW, Rosen H. The healing of rat skin wounds. Ann Surg 1965;161(2):293–308

2 Local Tissue Rearrangement Reviewed by William Y. Hoffman

Excisions • Elliptical Most common type of excision Avoid dog ears by excising in a 4:1 length/width ratio • Serial Staged excision of wide or large scars Skin expands between stages Shorter scar than single-stage elliptical excision

Random Cutaneous Flap • Length/width ratio 3:1 length/width ratio should be maintained for optimal circulation Length/width ratio not important if making axial flap (no longer random flap because contains vascular pedicle) • Delayed incisions: improves survival of distal tip • Tissue expansion Similar effect to surgical delay Takes time, cannot do intraoperative expansion

Rotation Flap (Fig. 2.1)

• Semicircular flap rotates on pivot point • Facilitate closure with back cut or Burow triangle

Advancement Flap • Principles Slide forward to adjacent defect No lateral or rotational movement Examples: rectangular advancement flap, V-Y flap

Fig. 2.1 Rotation flap. (From Chen W. Oculoplastic Surgery: The Essentials. New York Thieme; 2001. Used with permission.)

• Rectangular advancement flap (Fig. 2.2) Rectangular tissue is moved forward to close adjacent defect Burow triangles are excised to remove excess skin • V-Y flap (Fig. 2.3) Tissue to be moved forward is incised in a V shape

After donor site is closed directly, the suture line has a Y shape

Transposition Flap • Characteristics Rectangular or triangulated flap, may have rounded edges Rotates laterally about a pivot point to close adjacent defect • Examples: rhomboid, Z-plasty, and bilobed flaps

Fig. 2.2 Rectangular advancement flap.

Fig. 2.3 V-Y flap. (From Chen W. Oculoplastic Surgery: The Essentials. New York Thieme; 2001. Used with permission.)

• Rhomboid (Limberg) flap (Fig. 2.4) Angles: 120 and 60 degrees Four flaps can be designed, each off the 120-degree point Choose flap based on skin laxity to ensure donor site will close Flaps are not designed off the 60degree point • Z-plasty (Table 2.1) (Fig. 2.5) Lengthens scars by adding tissue Reverses direction of scar 15-degree incremental increases in Z-plasty angle lead to, theoretically, a 25% increase in

scar length Ideal angle is 60 degrees, leading to a theoretical 75% increase in scar length

Fig. 2.4 Rhomboid flap. (From Chen W. Oculoplastic Surgery: The Essentials. New York Thieme; 2001. Used with permission.) Table 2.1 Z-plasty angles and theoretical increases in length (percentage)

Angle (degree)

Theoretical increase in length (percentage)

100

120

Fig. 2.5 Z-plasty.

Fig. 2.6 Bilobed flap. (From Park SS. Facial Plastic Surgery. New York Thieme; 2005.

Used with permission.)

• Bilobed flap (Fig. 2.6) Each lobe rotates 45 to 50 degrees Use: defects 1 to 1.5 cm in lower third of nose (tip, ala)

Interposition Flap • Characteristics Distant transfer of tissue on pedicle, which rests over or under adjacent tissue Vascularity wound bed determines timing division • Example: forehead flap

Island Flap

• Skin flap elevated on vascular pedicle (no skin covering pedicle) and transposed to nonadjacent tissue

Distant Flap • Purpose: used when local tissue is not available for transfer • Attached distant flap Pedicled flap remains connected to vascular pedicle Examples: tubed flap, groin flap • Free flap Detached from vascular pedicle

Suggested Reading Broughton G, Rohrich RJ. Wounds and

Scars. Dallas TX: Selected Readings in Plastic Surgery, Inc.; 2005:5–7. Selected Readings in Plastic Surgery; vol 10, issue 7 Jackson IT. Local Flaps in Head and Neck Reconstruction. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2007 Thorne CH. Techniques and principles in plastic surgery. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:3–14 Thornton JF, Gosman AA. Skin Grafts and Skin Substitutes and Principles of Flaps. Dallas, TX: Selected Readings in Plastic Surgery, Inc.;

2004:1–78. Selected Readings in Plastic Surgery; vol 10, issue 1

3 Skin, Bone, and Cartilage Grafts Reviewed by Justine C. Lee

Skin Grafts (Table 3.1) • Types Split-thickness skin graft (STSG): epidermis and part of dermis Full-thickness skin graft (FTSG): epidermis and entire dermis • Donor site Replace like with like: choose based on match of color, texture, thickness, hair Retroauricular or supraclavicular

FTSG: for facial defects Eyelid FTSG: for thin eyelid defects • Graft failure causes Fluid collection beneath graft: prevent with hemostasis (best method), pressure (bolsters), meshing (not cosmetic) Infection Shear Poor bed vascularity • Reharvesting STSG Can reharvest from same donor site Number of reharvests depends on amount of dermis harvested Dermis does not regenerate as well as epidermis

Back best source for reharvesting • Contraction Normal process of wound healing Primary contraction: initial shrinkage of skin graft upon harvest secondary to amount of elastin in dermis. FTSG > STSG because more dermis in FTSG. Secondary contraction: shrinkage of skin graft over time in recipient site. STSG > FTSG because rigidity of dermis in FTSG prevents wound bed contraction • Contracture Negative sequelae of wound healing over flexor surfaces Causes: skin graft contraction, burns, Dupuytren disease

• Stages of skin graft sensation return Begins 4 weeks, lasts 2 years Table 3.1 Stages of skin graft healing

Stage

Time period

Plasmatic imbibition

Nutrient First 24–48 diffusion, hours of fibrin layer healing forms to adhere graft

Inosculation

Next 48 hours of healing

Description

Capillary ingrowth

Begins after Capillary

Revascularization inosculation anastomosis

Order of return: (1) pain, (2) light touch, (3) temperature, (4) vibration Recovers faster in FTSG: FTSGs have more neurilemmal sheaths than STSGs for nerve ingrowth from recipient site

Bone Grafts • Bone graft properties Osteoconduction: scaffold matrix to accommodate new bone ingrowth Osteoinduction: stimulates

osteogenesis Osteogenesis: bone formation with no indication of cellular origin • Cancellous bone grafts More osteoconductive and osteoinductive than cortical bone Osteoblasts brought with graft Example: iliac crest • Cortical bone grafts Stronger than cancellous bone Example: split calvarial bone graft, most commonly taken from parietal bone • Membranous bone formation Bone derived from mesenchymal tissue Examples: cranial vault, facial

skeleton • Enchondral bone formation Cartilage replaced by bone Example: long bones • Creeping substitution Process where new vascularity carries osteoblasts to form new bone Occurs faster in cancellous than in cortical bone grafts • Bone morphogenetic protein (BMP) Stimulates osteogenesis (osteoinductive) Example: recombinant human BMP • Pediatric cranioplasty Calvarial bone graft: cannot split until diploic space forms after 4

years old (some may argue earlier is possible) Particulate bone: harvested with low-speed bur, usable at any age Bone dust: powder harvested with high-speed bur, may be nonviable due to heat during harvest

Cartilage Grafts • Uses Nose Ear Craniofacial skeleton Joints • Compared to bone grafts, cartilage grafts Resorb less

Have less healing potential Have fewer donor sites Are carved easily Do not need vascular supply • Warping Scoring cartilage leads to curving toward contralateral side

Suggested Reading Greene AK, Mulliken JB, Proctor MR, Rogers GF. Pediatric cranioplasty using particulate calvarial bone graft. Plast Reconstr Surg 2008;122(2):563–571 Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg 2011;127(1):5e–22e

Lee WP, Feili-Hariri M, Butler P. Transplant biology and applications to plastic surgery. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:52–57 Lipschitz AH, Kenkel JM. Implantation: Bone, Cartilage, and Alloplasts. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2004;1–34. Selected Readings in Plastic Surgery vol 10, issue 2 Motoki DS, Mulliken JB. The healing of bone and cartilage. Clin Plast Surg 1990;17(3):527–544 Thornton JF, Gosman AA. Skin Grafts

and Skin Substitutes and Principles of Flaps. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2004;1–78. Selected Readings in Plastic Surgery; vol 10, issue 1 Vercler CJ, Sugg KB, Buchman SR. Split cranial bone grafting in children younger than 3 years old: debunking a surgical myth. Plast Reconstr Surg 2014 133: 822e-827e

4 Flaps and Microsurgery Reviewed by Suhail Khuzema Kanchwala

Muscle/Musculocutaneous Flaps •

Muscle/myocutaneous flap reconstruction (Tables 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7) (Figs. 4.1 and 4.2) Irrigation/debridement in preparation for flap reconstruction Provides robust vascularity (compared to random flaps, skin grafts) Conforms to site to fill large defect Type II is the most common pattern

of circulation

Table 4.2 Type I muscle/musculocutaneous flaps

Flap

One dominant pedicle Ascending

Tensor fascia lata

branch of lateral circumflex femoral artery

Gastrocnemius

Sural artery (medial and lateral branches supply medial and lateral muscle heads, respectively) off the popliteal artery

Vastus lateralis

Descending branch of lateral circumflex femoral artery Deep circumflex

iliac artery (off external iliac artery) courses along inner border of iliac crest (identify/avoid Iliac lateral femoral osseomusculocutaneous cutaneous nerve of thigh on iliacus muscle, runs medial to anterior superior iliac spine, passes downward under inguinal ligament to thigh Table 4.3 Type II muscle/musculocutaneous flaps

Flap

Dominant pedicle(s)

Minor pedicle(s)

Gracilis

Ascending branch medial circumflex artery, passes between adductor brevis and longus, enters gracilis 8– 10 cm inferior to pubic tubercle

Distal superficial femoral artery branches

Rectus femoris

Descending branch of Superficial lateral circumflex femoral artery femoral artery

Soleus

Popliteal artery, posterior Posterior tibial artery, tibial artery and peroneal artery

Sternocleidomastoid

Occipital artery

Posterior auricular artery, superior thyroid artery, bran

suprascapu artery

Trapezius

Minor pedicle to upper third Dominant of muscle: pedicle to occipital middle third artery (off of muscle: external superficial carotid cervical artery) artery (superficial Minor pedicle to branch of transverse lower third of muscle: cervical artery, which dorsal scapular is off thyrocervical artery (dee branch of trunk) transverse

transverse cervical artery) Table 4.4 Type III muscle/musculocutaneous flaps

Flap

Two dominant pedicles

Gluteus maximus

Superior and inferior gluteal arteries (off internal iliac artery)

Omental

Abdominal viscera flap classified as a type III flap: left and right gastroepiploic arteries (off splenic

and gastroduodenal arteries, respectively)

Rectus abdominis

Superior epigastric artery (off internal mammary artery) and deep inferior epigastric artery (off external iliac artery)

Serratus

Lateral thoracic and thoracodorsal arteries

Table 4.5 Type IV muscle/musculocutaneous flaps

Flap

Segmental pedicles

Sartorius

Superficial femoral artery

Tibialis anterior

Anterior tibial artery

External oblique

Superior half supplied by inferior eight intercostal perforators, inferior half supplied by deep circumflex iliac artery (95%) or iliolumbar artery (5%)

Table 4.6 Type V muscle/musculocutaneous flaps

Flap

One dominant Secondary pedicle segmental pedicles

Latissimus Thoracodorsal dorsi artery

Lumbar and posterior intercostal arteries

Pectoralis major

Internal Thoracoacromial mammary artery artery

Internal oblique

Thoracic and lumbar arteries, Deep circumflex deep iliac artery inferior epigastric artery

Fibula

Nutrient endosteal artery (off peroneal artery)

Periosteal and muscular branches (off peroneal artery)

Table 4.7 Innervation of thigh flaps

Flap

Motor nerve

Sensory nerve

Gracilis

Anterior femoral Obturator cutaneous (L2–L3)

Rectus femoris (harvest results in 15-degree Femoral extensor lag of knee)

Vastus lateralis

Tensor fascia lata

Anterior femoral cutaneous (L2–L3)

Femoral

Lateral femoral cutaneous (L2–L3)

Superior gluteal

Lateral femoral cutaneous (T12–L3), lumbar paraplegic sensory flap

V-Y hamstring (biceps femoris, Sciatic semitendinous, semimembranous)

Posterior femoral cutaneous (S1–S3) below level of most paraplegics

Fig. 4.1 Vascular supply to the iliac osteocutaneous flap, cutaneous groin flap, TFL, vastus lateralis muscle, rectus femoris muscle, and gracilis muscle. DCIA, deep circumflex iliac artery; DIEA, deep inferior epigastric artery; LCFA, lateral circumflex femoral artery; MCFA, medial circumflex femoral artery; SCIA, superficial circumflex iliac artery; SIEA, superficial inferior epigastric artery; TFL, tensor fascia lata.

Fig. 4.2 External oblique muscles.

Fasciocutaneous Flaps (Table 4.8) (Fig. 4.3) • Anterior lateral thigh flap Type B septocutaneous pedicle: perforates between rectus femoris and vastus lateralis muscles Type C musculocutaneous pedicle: perforates on medial aspect of vastus lateralis muscle, can harvest a cuff of vastus lateralis • Peroneal artery flap Type B fasciocutaneous flap based on peroneal artery Coverage: middle and lower thirds of leg • Lateral calcaneal flap (Fig. 4.4) Variation of peroneal artery flap

Pedicle: terminal branch of peroneal artery Coverage: lateral ankle Preoperative Doppler: check for perforators • Posterior interosseous flap Fasciocutaneous flap: type B Pedicle: posterior interosseous artery (off ulnar artery) travels between extensor carpi ulnaris and extensor digiti minimi Retrograde pedicle: based on anterior interosseous artery Coverage: elbow, wrist, dorsum of hand, thumb web space, proximal phalanx thumb

Fig. 4.3 Mathes–Nahai fasciocutaneous flap classification.

Fig. 4.4 Lateral calcaneal artery flap.

• Lateral arm flap

Fasciocutaneous flap: type B Pedicle: posterior radial collateral artery (off profunda brachii artery) arises between brachialis and triceps Reverse flap pedicle: radial recurrent artery (off radial artery) Free flap: covers dorsum of hand • Scapular and parascapular flaps (Fig. 4.5) Fasciocutaneous flaps: type B septocutaneous flaps Scapular flap: based on transverse branch of circumflex scapular artery Parascapular flap: based on vertical branch of circumflex scapular artery

Triangular space: space between teres minor, teres major, and long head of triceps transmits the circumflex scapular artery (branch of subscapular artery, which is branch of axillary artery; subscapular artery also later gives off thoracodorsal artery)

Fig. 4.5 Scapular and parascapular flaps.

Quadrangular space: space between teres minor, teres major, long head of triceps, and humeral neck transmits the posterior humeral circumflex artery (not

circumflex scapular artery) Coverage: head and neck, upper and lower extremity Osseocutaneous flap: can harvest bone from lateral scapula • Radial forearm fasciocutaneous free flap Fasciocutaneous flap: type B Reconstructive uses: lower lip, tongue, penis, nose (prelaminated), marginal mandibulectomy defects (osseocutaneous flap), lower extremity Allen test: preoperative evaluation confirms ulnar artery dominant supply to hand, but if hand gets cold after flap harvest, do vein graft

At level of elbow, radial artery arises between: brachioradialis and pronator teres At level of midforearm, radial artery arises between: brachioradialis and flexor carpi radialis At the level of the wrist, radial artery arises between: abductor pollicis longus and flexor carpi radialis Leave paratenon on flap donor site for skin graft Radial bone harvested between: brachioradialis and pronator teres (can take up to 10 cm and 40% diameter of radius); bone harvest risks distal radius fracture and so

must plate radius if taking bone

Fig. 4.6 Radial artery anatomical landmarks. APL, abductor pollicis longus; FCR, flexor carpi radialis.

•

Distally based radial forearm pedicled flap venous outflow bypasses valves through (Fig. 4.6) Collateral branches of each same vein Communicating branches crossing

over between comitantes

two

venae

Microsurgery • Free flap monitoring Clinical observation (most accurate): check skin color, temperature, capillary refill, muscle flap turgor, needle stick bleeding Exteriorize free jejunal flap to esophagus, because esophagoscopy is not practical for frequent monitoring Doppler ultrasound Implantable Doppler: for buried flaps

Pulse oximetry: useful with replants and toe to thumb transfer Quantitative fluoroscopy: uses fluorescein dye, which can cause nausea/allergies Temperature monitoring • Free flap failure Most common time: first 24 hours postop Most common cause: technical (surgical skill) Venous thrombosis more common than arterial thrombosis Treatment: immediately return to operating room to explore Radiation, smoking, and obesity: lead to worse peripheral flap perfusion (microcirculation),

• Multiple free flap failures from thrombosis Check platelets if on heparin: rule out heparin-induced thrombocytopenia Sickle cell: causes sludging Look for local options if multiple free flap failures have occurred; can always perform delayed pedicled flaps in multiple stages Pediatric microsurgery: higher sympathetic tone and vasospasms, but not a risk factor for thrombosis • Flap perfusion may be improved by the following: Heparin and dextran: anticoagulants inhibit platelet aggregation, decrease platelet

adhesiveness Heparin mechanism of action: activates antithrombin III, inactivates thrombin Nifedipine: calcium channel blocker, smooth muscle cell relaxant causes vasodilation Topical nitroglycerin: affects venous circulation on axial and random flaps Anti-inflammatory agents and corticosteroids (prednisolone): cause vasodilation and antiinflammatory properties Streptokinase/urokinase/tissue plasminogen activator (TPA): thrombolytics administered via intravascular infusion. These

agents are utilized to salvage a free-flap thrombosis. Mechanism: convert plasminogen to plasmin, breaking down fibrinogen and fibrin found in proximal thrombosis, can cause bleeding (TPA causes least bleeding because acts locally, enhanced by fibrin presence in clot) • Dextran Volume expander and anticoagulant improves flap perfusion Decreases clotting factor VIII and von Willebrand factor, causing decreased platelet function Increases alpha-2 antiplasmin, leads to increased plasminogen (thrombolytic)

Increases electronegativity of platelets, preventing aggregation Modifies fibrin structure, leads to fibrin degradation Give test dose to prevent anaphylaxis reaction (adult respiratory distress) • Mechanisms of delay Open choke vessels Sympathectomy Vascular reorganization Reactive hyperemia Nonspecific inflammatory reaction Acclimatization to hypoxemia • Anastomotic coupler devices Anastomosis of veins and arteries Saves time versus hand suturing

Can use with size mismatch Cannot use with rigid vessels (radiation, plaques) • Medicinal leeches (Hiruda medicinalis) Use: relieve venous congestion Aeromonas hydrophila: gramnegative bacteria found in gut of leeches Antibiotic prophylaxis: Bactrim (AR Scientific, Philadelphia, PA) (trimethoprim sulfamethoxazole [TMP-SMX]), ciprofloxacin, and tetracycline • Venous flow through flap Thin flap with inflow and outflow veins Coverage: small wounds on hand

or finger Arterialized through microsurgical anastomosis Epidermolysis and congestion for approximately 1 week

Perineal and Penile Reconstruction • Perineal and vaginal reconstruction VRAM: gold standard, leaves abdominal scar, has skin paddle, good blood flow Pudendal flap: sensate with pudendal nerve (S2–S4) Posterior thigh flap: sensate with posterior femoral cutaneous nerve

(S1–S3) • Penile reconstruction: single stage with radial forearm free flap • Penis replantation: reanastomose dorsal vein, dorsal nerve, deep dorsal artery, and urethra

Suggested Reading Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993;92(2):285–293 Ariyan S. One-stage reconstruction for defects of the mouth using a sternomastoid myocutaneous flap. Plast Reconstr Surg

1979;63(5):618–625 Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg 1971;24(2):174 Das SK. The size of the human omentum and methods of lengthening it for transplantation. Br J Plast Surg 1976;29(2):170–44 Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. Br J Plast Surg 1992;45(2):89–93 Freeman JL, Walker EP, Wilson JSP, Shaw HJ. The vascular anatomy of

the pectoralis major myocutaneous flap. Br J Plast Surg 1981;34(1):3– 10 Giordano PA, Abbes M, Pequignot JP. Gracilis blood supply: anatomical and clinical re-evaluation. Br J Plast Surg 1990;43(3):266–272 Griffin JR, Thornton JF. Microsurgery: Free Tissue Transfer and Replantation. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005;1–39. Selected Readings in Plastic Surgery; vol 10, issue 5 Gu YD, Wu MM, Li HR. Lateral lower leg skin flap. Ann Plast Surg 1985;15(4):319–324 Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg

2011;127(1):5e–22e Lin SD, Lai CS, Chiu CC. Venous drainage in the reverse forearm flap. Plast Reconstr Surg 1984;74(4):508–512 Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 1981;67(2):177–187 Mathes SJ, Vasconez LO. The cervicohumeral flap. Plast Reconstr Surg 1978;61(1):7–12 Monstrey S, Blondeel P, Van Landuyt K, Verpaele A, Tonnard P, Matton G. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap. Plast Reconstr Surg

2001;107(3):719–725 Ramasastry SS, Tucker JB, Swartz WM, Hurwitz DJ. The internal oblique muscle flap: an anatomic and clinical study. Plast Reconstr Surg 1984;73(5):721–733 Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 1984;37(4):574–576 Snower DP, Ruef C, Kuritza AP, Edberg SC. Aeromonas hydrophila infection associated with the use of medicinal leeches. J Clin Microbiol 1989;27(6):1421–1422 Spear SL, Walker RK. The external

oblique flap for reconstruction of the rectus sheath. Plast Reconstr Surg 1992;90(4):608–613 Stan M, Blondeel P, Van Landuyt K, et al. The versatility of the pudendal thigh fasciocutaneous flap Used as an island flap. Plast Reconstr Surg 2011;107:719 Thornton JF, Gosman AA. Skin Grafts and Skin Substitutes and Principles of Flaps. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2004;1–78. Selected Readings in Plastic Surgery; vol 10, issue 1 Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 1986;77(1):80–92 Watson JS, Craig RD, Orton CI. The

free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1979;64(3):299–305 Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 1991;44(2):91–96

5 Implants and Biomaterials Reviewed by Michael J. Yaremchuk

Implants • Purpose: reconstruct soft tissue and osseous defects, cosmetic surgery, reconstructive surgery • Ideal implant Inert, causes no foreign body reaction Resistant to infection Sterilizable Nontoxic No donor site morbidity • Autologous tissue preferred in some

cases Poor quality of surrounding tissue Radiation Lack of soft tissue coverage Compromised vascularity • Alloplastic implants to augment facial skeleton Smooth contour No donor site morbidity No resorption Simplifies procedure (time, complexity) Placement technique: antibiotic prophylaxis, sterile handling, wide subperiosteal undermining to develop pocket • Solid silicone

Firm Resists compression Resorption of underlying bone Forms fibrous capsule Easy to remove with revisional surgery • Porous polyethylene (Medpor) Allows for tissue ingrowth because porous Difficult to remove with revisional surgery • Metal Used in craniofacial, hand, orthopedic, dental surgery • Calcium bone substitutes Hydroxyapatite: calcium substitute Tricalcium phosphate (TCP)

Calcium phosphate cement (Norian, Synthes, West Chester, PA) • Polymethyl methacrylate (PMMA) Exothermic reaction Used for cranioplasty • Resorbable plating Poly-L-lactic acid and polyglycolic acid Useful for pediatric craniofacial reconstruction

Biomaterials •

AlloDerm (LifeCell Corp., Bridgewater, NJ) Acellular human cadaveric dermis • Apligraf (Organogenesis, Inc.,

Canton, MA) Neonatal foreskin epidermal keratinocytes, dermal fibroblasts, matrix bovine collagen Venous stasis ulcer and diabetic foot ulcer dressing Requires multiple applications • Biobrane (Smith & Nephew, Andover, MA) Nylon and silicone fabric coated with porcine collagen Temporary burn dressing • Integra Dermal Regeneration Template (Integra LifeSciences Corp., Plainsboro, NJ) Bilayer skin substitute composed of dermal matrix bovine collagen and shark-derived chondroitan-6-

sulfate, covered with a layer of silicone Remove silicone layer after 21 days and cover with splitthickness skin graft Used for full-thickness and partialthickness wounds, burn reconstruction, tendon without paratenon, cartilage without perichondrium, and bone without periosteum • TransCyte (Advanced Tissue Sciences, La Jolla, CA) Temporary human skin substitute with dermal fibroblasts cultured on a nylon mesh coated with porcine dermal collagen, bonded to silicone membrane

•

Surgisis (Cook Biotech, West Lafayette, IN) Porcine small intestine submucosa (SIS) with collagen

Suggested Reading Breitbart AS, Ablaza VJ. Implant materials. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:58–65 Lipschitz AH, Kenkel JM. Implantation: Bone, Cartilage, and Alloplasts. Dallas TX: Selected Readings in Plastic Surgery, Inc.; 2004:1–34. Selected Readings in Plastic

Surgery; vol 10, issue 2 Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg 2003;111(6):1818– 1827 Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg 2003;112(5):1422–1432, discussion 1433–1434 Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg 2000;106(3):697–706

6 Burns Reviewed by Ludwik K. Branski

Thermal Burns • Degrees of burns (Table 6.1) • Zones of injury Coagulation: necrotic center Stasis: could become necrotic or live (watch for demarcation, could improve with fluids and wound care) Hyperemia: outer margin will live Table 6.1 Degrees of burns

1st

Sunburn, heals

2nd

Partial thickness, blisters, superficial second-degree burn is sensate, deep second-degree burn is insensate, reepithelialize spontaneously, treat with cleaning, debridement, topical antimicrobial

3rd

Full thickness, insensate, charred, require excision and skin grafting

Burn Center Transfer Criteria Second- and third-degree burns > 20% total body surface area (TBSA) in patients 10 to 50 years old Third-degree burns > 5% TBSA in any age group Second- and third-degree burns involving the face, hands, feet, genitalia, perineum, or major joints Electric burns, including lightning injury Chemical burns with serious threat of functional or cosmetic impairment

Inhalation injuries Lesser burns in patients with preexisting medical conditions Problems that could complicate management Combined mechanical and thermal injury in which the burn wound poses the greater risk • Immunology ⇩ Leukocyte function ⇧ Complement activation ⇧ Suppressor T lymphocytes ⇩ Help T cell lymphocytes ⇩ Production immunoglobulins ⇧ Erythroblasts (predicts mortality) • Rule of nines to estimate TBSA (Fig. 6.1): the rule of nines differs

between adult and pediatric patients based on differences in body proportions (i.e., pediatric head size is larger relative to body size compared to the adult head size)

Fig. 6.1 Rule of nines for (a) adult and (b) pediatric patients.

• Parkland rule for fluid management 4 × TBSA kg = 24 h intravenous fluid (IVF) Give half in first 8 hours, half in next 16 hours Calculate hourly rate based on hours after injury For burns > 20% TBSA Parkland Rule should only be used as a general guideline because severe over-resuscitation with lung and tissue edema can occur if too much fluid is administered. • Fluid management Practice calculation: a 70 kg

patient presents 4 hours after sustaining a 30% TBSA: 4 × 70 × 30 = 8400/2 = 4,200 mL in first 8 hours, give 4,200/4 hours remaining in first 8 hours = 1,050 mL/h for first 4 hours. Then give 4,200/16 = 262.5 mL/h for next 16 hours. Add 5% albumin after 24 hours to maintain intravascular volume Sensitive markers of fluid resuscitation course: urine output (most common), mean arterial pressure, pH and base deficit • Nutrition for burn patients Protein requirements: 1.5 to > 2.0 g/kg/d for adults, up to 3.0 g/kg/d for children

Fat requirements: up to 1 g/kg/day Arginine, Vitamins A, C, Zn, and Cu supplements Modulators of hypermetabolic response: propranolol, growth hormone, insulin, and oxandrolone • Mechanism of action of silver (used in Silvadene and numerous burn wound dressings widely used such as Mepilex AG) Antimicrobial: poisons microbe cell respiration (Table 6.2) Wound healing: inhibits excessive activity of matrix metalloproteinase (MMP), a collagenase, by decreasing zinc (essential for MMP activity) Silver nitrate: has silver, like

Silvadene, but unlike Silvadene can rarely cause methemoglobinemia (silver nitrate is used wisely without complications) • Contractures Areas of contracture: neck, hands, wrist, elbows, shoulders Prevention: use full-thickness, not split-thickness, grafts, maintain position opposite direction of contraction while graft is healing and use compression garments Treatment: excision/grafting, local tissue rearrangement (Z-plasty), distant flaps (parascapular flap), Integra Dermal Regeneration Template (Integra LifeSciences

Corp., Plainsboro, NJ) Integra: useful for patients with mentosternal contractures and high TBSA with no viable distant tissue to harvest (Integra is collagen, glycosaminoglycan covered by silicone; at postoperative day 21 the silicone is removed and STSG is placed) • Inhalational injury Mechanism of injury: burned in closed space, asphyxiation, direct mechanical injury of particles to airway, upper airway thermal injury Carboxyhemoglobin (COHb) may be elevated > 15% (10% seen in smokers)

Bronchoscopy: used to rule out airway disease if there is singed nasal hair and carbonaceous sputum, find erythema and sooty deposits in airway Table 6.2 Topical antimicrobials

Silver sulfadiazine (Silvadene, Pfizer)

Mafenid acetate (Sulfam

Yes

Antipseudomonal No

Yes

Penetrates eschar

Can use with

Yes

sulfa allergy Painful

Side effects

Mafenid acetate ( causes metaboli Granulocytopenia acidosis (MA) be inhibits carbonic anhydras

Treatment: supportive, possibly prophylactic intubation, aggressive suctioning, bronchodilators, inhalative heparin, fluid resuscitation, aggressive diuresis often necessary at later timepoint

• Complications from burn Pneumonia: most common cause of death Burn shock: can try to prevent with IVF resuscitation but unfortunately still common Over-resuscitation with severe lung and tissue edema Infection: depends largely on the size of the burn; almost all large burns get infected; give prophylactic topical antibiotics, give Zosyn for antipseudomonal prophylaxis, vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis Arrhythmias: succinylcholine use

in burn patients can lead to hyperkalemia-induced arrhythmias

Frostbite •

Mechanism of action: water molecules free, inducing cell death • Treatment Rapid rewarming in water bath 104°F (40°C) × 15 to 30 minutes, not by a radiant heat source, which provides uneven warming and possibly a secondary thermal burn due to insensate skin Give oral ibuprofen, apply aloe vera, elevate, antitetanus, debride clear not hemorrhagic blisters, penicillin if cellulitis

“Freeze in winter, amputate in spring”: delay amputation after demarcation

Electric Burns • Electric burns Injury may be worse than appears on surface Electrocardiography to confirm heart in normal rhythm Heat injury along bone and deeper compartments where increased resistance Check for compartment syndrome (e.g., by measuring compartment pressures) If needed release compartments

and debride deeper tissues • Myoglobinuria Electric burns can injure muscles, leading to rhabdomyolysis Symptoms: red urine from myoglobin released into the urine, renal failure Treatment: check for compartment syndrome—if present, fasciotomy is mandatory; fasciotomy of volar forearm includes decompression of the carpal tunnel and pronator quadratus in the deep compartment Supportive treatment includes IV fluids, diuresis with Lasix, Diamox and mannitol, and sodium bicarbonate

Chemical Burns (Table 6.3) Table 6.3 Chemical burns

Chemical

Antidote

White phosphorus

Water irrigation, Wood's lamp, dermabrasion

Hydrofluoric acid

Calcium gluconate gel or injection

Tar

Cool tar, then fat emulsifier such as petroleum, Neosporin (Johnson & Johnson, New Brunswick, NJ) (Tween 80, Sigma-

(Tween 80, SigmaAldrich, St. Louis, MO), or mineral oil

Dermatologic Conditions Requiring Burn Care • Toxic epidermal necrolysis (TEN) Life-threatening epidermal sloughing and blisters, mucosal inflammation and ulceration Involves 30 to 100% TBSA Etiology: infection, drug-related (phenobarbital, diphenylhydantoin, sulfonamides, antibiotics, nonsteroidal anti-inflammatory drugs) Treatment: transfer to burn center,

stop offending drug, prevent infection • Stevens–Johnson syndrome (SJS) TEN and SJS are part of same spectrum of disease SJS involves < 30% TBSA Treatment: same as for TEN • Erythema multiforme (EM) Does not require burn care Confused with TEN and SJS Self-limited maculopapular target lesions Minor form cutaneous, major form involves mucous membranes • Purpura fulminans Etiology: hereditary deficiency of anticoagulants (protein S, protein

C, antithrombin III), infection (Neisseria meningitidis) Diagnosis: rapidly progressive hemorrhagic bullae, septic shock, disseminated intravascular coagulation, low assay levels of anticoagulants Treatment: antibiotics, supportive care, activated protein C, debridement and digit amputation once dermatologic condition demarcated

Suggested Reading Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg 2012;130(2):349e–358e

Broughton G, Zbar RI. Burns and Postburn Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–27. Selected Readings in Plastic Surgery; vol 10, issue 7 Donelan MB. Principles of burn reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:150–161 Klein MB. Thermal, chemical, and electrical injuries. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:132–149

7 Trunk Reconstruction Reviewed by Derek E. Bell

Abdominal Wall Anatomy • Arcuate line: lower limit of posterior rectus sheath • Anatomy above the arcuate line (Fig. 7.1) Rectus is covered by posterior and anterior rectus sheaths External oblique and anterior half of internal oblique aponeurotic fibers form the anterior rectus sheath Posterior half of the internal oblique sheath, and the transversus

abdominis aponeurosis, form the posterior rectus sheath Transversalis fascia is the most posterior layer • Anatomy below the arcuate line Rectus is covered ventrally by only anterior rectus sheath External oblique, internal oblique, and transversus abdominis aponeuroses form the anterior rectus sheath • Blood supply Upper abdomen supplied by superior epigastric artery Lower abdomen supplied by inferior epigastric (deep and superficial) arteries Lateral abdomen supplied by

intercostals and lumbar vessels

Abdominal Wall Reconstruction • Flap reconstruction Component separation: rectus advancement covers midline abdominal defects Tensor fascia lata (TFL): covers lower abdominal defects Gracilis: covers lower abdominal defects Vastus lateralis: covers lower abdominal defects

Fig. 7.1 Structure of the rectus sheath. (From Schuenke M, Schulte E, Schumacher U. General Anatomy and Musculoskeletal System. Stuttgart, Germany: Thieme; 2010. Used with permission.)

Free flaps (latissimus dorsi, TFL): if no local options exist Abdominal wall transplant: if no local and free flap options • Mutton chop flap Named after extravagant 19th century sideburns

Rectus femoris flaps (unilateral or bilateral) with or without TFL Can include distal posterior lateral iliotibial tract into the fascial unit • Component separation Described by Dr. Oscar Ramirez in 1990 to medialize the rectus abdominis muscles with attached internal oblique muscle and transversus abdominis muscle to the midline Can close 10 cm, 20 cm, and 5 cm in epigastric, midabdominal, and low abdominal regions, respectively Includes extra 2 cm for incising posterior rectus fascia If > 20 cm defect, add mesh to

repair Do not need tissue expansion unless missing skin Incise external oblique aponeurosis 2 cm lateral to the rectus abdominis muscle Separate plane between the external and internal oblique muscles Violation of the plane between the internal oblique and transversus abdominis could damage the innervation to the rectus abdominis muscles (regional block for abdominoplasty is administered in this plane) Open book technique: modification of component separation includes

single fascial incision releasing external oblique and concurrently creates an anterior rectus sheath turnover flap • Prosthetic mesh Polytetrafluoroethylene: Gortex Polypropylene (Marlex or Prolene) Used in clean fields because needs to be removed if infected Increased risk of adhesions, bowel obstruction, and fistula formation compared to biologic mesh • Biologic mesh Examples AlloDerm (LifeCell Corp., Bridgewater, NJ): human cadaveric acellular dermal matrix

Strattice (LifeCell): porcine acellular dermal matrix Permacol (Covidien, Mansfield, MA): porcine dermal collagen Surgisis (Cook Biotech, West Lafayette, IN): porcine small intestine submucosa Uses Contaminated field Immunocompromised patients If concerned about wound breakdown and exposure of prosthetic mesh

Chest Reconstruction (Table 7.1)

• Flap options Pectoralis major muscle advancement flap Based on the thoracoacromial arteries Most commonly used flap to cover the anterior central chest, especially superior chest wounds Pectoralis major muscle turnover flap: based on the internal mammary artery (IMA) Rectus abdominis muscle flap: based on superior epigastric artery (if IMA patent) Omental flap Based on gastroepiploic artery Covers large chest wounds

Used if pectoralis flap or rectus abdominus muscle not options Latissimus dorsi muscle Based on thoracodorsal artery Covers ipsilateral hemithorax and sternum Sternal debridement and immediate reconstruction for early wound infections, versus staged reconstruction after multiple debridements for chronic infected wounds

Congenital Chest Anomalies • Marfan syndrome Connective tissue disorder Patients are tall with a concave

chest (pectus excavatum) Usually asymptomatic unless compression of heart from a severe deformity • Anterior thoracic hypoplasia Syndrome of anterior chest wall depression, posteriorly displaced ribs, hypoplasia of ipsilateral breast, superiorly displaced nipple areola complex

Sternum and pectoralis are normal

• Sternal cleft: midline fusion defect, lacks protection of the heart

Lower Back Reconstruction • Spina bifida Congenital neural tube defect Vertebrae not fully formed Skin covering present • Myelomeningocele Most severe form of spina bifida Neural sac exposed without skin covering Treatment: local paraspinous musculofascial flaps followed by coverage with skin advancement flaps • Lower back wound

Reverse latissimus dorsi flap: coverage over inferior posterior trunk Skin graft: if no exposed vertebrae No recipient vessels for free flap

Suggested Reading Arnold PG, Pairolero PC. Chest-Wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg 98(5): 804-810, 1996 Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for meshrelated complications. Plast Reconstr Surg 2005;116(5):1263–

1275, discussion 1276–1277 Chang RR. Thoracic reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:665–669 Dibbell DG Jr, Mixter RC, Dibbell DG Sr. Abdominal wall reconstruction (the “mutton chop” flap). Plast Reconstr Surg 1991;87(1):60–65 Dumanian GA. Abdominal wall reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:670–675 Fiala TG, Buchman SR, Muraszko KM.

Use of lumbar periosteal turnover flaps in myelomeningocele closure. Neurosurgery 1996;39(3):522–525, discussion 525–526 Hoxworth RE. Trunk Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2009:1–60. Selected Readings in Plastic Surgery; vol 10, issue 24 Izaddoost S, Withers EH. Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases. Ann Plast Surg 2012;69(3):296–300 Mathes SJ, Steinwald PM. Foster RD, et al. Complex Abdominal Wall Reconstruction: a Comparison of Flap and Mesh Closure. Ann Surg

2000 Oct; 232(4): 586–596 Mericli AF, Bell D, DeGeorge BR Jr, et al. The single fascial incision modification of the “0pen-book” component separation repair: a 15Year experience. Ann Plast Surg 2013;71(20): 203–20 Netscher DT, Baumholtz MA. Chest reconstruction: I. Anterior and anterolateral chest wall and wounds affecting respiratory function. Plast Reconstr Surg 2009;124(5):240e– 252e Netscher DT, Baumholtz MA, Bullocks J. Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral

chest, and posterior trunk). Plast Reconstr Surg 2009;124(6):427e– 435e Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86(3):519–526 Rubayi S, Chandrasekhar BS. Trunk, abdomen, and pressure sore reconstruction. Plast Reconstr Surg 2011;128(3):201e–215e Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy,

surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000;105(2):731–738, quiz 739 van Aalst JA, Phillips JD, Sadove AM; van AJ. Pediatric chest wall and breast deformities. Plast Reconstr Surg 2009;124(1, Suppl):38e–49e

8 Tissue Expansion Reviewed by Sara R. Dickie

• Effects of tissue expansion Epidermis thickens Dermis thins Dermal elastic fibers microfragment Dermal interstitial fluid displaced Collagen fibers realign Rete ridges flatten Underlying bones thin Skeletal muscles atrophy Vascular endothelial growth factors (VEGFs) upregulated during ischemia

Circulation increased in delayed fashion Surface area increases as cells creep (stretch then proliferate) • Delay procedure Immediate tissue expansion is suboptimal for acute wounds Need healed skin with no evidence of infection • If erythema, mottling, severe pain without fever or purulent drainage Withdraw fluid or deflate Do not remove expander • Calculate tissue expansion design to fill defect (Fig. 8.1) Amount of advancement achieved by tissue expansion to fill the

defect can be calculated Subtract the diameter of the tissue expander base (A) from the distance of the arc of skin overlying the tissue expander (C) This calculation refers to direct advancement only. Flaps expanded many times can be rotated or transposed and therefore this calculation does not apply • Scalp expansion Place between galea and periosteum Used for large wounds > 6 cm (> 15%) and alopecia • Forehead expansion: place between frontalis muscle and periosteum • Breast expansion and radiation

therapy

Fig. 8.1 Tissue expander.

Autologous reconstruction after radiation has improved aesthetic outcomes and reduced complications compared with implant reconstruction If an implant-based reconstruction

has to be radiated, for best outcomes remove the tissue expander, radiate, and convert to autologous reconstruction Can also deflate, radiate, reinflate, then do implant or autologousbased reconstruction • Failures in tissue expansion Complications: infection, extrusion, pain, failure of device Lower extremity: highest complication rates 37 to 50% Scalp: complication rates < 20% Areas of greater skin elasticity: lowest complication rates • Giant congenital melanocytic nevi Treat with tissue expansion and staged excision

Do not do punch biopsy because risk of false-negative results Estimated 5% risk of malignant transformation (newer data suggests 2 to 3% risk) In comparison, for small nevi, melanoma risk is < 1%: may observe or excise • Osmotic tissue expander Composed of: hydrogel (vinyl pyrrolidine and methylmethacrylate) Second generation has silicone membrane with pores Self-filling, no injections required, decreased infection rate compared with conventional tissue expansion with external fillings

Drawbacks: cannot slow or stop expansion, cannot overfill

Suggested Reading Anwander T, Schneider M, Gloger W, et al. Investigation of the expansion properties of osmotic expanders with and without silicone shell in animals. Plast Reconstr Surg 2007;120(3):590–595 Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr Surg 2009;124(1, Suppl):1e–13e Bauer BS. Tissue expansion. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA:

Lippincott Williams & Wilkins; 2006:84–90 Gosain AK, Santoro TD, Larson DL, Gingrass RP. Giant congenital nevi: a 20-year experience and an algorithm for their management. Plast Reconstr Surg 2001;108(3):622–636 Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 2005;31(1):1–4 Krengel S, Hauschild A, Schafer T. Melanoma Risk in Congenital Melanocytic Naevi: a Systematic Review. Br. J. Dermatol. 155(1):1– 8, 2006

9 Lymphedema and Pressure Sores Reviewed by Reid A. Maclellan

Lymphedema • Definitions Primary lymphedema: abnormal collection of interstitial fluid due to embryological lymphatic maldevelopment Secondary lymphedema: acquired lymphatic obstruction • Causes (Table 9.1) • Symptoms Thick, peau d'orange skin due to

congested dermal lymphatics Pits, fissures, and open wounds accommodate debris and bacteria Lymphorrhea: leakage of lymph out of the skin Infection • Nonsurgical treatment Start with conservative therapy: compression, elevation, physical therapy, weight loss Do not compress with Unna boots (for venous stasis not for lymphedema) Diuretics are not a useful treatment • Surgical treatment Liposuction only for mild/moderate cases, still need compression

Table 9.1 Causes of lymphedema

Primary lymphedema

Description

Congenital lymphedema

Presents < 10 months of age (Milroy disease is familial form of lymphedema presenting at this age)

Lymphedema praecox

Presenting during adolescence (Meige disease is familial form of lymphedema presenting at this age), most common

cause of primary lymphedema Lymphedema tarda

Presenting in adulthood

Secondary lymphedema

Description

Filariasis

Most common cause worldwide, 90% of all cases, infestation of lymph nodes by parasite Wuchereria bancrofti

Breast cancer

Most common cause in the United States, following mastectomy, axillary

lymphadenectomy, and radiation therapy

Other secondary causes

Massive localized lymphedema (MLL) due to obesity; vein stripping, peripheral vascular disease surgery, infection, tumor invasion and compression, trauma

Staged excision of skin and subcutaneous tissue: best surgical procedure (popularized by Miller) Physiological procedures (lymphovenous and lympholymphatic anastomoses) are not shown to have great long-term

results Charles procedure: extreme operation where skin, subcutaneous tissue, and fascia are completely excised; skin from resected specimen used for immediate skin grafting • Stewart–Treves syndrome Lymphangiosarcoma from longstanding arm lymphedema after mastectomy Best treated by wide local excision or amputation • Massive localized lymphedema (MLL) and morbid obesity Undergo resection of MLL, then gastric bypass

Pressure Sores • Etiology Prolonged pressure above end capillary pressure (32 mm Hg) > 70 mm Hg for > 2 hours causes irreversible tissue necrosis Ischial sores from sitting Sacral ulcers from supine position Trochanter sores from lateral decubitus position Secondary causes: diabetes mellitus (DM), incontinence, malnutrition • Stages (Table 9.2) • Prevention Avoid pressure by changing position every 2 hours

Improve nutrition, control diabetes, manage comorbidities Antispasmodics: intrathecal baclofen via implantable pump Diverting colostomy to prevent fecal soilage Negative pressure wound therapy does not work over fibrotic pressure sore Dry eschars should be directly excised; do not use Accuzyme (enzymatic debridement) • Osteomyelitis Diagnosis: bone culture Treatment: resect bone Do partial ischiectomy if bone exposed

Table 9.2 Staging of pressure sores

Stage

Description

Nonblanching erythema

Through dermis

III

Through subcutaneous tissue, not fascia or muscle (full-thickness wound)

Through fascia or muscle to bone (full-thickness wound)

Do not do complete ischiectomy, because will increase pressure on opposite side Do not do bilateral ischiectomy, because will increase pressure on perineum, leading to urethrocutaneous fistula Juncture S2–S3: highest-level bone debridement without entering dural space Cauda equina L2: end of spinal cord where bundlelike structures of nerves exit • Most common cause of death in chronic pressure sore patients: renal failure • Marjolin ulcers: squamous cell

carcinoma in chronic wound, seen in 0.5% of pressure sores • Reconstruction (Table 9.3) If ambulatory, use fasciocutaneous flap instead of muscle flap to decrease morbidity (harvesting gluteus maximus muscle flap affects ability to rise from a seated position) Rehabilitation: patient should avoid sitting for 3 weeks after reconstruction, then sitting protocol is initiated Table 9.3 Reconstruction of pressure sores

Pressure sore

Management

Sacrum

Ischium

Superior gluteal artery flap, transverse back flap Gluteal fasciocutaneous flap: use if ambulatory TFL: use if paraplegic below T12, a sensory flap based on lateral femoral cutaneous nerve from T12–L3 spinal roots Posterior thigh (hamstring) V-Y flap (biceps femoris, semitendinosus, semimembranosus): use if paraplegic

above T12; detach origin of insertion for additional length; do not use V-Y if ambulatory

Trochanter

TFL, vastus lateralis flap, girdlestone (remove proximal femur, stops contraction and pressure)

Suggested Reading Bauer JD, Mancoll JS, Phillips LG. Pressure sores. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery.

6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:722–729 Bauer J, Phillips LG. MOC-PSSM CME article: Pressure sores. Plast Reconstr Surg 2008;121(1, Suppl):1–10 Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 1998;102(4): 1058-1067 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010;126(3):752–758

Chim H, Drolet B, Duffy K, Koshima I, Gosain AK. Vascular anomalies and lymphedema. Plast Reconstr Surg 2010;126(2):55e–69e Rubayi S, Chandrasekhar BS. Trunk, abdomen, and pressure sore reconstruction. Plast Reconstr Surg 2011;128(3):201e–215e Rudkin GH, Miller TA. Lymphedema. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:717–721 Schook CC, Mulliken JB, Fishman SJ, et al. Primary lymphedema: clinical features and management in 138 pediatric patients. Plast Reconstr

Surg 2011;127(6): 2419–2431 Tchanque-Fossuo CN, Kuzon WM Jr. An evidence-based approach to pressure sores. Plast Reconstr Surg 2011;127(2):932–939

10 Skin Lesions and Soft Tissue Tumors Reviewed by Jeffrey H. Kozlow

Skin Cancer • Classification Melanoma Nonmelanoma Squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) • Risk factors Sun exposure: UVB > UVA Family history Fair skin complexion (Fitzpatrick I-III)

Immunosuppression Xeroderma pigmentosum Autosomal recessive inheritance Altered DNA repair mechanisms in response to UV damage Increased risk for melanoma, SCC, and BCC Management: minimize sun exposure • Prevention Sunscreen Components: para-amino benzoic acid (PABA), padimate, oxybenzone, and zinc oxide

Melanoma • Melanoma: skin cancer originating

from melanocyte cells • Layers of epidermis (from superficial to deep) Stratum (S) corneum: superficial layer S. lucidum S. granulosum S. spinosum S. basale: deep layer containing melanocytes • Diagnosis Mnemonic ABCDE Asymmetry: shape not symmetrical Borders: irregular borders Color variegation: different colors within lesion

Diameter: > 6 mm Evolving: change in size, shape, color, or new symptom (bleeds, ulcerates) Punch biopsy: often preferred over shave biopsy; provides depth of invasion • Types Lentigo maligna: least aggressive, “Hutchinson freckles” Acral lentiginous: seen in African Americans, soles and palms Nodular: aggressive Superficial spreading: most common • Tumor depth Breslow: most common

classification of tumor depth T1 < 1 mm (T1a without ulceration, T1b with ulceration and/or mitrotic rate < 1 mitosis/mm2) T2 1 to 2 mm (T2a without ulceration, T2b with ulceration) T3 2 to 4 mm (T3a without ulceration, T3b with ulceration) T4 > 4 mm (T4a without ulceration, T4b with ulceration) Clark's classification of tumor depth Mnemonic: Every Pigmented Junction Requires Formalin Epidermis Papillary dermis

Junction of papillary and reticular dermis Reticular dermis Fat (subcutaneous) layer • Nodal involvement N0: no nodes N1: 1 regional lymph node N2: 2 to 3 nodes or in-transit disease N3: ≥ 4 nodes or in-transit disease N1-3a: microscopic disease; N13b: macroscopic disease; N1-3c: satellitosis or in-transit • Metastasis M0: no metastasis M1a: skin and distant lymph nodes M1b: lung

M1c: other organs, elevated serum lactate dehydrogenase (LDH) • Staging 0: melanoma in situ IA: T1a, N0, M0 90% 5-year survival IB: T1b, N0, M0 or T2a, N0, M0 II: T2b-T4b, N0, M0 45 to 80% 5-year survival III: any T, N1-3, M0 25 to 65% 5-year survival Nodal involvement, only, no distant disease Candidate for postsurgical chemotherapy or immunotherapy IV: any T, any N, M1 5 to 20% 5-year survival

Metastasis • Surgical margins based on depth In situ: 0.5 cm margin < 1 mm deep: 1 cm margin; sentinel lymph node biopsy (SLNBx) if between 0.75 to 1.0 mm with increased mitotic rate 1 to 4 mm deep: 2 cm margin and SLNBx (if 1 to 2 mm deep on face can do 1 cm margin) > 4 mm deep: 2 cm margin • Nail bed melanoma Melanoma of germinal matrix Diagnosis Hutchinson sign: paronychial pigment Shave biopsy

Treatment Amputation proximal to most distal joint with SLNBx based on depth Nailbed resection only if atypical junctional melanocytic hyperplasia (AJMH) or melanoma in situ

Sentinel Lymph Node Biopsy • Indications Melanoma 1 to 4 mm deep (T2, T3) or if between 0.75 to 1.0 mm with increased mitotic rate Marjolin SCC

SCC > 2 cm diameter Merkel cell carcinoma • Contraindications Node positive melanoma: do lymph node dissection, not SLNB BCC

Giant Congenital Melanocytic Nevi (CMN) • Definitions Nevi > 20 cm in diameter in adults Expected to become 20 cm in adulthood (translated to 9 cm on an infant's head) 2% body surface area, or 1% of body surface area in head and neck

Requires staged excision, often with tissue expansion and skin grafts • Melanoma association Estimated 5% risk of malignant transformation (newer data suggests 2 to 3% risk) • Neurocutaneous melanosis (NCM) Melanocytes in leptomeninges Risk factors Large or multiple axial nevi Calvarial and posterior midline nevi Multiple satellite nevi (> 20) Diagnosis Central nervous system (CNS) manifestations usually present

by 2 years of age: hydrocephalus, seizures, focal deficits, paresis Magnetic resonance imaging: meningeal, cerebral, cerebellar, or spinal cord involvement Life-threatening symptom Hydrocephalus Need ventriculoperitoneal (VP) shunt, which disseminates tumor cells Treatment: if NCM is asymptomatic, do not treat CMN until 2 years old to see whether neurological symptoms present, because may not survive long enough to benefit from resection of CMN

Melanocytic Nevi •

Definition: benign melanocyte lesions with low malignant potential • Junctional nevus Located in the border between epidermis and dermis • Intradermal nevus Found within the dermal layer • Compound nevus Present in both the epidermis and the dermis • Halo (Sutton) nevus Central nevus surrounded by hypopigmented skin (less pigment corresponds to regression of central nevus and occurs secondary to immune response)

• Nevus spilus Café au lait spots • Spitz nevus Benign pink lesion in head and neck region Called “juvenile melanoma” because occurs in 5- to 10-yearolds and histologically is similar to melanoma Treatment: excision alone, although pathologically high risk lesions should be treated like melanoma • Nevus of Ota Blue gray lesion in cranial nerve V1 and V2 distribution Treatment: Q-switch ruby laser • Nevus of Ito

Similar to nevus of Ota but in lateral brachial cutaneous and supraclavicular nerve distribution • Blue nevus Small intradermal nevus rarely malignant Do not confuse with blue rubber bleb nevi (venous malformation) • Mongolian spot Benign blue-gray-brown lesion on sacrum, which spontaneously resolves by age 5

Squamous Cell Carcinoma • Squamous cell carcinoma (SCC) Nonmelanoma skin cancer originating from squamous cell in

epidermis Low metastatic rate (compared to mucosal SCC, which has 10% meta-static rate) except when large or with aggressive pathologic features Treatment Excision with 4 to 10 mm margins; can perform Mohs in critical areas Radiation therapy Cryosurgery Topical chemotherapy • Actinic (solar) keratosis Precursor to SCC (10% transformation risk) Most common premalignant lesion

in elderly fair-skinned patients Dry, scaly, rough patches, itch, painless Treatment 5-Fluorouracil (5-FU) Best treatment Good cosmetic treatment, no hypopigmentation Side effects: irritation, burning, erythema Imiquimod (Aldara, 3M Pharmaceuticals, St. Paul, MN) Stimulates immune response by increasing interferon levels and inducing apoptosis Also treatment for viral warts Cryotherapy

Curettage Retinoids: derived from vitamin A • Bowen disease SCC in situ Red-brown scaly patches Erythroplasia of Queyrat: SCC in situ arising on the penis • Keratoacanthoma Benign round, smooth nodule around a keratinous plug Rapidly grows over weeks Potential for spontaneous regression over months 5.7% develop into SCC • Cutaneous horn Hard, keratinized skin protrusions

secondary to excessive epidermal growth 20% premalignant, 15% associated with SCC Treatment: excision or shave

Basal Cell Carcinoma • Basal cell carcinoma (BCC) Most common type of cancer Originate from basal layer of epidermis (deepest layer) Small, dome-shaped, pearly white color Rarely metastasize Treatment Excision with 3 to 10 mm margins

Mohs in sensitive areas or aggressive growth patterns Radiation Electrodesiccation and curettage (ED&C) Cryosurgery Photodynamic therapy Topical fluorouracil (5-FU) Topical imiquimod • Gorlin syndrome Nevoid BCC syndrome Autosomal dominant Triad Multiple BCC: dome-shaped tan papules on face, neck, and trunk Keratocystic odontogenic tumor: swelling, pain in molar and

premolar area Palmar and plantar erythematous skin pits • Bazex syndrome Autosomal dominant Multiple BCCs on the face Similar to Gorlin syndrome, but no skin pits or odontogenic tumor • Nevus sebaceous of Jadassohn Potential to transform to BCC (15% risk) Yellow-orange, elevated plaque on face or scalp since birth Treatment: excision

Mohs

• Indications Tumors without distinct margins Morpheaform BCC: fingerlike extensions can be missed with standard excision Recurrent tumors Cosmetic and functionally sensitive areas Sclerosing BCCSCC with perineural invasion Microcystic adnexal carcinoma Dermatofibrosarcoma protuberans Desmoplastic melanoma • Recurrence rate: low compared to standard excision, cryotherapy, ED&C, 5-FU, and radiation therapy

Miscellaneous Skin Lesions and Soft Tissue Tumors • Seborrheic keratosis Benign, stuck-on lesion Waxy, sharply circumscribed • Dermatosis papulosa nigra Variant seborrheic keratosis in blacks Seen in cheeks • Xanthelasma palpebrarum Yellow periorbital plaques 50% familial dyslipidemia • Pseudofolliculitis barbae Seen in African American men Papules over chin, cheeks, back of neck can develop into keloids

• Acrochordon Benign skin tag • Tricholemmoma Benign tumor arising from outer root sheath of hair follicle Found on face, neck, scalp, chest, hands • Epidermal inclusion cyst Dermal cyst containing epidermal elements • Becker nevus Benign hamartoma (normal tissue disorganized) Nevus misnomer because no melanocytes Brown patch with hair in upper trunk

Males 20 to 30 years old • Neurofibromatosis Type 1 (von Recklinghausen disease) Inheritance: autosomal dominant Café au lait spots: macules Neurofibroma Benign tumor of superficial peripheral nerve sheath Treatment: excision if symptomatic or for cosmesis Lisch nodules: iris hamartomas, do not affect vision Malignant peripheral nerve sheath tumor (MPNST): 7 to 13% lifetime risk Type 2

More severe CNS involvement Acoustic neuroma (schwannoma): tumor of eighth cranial nerve • Simple lentigo Benign proliferation of melanocytes in children Not sun-related • Solar (senile) lentigo Benign proliferation of melanocytes Sun-related • Ephelis Benign common freckle Normal number of melanocytes Increased melanin production • Syringoma

Benign lower eyelid papule in women • Cylindroma Benign round, firm scalp nodule • Melasma Hyperpigmented macules in face and neck Secondary to pregnancy or estrogen Treatment: bleaching • Pyogenic granuloma Common in children and young adults Pedunculated mass rapidly develops and can bleed Treatment: excision and cautery of base

• Pilomatricoma Benign hard, solitary, calcifying nodule of hair origin in children • Molluscum contagiosum Virally induced papules in children and young adults • von Hippel-Lindau disease Inheritance: autosomal dominant Hemangioblastomas in cerebellum, spinal cord, kidney, retina Renal cell carcinoma Café au lait spots • Dermatofibroma Benign dermal fibrous histiocytoma of anterior lower leg Neoplasm, nodule, or reaction to trauma

Asymptomatic, firm, raised 3 to 10 mm diameter Treatment: excisional biopsy • Dermatofibrosarcoma protuberans Sarcoma of the dermal skin layer Locally invasive, rarely metastasizes, high recurrence rate Treatment: surgical margin of 2.5 cm or Mohs excision • Lymphangioma circumscriptum Cutaneous lymphatic malformation Small multiple clusters clear-towhite appearance vesicular lesions Obliterate with pressure, then reappear and refill Treatment: excision of skin with

deeper lymphatics • Merkel cell carcinoma Characteristics Aggressive, malignant neuroendocrine skin cancer Smooth, painless, solitary dermal nodule Patients > 65 years old 50% in head and neck, 40% in trunk Treatment Wide local resection SLNBx Radiation therapy and chemotherapy postoperatively Eyelid involvement: treat with wide excision with subtotal and

total eyelid reconstruction Low 5-year survival: 66%

Suggested Reading Anderson RG. Skin Tumors II: Melanoma. Dallas TX: Selected Readings in Plastic Surgery, Inc.; 2004:1–50. Selected Readings in Plastic Surgery; vol 10, issue 3 Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr Surg 2009;124(1, Suppl):1e–13e Culliford A, Hazen A. Dermatology for plastic surgeons. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott

Williams & Wilkins; 2006:105–114 Gosain AK, Santoro TD, Larson DL, Gingrass RP. Giant congenital nevi: a 20-year experience and an algorithm for their management. Plast Reconstr Surg 2001;108(3):622–636 Gulleth Y, Goldberg N, Silverman RP, Gastman BR. What is the best surgical margin for a Basal cell carcinoma: a meta-analysis of the literature. Plast Reconstr Surg 2010;126(4):1222–1231 Krengel S, Hauschild A, Schafer T. Melanoma risk in congenital melanocytic naevi: a systematic feview. Br. J. Dermatol 2006;155(1): 1-8

Lee EH, Nehal KS, Disa JJ. Benign and premalignant skin lesions. Plast Reconstr Surg 2010;125(5):188e– 198e Netscher DT, Leong M, Orengo I, Yang D, Berg C, Krishnan B. Cutaneous malignancies: melanoma and nonmelanoma types. Plast Reconstr Surg 2011;127(3):37e–56e O'Connor WJ. Roenigk RK, Brodland DG. Merkel cell carcinoma: comparison of Mohs micrographic surgery and wide excision in eightysix patients. Dermatol Surg 1997;23(10):929–933 Rogers CR, Bentz ML. An evidencebased approach to the treatment of nonmelanoma facial skin

malignancies. Plast Reconstr Surg 2011;127(2):940–948 Weedon DD, Malo J, Brooks D, Williamson R. Squamous cell carcinoma arising in keratoacanthoma: a neglected phenomenon in the elderly. Am J Dermatopathol 2010;32(5):423–426 Zbar RI. Skin Tumors I: Basal Cell and Squamous Cell Carcinoma. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2004:1–34. Selected Readings in Plastic Surgery; vol 10, issue 3 Zbar RI, Canady JW. MOC-PSSM CME article: Nonmelanoma facial skin malignancy. Plast Reconstr Surg 2008;121(1, Suppl):1–9

11 Soft Tissue Infection Reviewed by Andre Yuan Levesque

Snake Bites (Table 11.1) • Pit viper family Cause 99% of bites in United States Pit vipers: rattlesnakes, copperheads, cottonmouths Rattlesnakes have most potent venom • Dry bites (no envenomation) 10 to 50% of bites are dry Treatment: observe, give tetanus, intravenous fluid (IVF), broad

spectrum antibiotics Mark with pen for progression and monitor for signs of envenomation (no antivenom required unless progresses) • Envenomation Presentation: pain, swelling, ecchymosis, coagulopathy, hypotension, mental status changes, vomiting Transfer: if being transferred to medical center, transfer immediately without intervention Equine antivenom: can cause serum sickness, do skin testing with horse serum to rule out hypersensitivity reaction Incision and suction: do shallow

linear incision around fangs and snakebite suction cup therapy to remove venom if within 15 to 30 minutes of bite and snake was large Resuscitation: use lactated Ringer solution, not normal saline, because chloride exacerbates metabolic acidosis Fasciotomy: can be done if symptoms of compartment syndrome (early symptoms are pain on passive stretching, pressures > 30 mm Hg; late finding is loss of pulse) Not necessary: ice packs, debridement, suction therapy if does not meet above criteria,

cryotherapy, tourniquet more ischemia)

(causes

Table 11.1 Snake bite grades

Antivenom administration

Grade

Presentation

Mild

Fang marks, local swelling 0–5 vials, after and pain, not serum testing systemic

Pain and erythema Moderate extending beyond fang site

5–20 vials, after serum testing

Severe

Marked swelling, > 20 vials, do coagulopathy, not delay for ecchymosis, serum testing shock, compartment syndrome

Spider Bites •

Black widow (Lactrodectus mactans) Venom is neurotoxic Presentation: within 15 minutes have muscle pain and cramps, can lead to tremors, vomiting, increased salivation, paresthesias, and shock

Treatment: muscle relaxants (calcium gluconate intravenous [IV] and methocarbamol), antivenom • Brown recluse (Loxosceles reclusa) Venom causes tissue necrosis Presentation: edema, erythema, tissue necrosis, demarcates over weeks, systemic reactions lead to hemolysis and disseminated intravascular coagulation Treatment: dapsone 100 mg orally twice a day for 14 days (leukocyte inhibitory properties) Dapsone: side effects of hemolysis, therefore do not give if patient has glucose-6-phosphate dehydrogenase (G6PD) deficiency

Hydradenitis Suppurativa • Apocrine gland disease, which secretes malodorous viscous milky fluid with bacterial colonization • Does not involve Eccrine glands in skin that secrete thin clear sweat Sebaceous glands in face/scalp that secrete sebum • Location: axilla, groin, mons, buttock, inframammary fold, and perineum • Categorized according to system proposed by Hurley (Table 11.2) • Treatment Medical Long-term antibiotics (2 to 3

months) Commonly tetracycline, (Clindamycin/Rifampin) among others Accutane TNF-alpha inhibitors Topical clindamycin and hibiclens Surgical Radical excision Healing by secondary intention Reconstruction via skin grafts or flaps Table 11.2 Hurley staging of hidradenitis suppurativa

Stage

Characteristics

Single or multiple abscesses without sinus or scar formation

Recurrent abscesses, single or multiple abscesses with sinus tract formation

Diffuse or broad involvement across a regional area with many interconnected sinuses

Necrotizing Fasciitis

• Definition: soft tissue infection spreads along fascial planes in subcutaneous tissue • Etiology Trauma Infection: most commonly polymicrobial, but group A streptococcus is also common Immunocompromised patients: diabetes is most common comorbidity • Presentation Pain out of proportion to exam, crepitus, dishwater pus (gray watery discharge), edema, erythema, fever Progresses to blisters, necrotic skin, sepsis, death

• Workup Labs:↑white blood cells, ↓platelets, ↑potassium Radiography: clostridium associated with subcutaneous air • Treatment Immediate debridement followed by serial debridements until infection control achieved IV antibiotics for gram-negative, gram-positive, and anaerobic bacteria Hyperbaric oxygen can be adjunct • Streptococcus toxic shock syndrome ⇧Creatinine Hepatotoxicity Coagulopathy (↑international

normalized ratio)

Suggested Reading Anz AW, Schweppe M, Halvorson J, Bushnell B, Sternberg M, Andrew Koman L. Management of venomous snakebite injury to the extremities. J Am Acad Orthop Surg 2010;18(12):749–759 Broughton G, Rohrich RJ. Wounds and Scars. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–56. Selected Readings in Plastic Surgery; vol 10, issue 7 Culliford A, Hazen A. Dermatology for plastic surgeons. In: Thorne CH, Beasley RW, Aston SJ, et al, eds.

Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:105–114 Elliott DC, Kufera JA, Myers RAM. Necrotizing soft tissue infections: risk factors for mortality and strategies for management. Ann Surg 1996;224(5):672–683 Hurley HJ. Axillary Hyperhidrosis, Apocrine Bromhidrosis, Hidradenitis Suppurativa, and Familial Benign Pemphigus: Surgical Approach. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. New York: Marcel Dekker; 1989: 729–739 Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant

therapy in the management of necrotizing fasciitis. Am J Surg 2005 189(4): 462-466 Rees RS, Altenbern DP, Lynch JB, King LE Jr. Brown recluse spider bites: a comparison of early surgical excision versus dapsone and delayed surgical excision. Ann Surg 1985;202(5):659–663

12 Immunology and Transplantation Reviewed by Eduardo D. Rodriquez

History of Transplantation • 1954 Kidney (Murray) • 1959 Azathioprine • 1963 Lung (Hardy) • 1966 Pancreas (Lillehei) • 1967 Intestine (Lillehei) • 1967 Heart (Barnard) • 1967 Liver (Starzl) • 1970 Cyclosporine • 1981 Heart and lung (Reitz) • 1988 Peripheral nerve (MacKinnon)

• 1988 Flexor tendon (Guimberteau) • 1996 Knee (Hofmann) • 1998 Hand (Dubernard) • 1998 Laryngeal (Strome) • 2000 Double hand (Dubernard) • 2003 Abdominal wall (Levi) • 2003 Tongue (Kermer) • 2004 External ear (Jiang) • 2005 Face (Dubernard) • 2006 Penis (Hu) • 2008 Double arm (Biemer)

Transplant Immunology • Transplantation grafts Autograft: transplantation on the same individual

Allograft: transplantation between different individuals of the same species Xenograft: transplantation between different species Isograft: transplantation between identical twins • Solid organ transplantation: transplantation of mainly one tissue type • Composite tissue allotransplantation Transplantation of an allograft composed of heterogeneous tissues Most antigenic tissue in body: skin Most commonly used tissue for biopsy to monitor rejection: skin (visible, accessible, most antigenic)

• Epitope Molecular unit of specific immune recognition Can be bound to TCR of T cells or the antibody of B cells • Antigen Epitope containing molecule Each antigen may contain many epitopes • Histocompatibility Degree to which the donor and recipient share regulatory molecules of immune system Major histocompatibility complex (MHC): in vertebrates Human leukocyte antigens (HLAs): in humans

MHC and HLA genes can differ among individuals serving as antigens • Innate versus adaptive immunity Innate: nonspecific response Adaptive: specific response by cellular (T cells) and humoral (anti-body-producing B cells) • Immunosuppressive agents (Table 12.1) • Common side effects of transplant medications Leukopenia Increased risk of forming malignancy Infections • Dynamics of rejection (Table 12.2)

Table 12.2 Dynamics of rejection

Rejection

Timing

Mechanism

Hyperacute

Minutes

Preexisting antibodies

Acute

First 3–6 months

T cells

Chronic

Months to years

Mechanism unclear

• Chimerism Coexistence of donor and recipient cell lines Holy grail of transplant immunology is to induce tolerance and prevent the need for lifelong immunosuppression

Suggested Reading Gordon CR, Hewitt CW, Lee WP. Transplantation of Composite Tissue Allografts. New York: Springer; 2007 Hettiaratchy S, Randolph MA, Petit F, Lee WP, Butler PE. Composite tissue allotransplantation—a new era in plastic surgery? Br J Plast Surg 2004;57(5):381–391 Lee WP, Feili-Hariri M, Butler P. Transplant biology and applications to plastic surgery. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins;

2006:52–57 Siemionow M, Klimczak A. Basics of immune responses in transplantation in preparation for application of composite tissue allografts in plastic and reconstructive surgery: part I. Plast Reconstr Surg 2008;121(1):4e–12e Siemionow M, Klimczak A. Tolerance and future directions for composite tissue allograft transplants: part II. Plast Reconstr Surg 2009;123(1):7e–17e Siemionow MZ, Kulahci Y, Bozkurt M. Composite tissue allotransplantation. Plast Reconstr Surg 2009;124(6, Suppl):e327– e339

13 Coding, Medicolegal, and Psychiatric Aspects Reviewed by Kent K. “Kye” Higdon

Coding • Wound closure coding (Table 13.1) Skin lesion excisions are reported based on the total excised diameter, including margins, not just the size of the lesion; simple closures are included in the excision Skin lesion excision with adjacent tissue transfer: cannot bill for excision if doing closure with

adjacent tissue transfer; report excised diameter including margins and dimensions of secondary defect of flap created Benign skin lesion: benign skin lesion excision reimbursement requires an ICD-9 code for benign lesion and a code for a complicating pathology (e.g., bleeding, itching, pain) Wound closure global to another procedure: if performing another procedure (e.g., nerve repair, parotid tumor resection), cannot report wound closure in addition to primary procedure • Breast reconstruction coding Implant removal: included with

capsulectomy and replacement procedures; capsulotomy is included with these procedures Tissue expander insertion: includes expansion during a 90 day global period Free flaps (TRAM, DIEP, SIEA, GAP, etc.) have the same code and are bundled with microsurgical anastomosis, use of operating room microscope, harvest and insetting of the flap, closure of the abdominal site, and rib excision to expose the internal mammary artery • Free flap coding Includes: the use of a microscope, harvesting and insetting the flap,

closure of the donor site defect, microsurgical anastomosis Does not include: procedures additional to those listed above, split-thickness skin grafts, closures more complex than primary closure of donor defect, use of vein or nerve grafts Table 13.1 Wound closure classification

Type

Definition

Simple

One layer (skin only)

Intermediate

More than one layer (skin or fascia, no muscle)

Complex

Requires revision, debridement, extensive undermining, and creation of a defect

Adjacent tissue transfer

Local tissue rearrangement based on random blood supply

Musculocutaneous flap

Axial blood supply

• Abdominoplasty coding Billed as two codes: abdominoplasty and resection of abdominal skin (panniculectomy) Includes: closure of abdominal

wall, translocation of umbilicus, musculofascial plication of the rectus sheath, resection of skin and fat, undermining of abdominal flap • Facial trauma coding Includes: exploration of nerves, exploration of fracture site, reduction of fracture, debridement of tissue Does not include: separate codes for bone grafting or implants used, separate codes for approach to orbital floor, separate codes for each fracture site repaired (e.g., orbital vs. malar fracture repair) • Global period Definition: time after an operation when physician cannot bill for

follow-up appointments Duration: 3 months for most operations, 10 days for lesion excision, and simple, intermediate, and complex repairs • Aesthetic versus insurance cases Aesthetic cases: patient pays out of pocket for entire fee Insurance cases: insurance covers majority of case, depending on policy descriptions, deductibles, and maximum out-of-pocket limits Combined aesthetic and insurance cases: insurance part of case billed to insurance company, aesthetic part billed directly to patient (typically prepaid) Aesthetic case bill based on:

surgeon, anesthesia, and operating room fees

Medicolegal • Injectables and fillers American Society of Plastic Surgeons (ASPS) Code of Ethics states that procedures requiring an incision may not be donated Injectables and fillers can be donated, because no incision is made Food and Drug Administration (FDA)-approved filler or injectable brought from another country may be used even if it is no longer manufactured in the

United States Physicians may advertise approved uses for FDA-approved injectables and fillers in specific locations Physicians must obtain consent and disclose any nonapproved use • Most common lawsuit in plastic surgery: breast surgery • Doctor–patient relationship: begins the moment you have a professional discussion regardless of whether or not you are in the office, hospital, or exam room • Complications: see patients frequently (every day to every other week) if there is a complication until the patient gets better or does not

want to see you • Job hiring: do not ask about age, religion, race, childcare responsibilities, disabilities, arrests • Health Insurance Portability and Accountability Act (HIPAA) Protects privacy of medical records Personal identifiable information, which cannot be released unless written consent from patient is obtained: identifiable photographs (face, tattoos), name, date of birth, contact information (i.e., telephone number, address) • Wrong site surgery Surgery on the wrong extremity, person, or organ

Joint commission recommendations for prevention include: site marking, time-out, informed consent, specifying laterality • Informed consent discusses: indications, procedures, alternatives, risks, benefits

Psychiatric Aspects • Patients to potentially avoid Unrealistic expectations Unstable male Minimum deformity Incompatible with you Argumentative Dissatisfaction with previous surgery

Pushed to surgery by someone else Excessively demanding • Body dysmorphic disorder (BDD) Overly concerned about minor defects 1 to 3% of general population 7 to 15% of plastic surgery population Refer to a psychiatrist before operating 50% associated with suicidal thoughts 70% never marry • SIMON Acronym for warning signs of problem patients Single

Immature Male Overexpectant Narcissistic • Malingering for anosmia Test with irritants (bleach, ammonia) that stimulate trigeminal nerve If patient claims they cannot smell irritant, they are malingering • Gender reassignment Send for psychiatric evaluation Medical treatment for 1 year after initial contact Surgical treatment 2 years after initial contact

Suggested Reading American Society of Plastic Surgeons; American Society for Aesthetic Plastic Surgery. Injectables and fillers: legal and regulatory risk management issues. Plast Reconstr Surg 2006;118(3, Suppl):129S– 132S CPT. Professional ed. Chicago, IL: American Medical Association; 2013 Crerand CE, Franklin ME, Sarwer DB. C-PS (SM) CME Article: Patient safety: body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg 2008;122(4S):1–15 Standards for privacy of individually

identifiable health information. Office of the Assistant Secretary for Planning and Evaluation, DHHS. Final rule. Fed Regist 2000;65(250):82462–82829 Rohrich RJ. The who, what, when, and why of cosmetic surgery: do our patients need a preoperative psychiatric evaluation? Plast Reconstr Surg 2000;106(7):1605– 1607

Section II Craniomaxillofacial Surgery

14 Head and Neck Anatomy Reviewed by Andrew Wexler

Orbital Anatomy (Fig. 14.1) • Seven bones compose the orbit: frontal, lacrimal, ethmoid, palatine, maxilla, zygoma, and sphenoid • Optic canal In lesser wing of sphenoid Transmits optic nerve and ophthalmic artery • Superior orbital fissure In greater wing of sphenoid Transmits cranial nerves (CN) III, IV, VI, and V1

• Medial wall: ethmoid makes up most of wall, also composed of lacrimal, palatine, and lesser wing of sphenoid • Floor: composed of maxilla medially, zygoma anteriorly • Inferior orbital fissure Between maxilla, sphenoid, palatine, and zygoma Transmits CN V2 and infraorbital vessels • Extraocular muscles (Table 14.1)

Fig. 14.1 Orbital anatomy.

Sinus Anatomy • Sinus drainage patterns Middle meatus: nasofrontal, frontal, maxillary, and anterior ethmoid sinuses

Inferior meatus: nasolacrimal duct Superior meatus: posterior ethmoid sinus Supreme meatus: sphenoid sinus Inferior concha: eustachian tube

Scalp • SCALP acronym Skin Connective tissue: subcutaneous tissue contains blood vessels and nerves Aponeurosis (galea): strength layer Loose areolar tissue: avulsions occur in this plane Periosteum: receives blood from diploic circulation via perforators

Skull Base (Table 14.2) (Fig. 14.2) • Cranial fossa Anterior: frontal bone, ethmoid bone, lesser sphenoid wing Medial: temporal bone, greater sphenoid wing Posterior: temporal bone, occipital bone

Mandible • Muscles of mastication (Table 14.3) • Depressors of mandible: platysma, geniohyoid, genioglossus, mylohyoid, digastrics (anterior head depresses mandible, posterior head

elevates hyoid) • Maximal mouth opening Vertical interincisal opening: 41 to 50 mm Horizontal: 10 mm • Inferior alveolar nerve Inferior alveolar nerve enters the mandibular foramen 10 mm below the sigmoid notch at the level of the occlusal plane Nerve course: along buccal side (1.8 mm from edge) in ramus/angle, runs toward lingual side (4.1 mm from buccal surface) around the first and second molars, then runs along inferior cortex through the body, exiting the mental foramen as the mental nerve

• Mental foramen: located below the second mandibular premolar Table 14.2 Skull base foramina and contents

Foramina

Contents

Anterior ethmoid foramen

Anterior ethmoid vessels

Cribriform

Olfactory nerve (CN I)

Foramen cecum

Encephaloceles

Optic foramen

Optic nerve (CN II) Oculomotor nerve (CN III), trochlear

Superior orbital fissure

nerve (CN IV), trigeminal nerve ophthalmic branch (CN V1), abducens nerve (CN VI)

Foramen rotundum

Trigeminal nerve maxillary branch (CN V2)

Inferior orbital fissure

CN V2 and its zygomatic branch

Foramen ovale

Trigeminal nerve mandibular branch (CN V3)

Foramen lacerum

Internal carotid artery, pterygoid canal nerve

Internal acoustic meatus

Facial nerve (CN VII) exits stylomastoid foramen, vestibulocochlear nerve (CN VIII)

Jugular foramen

Glossopharyngeal nerve (CN IX), vagus nerve (CN X), spinal accessory nerve (CN XI)

Hypoglossal canal

Hypoglossal nerve (CN XII)

Foramen magnum

Medulla oblongata

Fig. 14.2 Skull base. (a) Superior view of cranial cavity; (b) Inferior view of base of

skull. (From Baker EW, Schuenke M. Head and Neck Anatomy for Dental Medicine. New York: Thieme; 2010. Illustration by Karl Wesker. Used with permission.)

Dental Anatomy • Dental anatomy basics (Fig. 14.3; Fig. 14.4) 20 deciduous (baby) teeth: 4 central incisors, 4 lateral incisors, 4 canines, 4 first molars, 4 second

molars Deciduous first and second molars are replaced by the adult first and second premolars (bicuspids) First permanent molar and central incisors erupt ages 6 to 7 Mixed dentition: period when deciduous and permanent teeth coexist 32 permanent (adult) teeth: 4 central incisors, 4 lateral incisors, 4 canines (cuspids), 8 premolars (bicuspids), 12 molars (have four cusps each) Crown: exposed 1/3 of tooth is capped by enamel. Under the enamel is dentin and below that the pulp, which extends into the root.

Injury to the enamel may cause temperature sensitivity and require a crown. Infection of the pulp or fracture through the pulp blood supply may cause tooth death and require a root canal. Root: buried two thirds of tooth consists of dentin with a central pulp containing the nerve and artery of the tooth. A layer of cementum attaches the tooth to the socket. Periodontal ligaments (Sharpey's fibers) attach the tooth root to alveolar bone. • Terminology Palatal: surface of maxillary tooth facing palate Lingual: surface of mandibular

tooth facing the tongue Buccal: surface of mandibular and maxillary teeth facing the cheek

Fig. 14.3 Dental anatomy. (a) Deciduous dentition. (b) Adult dentition.

Fig. 14.4 Cross section of tooth. (From Baker EW, Schuenke M. Head and Neck Anatomy for Dental Medicine. New York: Thieme; 2010.

Illustration by Marcus permission.)

Voll. Used with

Mesial: surface of teeth facing the oral aperture Distal: surface of teeth toward the pharynx Labial: surface of teeth facing the lip

Tongue (Fig. 14.5) • Blood supply: paired lingual arteries travel laterally along the ventral third • Innervation for taste Anterior two-thirds: facial nerve (CN VII) chorda tympani branch Posterior one-third:

glossopharyngeal nerve (CN IX) lingual branch • Innervation for sensation Anterior two-thirds: trigeminal nerve mandibular branch (CN V3) Posterior one-third: glossopharyngeal nerve (CN IX) • Innervation for movement Hypoglossal nerve (CN XII) innervates majority of tongue muscles (hyoglossus, styloglossus, genioglossus) Vagus nerve (CN X) innervates the palatoglossus muscle

Fig. 14.5 Tongue innervation.

Branchial Arches (Table

14.4) • Head and neck structures are derived from branchial arches

Suggested Reading Gosain AK, Nacamuli R. Embryology of the head and neck. In: Thorne CH,

Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:179–190 Netter FH. Atlas of Human Anatomy. Rittenhouse Book Distributors Inc.; 1997 Thangavelu K, Kannan R, Kumar NS, et al. Significance of localization of mandibular foramen in an inferior alveolar nerve block. J. Nat. Sc. Biol. Med 2012;3(2): 156–160 Wexler A. Craniofacial anatomy. In: Thaller SR, Bradley JP, Garri JI, eds. Craniofacial Surgery. New York: Informa Healthcare; 2008:7– 39

15 Cleft Lip and Palate Reviewed by Jesse A. Taylor

Classification of Cleft Lip and Palate (CLP) (Fig. 15.1, Table 15.1) • Complete or incomplete • Kernahan and Stark's Striped Y (Fig. 15.1b) Visual component of uni- or bilaterality Can designate isolated cleft lip Oriented relative to incisive foramen Anterior to incisive foramen: 1 lip,

2 alveolus, 3 primary palate Posterior to incisive foramen: divided into three segments

Embryology • Age of development Cleft lip: 5 to 6 weeks Cleft palate: 7 to 8 weeks

Fig. 15.1 (a) Veau and (b) Kernahan and Stark's Striped Y classifications of cleft lip and palate. Table 15.1 Veau classification

Class

Characteristics

Soft palate only

Hard and soft palate

Suggested Reading

Alcalá-Galiano A, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric facial fractures: children are not just small adults. Radiographics 2008;28(2):441– 461, quiz 618 Chiasson G, Matic DB. Muscle Shape as a Predictor of Traumatic Enophthalmos. Craniomaxillofac. Trauma Reconstr 2010;3(3): 125130 Evans BG, Evans GR. MOC-PSSM CME article: Zygomatic fractures. Plast Reconstr Surg 2008;121(1, Suppl):1–11 Evans GR, Daniels M, Hewell L. An evidence-based approach to

zygomatic fractures. Plast Reconstr Surg 2011;127(2):891–897 Goldberg RA, Mancini R, Demer JL. The transcaruncular approach: surgical anatomy and technique. Arch Facial Plast Surg 2007;9(6):443–447 Hollier L, Kelley P. Soft tissue and skeletal injuries of the face. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:315–332 Hollier LH, Thornton JF. Facial Fractures. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–70. Selected Readings in

Plastic Surgery; vol 10, issue 6 Jordan DR, Allen LH, White J, et al. Intervention Within Days for Some Orbital Floor Fractures: the WhiteEyeds Blowout. Ophthal. Plast. Reconstr. Surg 1998;14(6): 379-390 Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort fracture treatment (organization of treatment for a panfacial fracture). J Craniofac Surg 1990;1(4):168–178 Losee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: classification, management, and early follow-up. Plast Reconstr Surg 2008;122(3):886–897 Markowitz BL, Manson PN, Sargent L, et al. Management of the Medial

Canthal Tendon in Nasoethmoid Orbital Fractures: the Importance of the Central Fragment in Classification and Treatment. Plast. Reconstr. Surg 1991;87(5): 843-853 Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg 2008;122(6):1850–1866 Sharabi SE, Koshy JC, Thornton JF, Hollier LH Jr. Facial fractures. Plast Reconstr Surg 2011;127(2):25e–34e

Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: II. Management of traumatic injury or fracture. Plast Reconstr Surg 2005;116(2):28e–41e Tessier P. The classic reprint. experimental study of fractures of the upper jaw I and II. René Le Fort, M.D. Plast Reconstr Surg 1972;50(5):497–506 Tessier P. The classic reprint: experimental study of fractures of the upper jaw. 3. René Le Fort, M.D., Lille, France. Plast Reconstr Surg 1972;50(6):600–607 Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41(2):89–98

23 Ear Reconstruction Reviewed by Reza Jarrahy

Ear Anatomy • External ear (Fig. 23.1) Pinna or auricle: outer ear Helix: peripheral prominent rim extending from concha to lobule Antihelix: prominence anterior to helical rim Superior crus: superior division of antihelix Inferior crus: inferior division of antihelix Triangular fossa: depression

between superior and inferior crus Scapha: depression between helix and antihelix Concha: depression anterior to antihelix, divided by root of helix Cavum concha: concha inferior to root of helix Cymba concha: concha superior to root of helix Tragus: cartilage ridge anterior to external auditory meatus, opposite to antitragus Antitragus: cartilage ridge opposite to tragus Intertragus notch: depression between tragus and antitragus, superior to the lobule Lobule: soft tissue on inferior of

auricle • Arteries Posterior auricular artery: primary supply Occipital artery Superficial temporal artery • Nerves Great auricular nerve (GAN): can injure during neck dissection, supplies lower lateral and lower cranial ear

Fig. 23.1 Structure of the auricle. (From Gilroy AM, MacPherson B, Ross L. Atlas of Anatomy. New York, NY: Thieme; 2009. Used with Permission.)

Auriculotemporal nerve (cranial nerve V3): superior lateral ear, anterior superior external auditory meatus

Lesser occipital nerve: superior cranial ear Arnold nerve (cranial nerve X): conchal bowl and posterior auditory canal; ring block would not anesthetize this nerve without direct infiltration • Embryology of external ear First branchial arch: three anterior hillocks form tragus, helical root, and superior helix Second branchial arch: three posterior hillocks form antitragus, inferior helix, and lobule First branchial groove: forms external auditory meatus

Microtia • Epidemiology Incidence: 1/7,000 births Craniofacial microsomia: unilateral or bilateral microtia Treacher Collins: bilateral microtia Goldenhar syndrome: also called oculoauricular vertebral syndrome (OAVS), includes microtia, epibulbar dermoids, and vertebral anomalies • Types Varying degrees from small ear to anotia Lobular type: only lobule present Conchal type: conchal bowl,

tragus, antitragus, and lobule present Anotia: complete absence of middle and external ear • Meurmann classification of microtia Grade I: small malformed ear, all components present Grade II: partial absence of recognizable structures Grade III: complete absence of auricular components, remnant usually lobule • Ear reconstruction options for microtia Autologous costal cartilage Alloplastic implant Silicone or porous polyethylene

(Medpor) Reinisch initially had 44% infection rate with Medpor implants, infection rate was reduced by adding a TPF flap Osteointegrated auricular prosthesis Difficult compliance with children because they are too active to keep attached, may lose it, and may not care for it Salvage for autologous and implant technique failure Useful if no local tissue to cover autologous or alloplastic construct Indicated in elderly with medical comorbidities, anesthetic risks,

and calcified costal cartilage that is too brittle for autologous reconstruction • Hearing in microtia Hearing aids used in patients with functioning inner ear cochlea Bone conduction hearing aids at 6 to 12 months in patients with bilateral microtia before ear reconstruction Bone anchored hearing aids (BAHAs) placed after external ear reconstruction in patients with bilateral microtia Aural atresia repair: ear canal created after external ear reconstruction when indicated per temporal bone computed

tomographic scan, may assist hearing and improve cosmesis

Autologous Ear Reconstruction (Table 23.1) • Technical details of autologous ear reconstruction Remove vestigial cartilage at initial stage from same incision used to place framework Closed suction drains promote skin adherence to cartilage construct Bulky gauze dressing to avoid skin necrosis due to compression Elevation combined with local fascial flap (TPF or retroauricular fascial flap) and skin graft

Tragus formed with costal cartilage (Nagata technique), or with composite chrondrocutaneous conchal graft from contralateral ear (Brent technique) Remove hair over construct with electrolysis, laser, or direct follicular excision • Complications of autologous ear reconstruction Skin necrosis without cartilage exposure: treat conservatively, allow skin to heal secondarily, topical local wound care, let demarcate Skin necrosis with cartilage exposure: debride exposed cartilage, close skin, antibiotics

Suppurative wound infection: incision and drainage, antibiotics, if does not resolve may need to do delayed secondary procedure to remove cartilage framework Table 23.1 Autologous costal cartilage ear reconstruction

Technique Timing

Brent

7 years old Contralateral unaffected ear growth complete to base construct design on

Stages

1. Base plate and helical rim 2. Lobule rotation 3. Elevation 4. Tragus

Nagata

10 years old Sufficient donor site cartilage exists Larger construct than Brent technique

1. Base plate, helical rim, lobule rotation, tragus/antitragus 2. Elevation

Traumatic Deformities • Cauliflower ear Subperichondrial hematoma in boxers and wrestlers Treatment: evacuation of hematoma via lateral incision parallel to

helix, and compressive dressing with cotton bolster If no treatment: new cartilage forms a thick, deformed ear • Skin avulsion Treatment with perichondrium intact: skin grafting over perichondrium Treatment if no perichondrium intact: excise cartilage if small defect • Ear avulsion Microsurgical reconstruction gives best cosmetic result Anastomose to posterior auricular artery, anterior auricular branch of superficial temporal artery, and branch of occipital artery

Head of bed elevated May be difficult to anastomose veins, but there is success of using leeches if reattached ear turns blue due to venous congestion If fails microsurgical reconstruction, remove ear and bury in pocket to salvage Pocket principle for salvage: dermabrade ear skin, bury for 21 days, unbury and let spontaneously reepithelialize • Burned ear Autologous costal cartilage reconstruction with local fasciocutaneous flap and skin graft: better result than under local stiff, scarred skin

Prosthesis: if no skin or local fasciocutaneous flap present to cover autologous reconstruction Alloplastic implants: risk for infection and exposure when placed under burned scar tissue Tissue expansion: does not stretch burned skin well, at risk for infection and exposure

Congenital Deformities • Cryptotia Superior auricle buried beneath skin Absent auriculocephalic sulcus Treatment: helical release with split-thickness skin graft to

retroauricular sulcus • Constricted ear (Fig. 23.2) Lop ear or cup ear Treatment: banner flap (flag flap) where split helical cartilage, partially detaching each helical flap from scapha to expand and resuture in a new position to the scapha • Stahl ear Also called: Spock ear, baboon ear, Vulcan ear, satyr ear Seen in Asians

Fig. 23.2 Constricted ear banner flap.

Characteristics: third crus, flat antihelix, malformed scaphoid, upper cartilage deformed Treatment: wedge excision of third crus, helical advancement

Miscellaneous Ear Defects and Reconstruction • Antia–Buch flap (Fig. 23.3) Chondrocutaneous helical rim advancement flap For superior and middle third helical rim defects < 2.5 cm Makes smaller ear Defects > 2.5 cm may require local fasciocutaneous flaps and costal cartilage • Chondrocutaneous composite conchal transposition flap (Fig. 23.4) Reconstructs defects in upper third of helical rim Pedicle based on crus of helix

Needs antihelical support to be present Split-thickness skin graft covers donor site raw surface • Upper third helical rim defect reconstruction options Antia–Buch flap Chondrocutaneous composite conchal transposition flap Local fascial cutaneous flap and costal cartilage • Middle third helical rim defect reconstruction options Antia–Buch flap Wedge resection Postauricular flap and costal cartilage

Local tissue rearrangement • Chondrodermatitis nodularis helicis Benign inflammation of helical or antihelical cartilage Chronic, painful, nodular, can ulcerate through the skin Mimics skin cancer on exam Do biopsy to rule out cancer Treatment Steroids Excision and primary closure or skin graft

Fig. 23.3 Bilateral helical advancement flaps. (From Sherris DA, Larrabee WF. Principles of Facial Reconstruction: A Subunit Approach

to Cutaneous Repair. New York, NY: Thieme; 2009. Used with permission.)

Fig. 23.4 Chondrocutaneous conchal transposition flap.

composite

Suggested Reading Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience

with 1200 cases. Plast Reconstr Surg 1999;104(2):319–334, discussion 335–338 Davis J. Reconstruction upper third of ear with chondrocutaneous composite flap based on crus helix. In: Tanzer RC, Edgerton MT, eds. Symposium on Reconstruction of the Auricle. St. Louis: Mosby; 1974:247:51 Donelan MB. Conchal transposition flap for postburn ear deformities. Plast Reconstr Surg 1989;83(4):641–654 Firmin F. Auricular reconstruction in cases of microtia: principles, methods and classification [in French]. Ann Chir Plast Esthet 2001;46(5):447–466

Firmin F. Ear reconstruction in cases of typical microtia. Personal experience based on 352 microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg 1998;32(1):35–47 Firmin F. State-of-the-art autogenous ear reconstruction in cases of microtia. Adv Otorhinolaryngol 2010;68:25– 52 Ha RY, Hackney F. Plastic Surgery of the Ear. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–36. Selected Readings in Plastic Surgery; vol 10, issue 9 Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg

1993;92(2):187–201 Reinisch J. Microtia reconstruction using a polyethylene implant: an 8year surgical experience. Presented at the 78th Annual Meeting of the American Association of Plastic Surgeons; Colorado Springs, CO; May 5, 1999 Tanzer RC. Microtia—a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61(2):161–166 Thorne CH. Otoplasty and ear reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:297–312

Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg 2012;129(4):701e–716e

24 Mandible Reconstruction Reviewed by Nidal Farhan ALDeek and FuChan Wei

Overview • Mandible reconstruction Rewarding procedure Technically demanding Necessitates teamwork approach • Indications Tumors Congenital Trauma: gun shot wounds Osteoradionecrosis • Reconstructive goals

Cosmesis Speech Mastication/swallowing • Extensive preoperative planning Reconstruction needs: bone, soft tissue, or both Flap selection Neck vessel availability Need for functional rehabilitation Timing of reconstruction • Intraoperative factors Meticulous execution of the procedure Constant communication with the ablative team during surgery • Postoperative factors critical for successful mandibular reconstruction

Intense postoperative monitoring Oral rehabilitation

Defect Classification • Bony and/or soft tissue involvement • Anterior vs posterior involvement • Whether involves the condyle, ramus, body, parasymphysis, or symphysis • Chang Gung mandible defect classification and flap selection (Table 24.1)

Mandible Tumors • Odontogenic Tumors Keratocystic odontogenic tumor Benign dental lamina remnant,

associated with impacted teeth Table 24.1 Chang Gung mandible defect classification and flap selection

Classification Defect

Flap selection

Fibula osteoseptocutaneo (OSC) flap is enou in most cases

Isolated

Bone alone

Compound

Bone with Fibula OSC flap is either enough in most mucosa or cases skin

Bone,

Double free flap: fibula OSC and anterolateral thigh

Composite

Extensive composite

mucosa, and skin

(ALT) flaps; in sma selected cases, one bony flap can be enough

Composite Double free flaps: with fibula OSC and ALT lateral flaps extension

Symptoms: pain and swelling in molar and premolar region, may be asymptomatic Diagnosis: X-ray and histologic appearance of keratin containing cyst Associated with Gorlin syndrome: triad of basal cell carcinomas, odontogenic

keratocyst, and skin pits in palms and soles Treatment: enucleate/curettage Ameloblastoma Benign tumor of posterior mandible in 20 to 30 year olds Location: 80% mandible, 20% maxilla Unicystic or multicystic Histology: palisading odontogenic cells Diagnosis: X-ray or CT scan, multicystic lesion has soap bubble or honeycomb appearance Treatment Enucleate/curettage: commonly

used If extends to bone: resect with 1 cm margin If extends to periphery/extraosseous: segmental hemimandibulectomy, and excise involved soft tissue Radiation therapy not needed because benign Chang Gung comprehensive single stage treatment Segmental hemimandibulectomy: complete excision is only one option that ensures zerorecurrence of this benign lesion

Mandibular reconstruction: bony reconstruction, soft tissue coverage or augmentation when needed Rehabilitation Inferior alveolar nerve repair with nerve graft Osseointegrated dental implants with dental prosthesis • Giant cell tumor Benign tumor Histology: multinucleated giant cells Treatment If small tumor: treat with curettage

If large: treat with resection/reconstruction • Osteogenic Sarcoma Rare malignant tumor: 0.5% of all head and neck tumors Treatment Excision Radiation therapy Chemotherapy

Osteonecrosis of Mandible •

Chemotherapy or radiotherapy induced • Osteoradionecrosis Late complication secondary to radiation therapy for cancer

Incidence could be as high as 22%, and the risk is lifetime Most common location: body of the mandible Risk factors include: advanced tumor stage, degree of bony invasion, total radiotherapy dose (> 64 Gy), and poor oral care Symptoms: pain, exposed bone, orocutaneous fistula CT scan: bony erosions Treatment Gold standard of treatment: segmental resection of the entire involved mandible and surrounding unhealthy soft tissue then reconstruction with vascularized bone graft

Antibiotics for accompanying infection or underlying osteomyelitis Hyperbaric oxygen therapy: not indicated once the bone is necrotic • Bisphosphonate-Related Osteonecrosis of Jaw (BRONJ) (Table 24.2) Related to taking osteoporosis medication

Mandible Reconstruction • Mandible Reconstruction Options (Table 24.3) • Mandibulectomy indications Marginal mandibulectomy: tumor

extending to periosteum without bony erosion/invasion Segmental mandibulectomy: tumor extending through cortex with bony erosion/invasion • Osseous Free Flaps for Mandible Reconstruction Fibula osteoseptocutaneous flap: most common, multiple osteotomies possible for large and anterior defects Radial and scapular osteocutaneous flaps Useful for large soft tissue defects/small bony defects Table 24.2 BRONJ staging

Stage Characteristics Treatment

Asymptomatic, Observation, exposed/necrotic antibiotic rinses bone

Infection, pain

III

Infection, pain, pathologic Surgical fracture, fistula, debridement/resection osteolysis

Antibiotics (PO/IV/rinses)

Table 24.3 Mandible reconstruction options

Type of Indication reconstruction

Example

Nonvascularized Mandible Iliac crest bone grafts defects < 6 cm

Mandible defects > 6 cm, Fibula +/- sk radiated paddle mandible defects Vascularized bone grafts

Fibula osteoseptoc Marginal flap (first ch mandibulectomy radial forear osteocutane flap

Anterolatera flap (ALT) h major advan other free fl Floor of mouth, because of t

Soft tissue flaps oral cavity approach; ra defects, no bony forearm free defect supraclavicu artery island (transverse c artery); pect major rotati

Metal plates

Mandible defects, no radiation

Titanium pla infection, ex plate breakin avoid in ante mandibular d due to high e rate; when in without a vascularized graft, lateral are more su their applica

Radial osteocutaneous flap bone dimensions are inadequate to support dental implants of 10 × 5 mm and is not frequently used for mandibular reconstruction Deep circumflex iliac artery osteocutaneous flap (ilium) • Osseointegrated dental implant Factors affecting osseointegration survival rates: oral hygiene, patient motivation, irradiation, implant dimensions Survival rates in nonirradiated vascularized bone grafts 95% 3-year survival 87% at 5 years 79% at 10-years follow-up Radiotherapy and dental implants

Radiotherapy is not a contraindication to osseointegrated dental implants Timing of irradiation has been shown to affect success rate When irradiation preceded implantation, success rate dropped to 64% compared to 86% when irradiation was given postimplantation

Free Fibula Flap (Fig. 24.1) •

Mathes-Nahai muscle flap classification Type V Dominant pedicle: nutrient endosteal artery (off peroneal

artery) Secondary segmental pedicles: periosteal and muscular branches (off peroneal artery) In multiple-osteotomy setting, which is usually the case in mandible reconstruction, periosteal blood supply becomes the only blood supply to the bone • Uses Mandible

Fig. 24.1 Lower leg transverse cross-section anatomy. EDL, extensor digitorum longus; EHL, extensor hallucis longus; FDL, flexor digitorum longus; FHL, flexor hallucis longus; Fib, fibula; Gastroc, gastrocnemius; PB, peroneus brevis; PL, peroneus longus; TA, tibialis anterior; Tib, tibia; TP, tibialis posterior.

Upper extremity Lower extremity • Technical pearls Fibula length: 40 cm Leave: at least 7 cm of fibula proximally and distally for support Flap can provide reliable skin paddle of 14 × 24 cm Flap can include the soleus muscle to provide volume and bulk, when needed In flap harvest, septocutaneous vessels are the major blood supply to the skin, and they should be identified early in flap dissection Harvesting with cuff of flexor hallucis longus muscle is controversial: may protect the

pedicle, but at the possible expense of additional donor site morbidity • Salvage flap A second free fibula OSC flap from the opposite leg is the salvage flap in case of free fibula OSC flap failure Do not use pedicled pectoralis major muscle/musculocutaneous flap If a free bony flap was indicated the first time, the indication remains the same (free bony flap) after flap failure

Computer Simulation

Surgery in Mandible Reconstruction by Fibula Osteoseptocutaneous Flap • Background The complex, three-dimensional shape of the mandible along with its crucial role in speech, deglutition, and social integration complicate mandible reconstruction Computer simulation surgery simplifies the procedure, especially when the surgeon's experience is limited Entire surgery from resection to reconstruction can be planned and executed virtually

Computer-aided design and modeling (CAD/CAM) software are utilized to design and produce customized surgical devices for transition from virtual into actual surgery • Benefits of this new technology Easiness in osteotomies Decreased surgical time Training potential • Limitations Expensive Necessitates teleconference meeting Cannot address all the factors involved in mandible reconstruction by the fibula OSC

Variable fibula cross-section topography, especially for osseointegrated dental implants Skin vessel anatomy, which is critical in simultaneous coverage reconstruction Inflexibility in revisiting the design due to changes in resection margins • Freehand technique is still useful, and at the present time, even more practical than computer-simulated mandible reconstruction for more complicated reconstruction

Suggested Reading Chang YM, Tsai CY, Wei FC. One-stage,

double-barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and aesthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg 2008;122(1):143–145 Chang YM, Wallace CG, Tsai CY, et al. Dental implant outcome after primary implantation into doublebarreled fibula osteoseptocutaneous free flap-reconstructed mandible. Plast Reconstr Surg 2011;128(6):1220–1228 Cordeiro PG, Disa JJ, Hidalgo DA, et al. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive

patients. Plast Reconstr Surg 1999;104:1314–1320 David DJ, Tan E, Katsaros J, et al. Mandibular reconstruction with vascularized iliac crest: a 10-year experience. 82(5): 792-801 Disa JJ, Hidalgo DA. Mandible reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery, 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006: 428–437 Fernandes R, Nikitakis NG, Pazoki A, et al. osteogenic sarcoma of the jaw: a 10-year experience. J Oral Maxillofac Surg 2007;65(7):1286– 1291 Foster RD, Anthony JP, Sharma A, et al.

Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 1999;21(1):66– 71 Frodel JL Jr, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg 1993;92(3):449–455 O'Brien JC. Head and neck: oral cavity and oropharyngeal tumors; salivary gland tumors. Selected Readings in Plastic Surgery 2004;10(4):1–84 Roumanas ED, Chang TL, Beumer J.

Use of osseointegrated implants in the restoration of head and neck defects. J Calif Dent Assoc 2006;34(9):711–718 Snyder MC, Gutowski KA. Head and neck II: reconstruction. Selected Readings in Plastic Surgery 2004;10(4):1–73 Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124(1):46–55 Wallace CG, Chang YM, Tsai CY, et al. Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction. Plast

Reconstr Surg 2010;125:305–314 Wei FC, Chen HC, Chuang CC, et al. Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 1986;78(2):191–199 Wei FC, Demirkan F, Chen HC, et al. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg 1999l;103(1):39–47 Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck 2010;32(9):1236–1245 Wu YQ, Huang W, Zhang ZY, et al. Clinical outcome of dental implants placed in fibula-free flaps for

orofacial reconstruction. Chin Med J 2008;121(19):1861–1865 Yim KK, Wei FC. Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 1994;15(4):245–249

25 Nasal Reconstruction Reviewed by Robert L. Walton

Nasal Reconstruction Principles • Nine aesthetic subunits (Fig. 25.1) Two soft triangles One columella Two ala One dorsum Two sidewalls One tip • Subunit rule (controversial) If > 50% lost, excise remainder of subunit and reconstruct the entire

subunit • Reconstruct three layers Coverage: skin Support: cartilage Lining: mucosa • Septal perforation (Table 25.1)

Fig. 25.1 Nasal subunits. (From Sherris D, Larrabee W. Principles of Facial Reconstruction: A Subunit Approach to

Cutaneous Repair. Stuttgart: Thieme, 2009.) Table 25.1 Septal perforation

Defect size < 5 mm in anterior septum

< 5 mm in posterior septum

Approach

Management

Closed

Unipedicled or bipedicled septal mucosal flap

Open

Unipedicled or bipedicled septal mucosal flap

5 mm–2 cm Open

Bilateral posteriorly based septal

mucosal flaps

> 2 cm

Midfacial degloving

Regional flaps: Expanded, posteriorly based mucosal flaps Facial artery myomucosal (FAMM) flap

Rhinophyma • Characteristics Sebaceous hyperplasia of nasal skin, which has pits Caucasian males > 60 years old Secondary to severe acne rosacea

• Treatment Mild rhinophyma: good hygiene, oral isotretinoin (Accutane), and tetracycline Severe rhinophyma: tangential excision, dermabrasion, CO2 laser for hemostasis, let heal by secondary intention, cover with moist bacteriostatic dressing (xeroform, bacitracin), sunscreen, retin-A

Auricular Composite Graft • Uses Reconstruction of alar rim lining and support defects measuring < 1.5 cm

Consists of ear cartilage and skin for support and lining • Clinical appearance First 6 to 8 hours: white First week: cyanotic After first week: pink If appears necrotic: observe and let eschar slough

Full Thickness Skin Graft • Uses: any nasal defect not requiring cartilage support • Prerequisites: subcutaneous base with intact perichondrium • Skin-graft donor sources Forehead or preauricular donor site closed primarily

May include fat for composite restoration and contour

Bilobed Flap • Use 1 to 1.5 cm defects of nasal tip and ala rim • Technique Undermine widely in submuscular plane 45 to 50 degrees/lobe (90 to 100 degrees total) Second lobe 75% smaller than first lobe

Forehead Flap (Fig. 25.2)

• Use > 1.5 cm defects on nasal tip and ala • Technique First stage: elevate on supratrochlear artery Subperiosteal elevation 1.5 cm above brow to preserve periosteal and subcutaneous branches from supraorbital artery (Fig. 25.3)

Fig. 25.2 Standard paramedian forehead flap.

Fig. 25.3 Rohrich modification of standard paramedian forehead flap. (Reece E, Schaverien M, and Rohrich R. The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications. Plast Reconstr Surg. 2008 Jun;121(6): 195663. Used with permission.)

Second stage: division and inset after 3 to 4 weeks Subsequent contouring for final shape after 6 to 8 weeks: insertion of cartilage support combined with thinning of lining Expanded forehead flap for larger flaps Folded forehead flap for alar defects with vestibular lining defect

Dorsal Nasal (Rieger) Flap (Fig. 25.4) • Use < 2 cm defect along central and lower thirds of dorsum

• Technique Nasoglabellar flap based on infratrochlear and angular artery Flap elevation in submuscular/supraperiosteal plane

Nasal Lining Reconstruction • Isolated vestibular lining defects Full thickness skin graft Composite skin cartilage graft from ear Nasolabial flap Facial artery musculomucosal (FAMM) flap Local bipedicle mucosal flap with

skin graft • Total and subtotal lining defects Radial forearm “Bat” flap Multi island radial forearm free flap Bilateral FAMM flaps

Fig. 25.4 Reiger flap.

For placement posteriorly in

vestibule Weep mucous if anteriorly near rim

placed

Partial Nasal Reconstruction • Alar defects Bipedicle mucosal advancement flap: for lining of alar defects Used infrequently Risks for scarring and obstruction of nasal airway Technique replaced with Composite skin cartilage graft Full thickness graft Folded forehead flap

Auricular composite graft: ear cartilage and skin for lining and support of alar defects < 1.5 cm Septal pivot flap: septal cartilage and mucosa used to line and support larger defects Bilobed flap Nasolabial flap: two-stage procedure with division and inset for coverage; turnover flap used for lining • Lateral aspect of nose Banner flap: single-lobed finger flap Bilobed flap Nasolabial flap: superiorly based for lateral nose Geometric advancement flap

• Nasal tip Bilobed flap Forehead flap Nasolabial flap • Cheek, alar, nasal sidewall defect Cheek advancement, septal mucoperichondrial flap with septal or conchal cartilage grafts, and staged paramedian forehead flap • Nasal dorsum Dorsal nasal (Rieger) flap Cantilever bone graft: used for dorsal nasal support, in conjunction with craniofacial procedures, calvarial bone graft keeps donor and recipient sites in the same field, inherently unstable

Rib cartilage graft: L-strut provides for stable dorsal support • Nasal defects < 0.5 cm Primary closure Delayed closure by secondary intent • Full-thickness skin grafts Used for upper two-thirds of nose Composite skin/fat grafts from forehead for lower third of nose • Nasal septum Local septal chondromucosal advancement flap Septal pivot flap Septal cartilage and mucosa used to line and support anterior midline defects

Based on septal branch of superior labial artery Used for support of middle nasal vault and tip

Total Nasal Reconstruction • Requires lining, support and external cover Radial forearm free flap for lining Multi island for element duplication Folded radial forearm for middle nasal vault and vestibular defects Anastomosis to facial artery and vein Rib cartilage support

Dorsum Columella Ala Side wall Tip External cover Paramedian forehead flap • Scalping flap (Fig. 25.5) Forehead scalp flap Used when supratrochlear inflow has been compromised Combine median forehead flap if needed for nasal lining Split-thickness skin grafts for donor defect coverage Second-stage division and inset, cartilage grafts placed for support,

return of unused portion of scalp flap • Sickle flap Median forehead flap based on superficial temporal artery Donor site temporal forehead

Fig 25.5 Scalping flap.

Split-thickness skin grafts used for nasal lining if needed Second-stage division and inset, cartilage grafts, and closure are similar to scalping flap • Temporomastoid (Washio) flap Last local flap option after forehead and scalp flaps Postauricular and mastoid skin elevated based on superficial temporal arteries • Prelaminated radial forearm free flap and paramedian forehead flap after cheek advancement • Remote free flap for lining and/or external cover

Suggested Reading Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84(2):189–202 Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 2007;120(5):1171–1207, discussion 1208–1216 Jackson IT. Nose reconstruction. In: Jackson IT. Local Flaps in Head and Neck Reconstruction. 2nd ed. St. Louis, MO: Quality Medical

Publishing; 2007:101–239 Menick FJ. Nasal reconstruction. Plast Reconstr Surg 2010;125(4):138e– 150e Menick FJ. Nasal reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:389–396 Ramsey KW, Georgeu GA, Pereira JA, El-Muttardi N. Nasal reconstruction in the Yemen with the Converse scalping flap. J R Soc Med 2003;96(5):230–232 Reece EM, Schaverien M, Rohrich RJ. The Paramedian Forehead Flap: A Dynamic Anatomical Vascular Study

Verifying Safety and Clinical Implications. Plast. Reconstr. Surg 2008;121: 1956-1963 Romo T III, Sclafani AP, Falk AN, Toffel PH. A graduated approach to the repair of nasal septal perforations. Plast Reconstr Surg 1999;103(1):66–75 Thornton JF, Griffin JR. Nasal Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2006:1–41. Selected Readings in Plastic Surgery; vol 10, issue 12 Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg 2005;115(7):1813–1829

Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125(7):957–959

26 Eyelid and Lacrimal System Reconstruction Reviewed by S. Anthony Wolfe

Eyelid Anatomy (Fig. 33.1) Eyelid Defect Reconstructive Algorithm • Evaluation of eyelid defects Zone injured (Fig. 26.1) Percent lid length affected Thickness of defect Partial thickness (PT): skin and muscle

Full thickness (FT): conjunctiva, tarsus • Zone I defects (upper eyelid) PT < 50% Primary closure with local tissue advancement > 50% Full thickness skin graft (FTSG) from retroauricular sulcus FTSG from contralateral upper eyelid Medium thickness split thickness skin graft (STSG) from upper inner arm FT

< 25% Primary closure, canthotomy, cantholysis, with local tissue advancement

Fig.

26.1

Spinelli–Jelks

periocular

reconstructive zones.

25 to 75% Sliding tarsoconjunctival flap (superiorly based upper eyelid posterior lamella flap) covered with FTSG: used for medial or lateral defects, not central defects Cutler Beard full thickness advancement flap from lower lid leaving tarsus intact > 75% Mustardé lower lid switch flap • Zone II defects (lower eyelid) PT < 50% Primary closure with local tissue

advancement > 50% FTSG from contralateral upper eyelid FTSG from retroauricular sulcus Upper eyelid Fricke unipedicle myocutaneous transposition flap Upper eyelid Tripier bipedicle myocutaneous transposition flap • FT < 50% Primary closure with canthotomy, cantholysis, local tissue advancement Hughes sliding tarsoconjunctival flap with FTSG 50 to 75%

Hughes sliding tarsoconjunctival flap with FTSG > 75% Mustardé cheek advancement flap with septal cartilage and lining composite graft Tessier nasojugal flap • Zone III defects (medial canthus) Nasoglabellar flap Medially based upper eyelid rotational flap Probe and stent lacrimal ducts • Zone IV defects (lateral canthus) Lateral canthal support Cheek advancement flap FTSG • Zone V defects (periocular)

Outside zones I-IV but may affect the eyelids Cervicofacial advancement flap Moderate to large defects of upper medial cheek Better color and texture than FTSG Fixate to periosteum to decrease risk of ectropion Stabilize lower eyelid with canthopexy or canthoplasty to avoid ectropion

Ptosis • Definition Upper eyelid malposition where upper eyelid droops below the

ideal position Ideal upper eyelid position: ciliary margin lies halfway between corneal-scleral junction and pupil (eyelid overlaps the superior limbus 1 to 2 mm) • Etiology True ptosis: related to levator complex malfunction Congenital Neurogenic Horner syndrome Symptoms triad: miosis, anhidrosis, ptosis Etiology: loss of sympathetic innervation at superior cervical ganglion, affects Muller muscle

Myasthenia gravis Symptoms: unilateral or bilateral ptosis exaggerated by fatigue, worsens toward end of the day, seen in young women Etiology: myoneural dysfunction, antibodies block acetylcholine at neuromuscular junction Pharmacologic diagnosis: symptoms relieved with edrophonium (Tensilon test) or neostigmine to block acetylcholine breakdown (acetylcholinesterase inhibitors) Tumors

Senescent Senile, involutional, or aponeurotic ptosis: most common cause of ptosis in elderly High or absent supratarsal lid crease due to levator dehiscence (levator disinserts from tarsus and skin) Treatment: levator plication or advancement Pseudoptosis Unrelated to levator complex malfunction Enophthalmos Brow ptosis Dermatochalasia: baggy eyelids with skin redundancy of middle

age, upper lids more commonly affected, due to loss of elasticity Pachydermoperiostosis: idiopathic hypertrophic osteoarthropathy with enlarging eyelids, hands, feet, and toes Blepharochalasia: unknown cause, occurs in young adulthood, recurrent episodes of mild to moderate painless edema of eyelids, giving a baggy appearance, treatment is excision of redundant skin to improve vision • Patient assessment Visual acuity exam Establish ptosis grade (Table 26.1) Levator function (Table 26.2)

Measure excursion between upward and downward gaze Hold brow to avoid compensatory brow elevation in severe ptosis Schirmer's test Measures tear film production Normal: >10 mm moisture on filter paper in 5 minutes Poor film production can signal potential of dry eye after ptosis repair Hering's law of equal innervation Some patients with unilateral ptosis may have induced contralateral eyelid retraction masking ptosis Hering's test

Hold brow in relaxed position Manually retract the ptotic eyelid Positive test: contralateral eyelid drops Do bilateral ptosis repair if Hering's test unmasks contralateral ptosis to avoid postop contralateral ptosis • Ptosis repair (Table 26.3) Table 26.1 Grades of ptosis

Grade

Ptosis

Mild

2–3 mm

Moderate

3–5 mm

Severe

> 5 mm

Table 26.2 Grades of levator function

Grade

Levator function

Good

10–15 mm

Fair

6–9 mm

Poor

< 5 mm

Table 26.3 Ptosis management

Ptosis degree

Levator function

Surgical options

Good

Tarsal conjunctival müllerectomy, levator plication, levator advancement

Moderate

Good

Levator plication, levator advancement

Severe

Good

Levator advancement

Mild, moderate, severe

Fair

Levator advancement

Mild

Mild, moderate, severe

Poor

Frontalis sling

Levator advancement: most common ptosis repair Tarsal conjunctival mullerectomy (Fasanella-Servat procedure) Technique: running suture behind clamps on posterior lamella, trim excess clamped tissue Disadvantage: does not address excess eyelid skin Levator plication: can address excess eyelid skin Frontalis sling Indication: poor levator function, congenital ptosis

Grafts: fascia lata or palmaris longus (PL) • Complications after ptosis repair Asymmetry: most common complication Undercorrection: most common asymmetry Lagophthalmos: overcorrection resulting in inability to close eye Corneal abrasion Entropion or ectropion

Lower Lid Malposition • Patient assessment Visual acuity exam Lid position

Normal: 2 mm superior to inferior limbus Vertical shortening: can cause scleral show Horizontal lid laxity Snap-back test Describes horizontal lid laxity Should spring back immediately >1 second is abnormal Grade 1: 2 to 3 seconds Grade 2: 4 to 5 seconds Grade 3: > 5 seconds, lower lid returns with blink Grade 4: lower lid never returns Distraction test If 1 to 2 mm: do suborbicularis oculi fat (SOOF) lift

If 3 to 6 mm distraction: do canthopexy Lower lid pulled > 6 mm from globe: do lateral strip tarsoplasty to correct laxity Malar support Hertel exophthalmometry: measures globe position relative to anterior part of lateral orbital wall < 15 mm: enophthalmos 15 to 18 mm: normal > 18 mm: exophthalmos Negative vector: globe anterior to rim (poor globe support) Positive vector: globe posterior to rim (can be due to enophthalmos)

Schirmer's test • Ectropion Lid turns outward Involutional Most common type of ectropion Results in horizontal lid laxity Treatment Lateral canthoplasty Kuhnt-Szymanowski procedure: split lower lid along grey line, shorten posterior lamella Pentagonal wedge excision Congenital: vertical shortening anterior lamella Cicatricial Vertical shortening anterior

lamella Management Steroid injections: for early ectropion with minor scarring Massage and tear supplements for first 6 to 9 months Excise scar and full thickness skin graft to lower eyelid to address vertical contracture if cutaneous deficiency Alloplastic spacer graft, hard palate graft, or auricular cartilage graft for midlamellar scarring Lateral canthopexy or canthoplasty to correct horizontal lid laxity Tarsorrhaphy to temporarily

protect the cornea Neurogenic: paralysis of orbicularis oculi muscle Neoplasia within the lower eyelid Edema • Entropion Lid turns inward Etiology Involutional Congenital Cicatricial Animation test: attempt to close eye contracts orbicularis oculi muscle causing inversion of lower eyelid on attempted May have horizontal lid laxity similar to ectropion

Epiblepharon Abnormal horizontal skin excess causes eyelashes to turn inward Seen in Asians Treatment Mild corneal irritation: topical lubrication Severe corneal irritation: skin and orbicularis oculi muscle excision • Canthopexy vs canthoplasty Canthoplasty: division and repositioning of the lateral canthal tendon Canthopexy: no division of canthus, only repositioning of canthal tendon

If vertical shortening and horizontal laxity: correct with tarsal strip canthoplasty and full thickness skin graft Vector of lateral canthal repositioning: superior, lateral, and posterior

Lagophthalmos • Definition: inability to close eyelids • Etiology Facial nerve paralysis Bell's palsy most common cause of facial nerve paralysis Affects cranial nerve VII innervation to orbicularis oris Upper eyelid surgery complication

Upper eyelid blepharoplasty complication Ptosis repair complication Lower eyelid laxity or ectropion Proptosis Graves’ thyroid ophthalmopathy Craniofacial syndrome Trauma • Management Conservative management first Topical lubrication with eye drops and gel Taping Temporary tarsorraphy Facial nerve paralysis Gold weight Upper eyelid surgery complication

Massage eyelid with downward motion Definitive surgical repair with split thickness skin graft Lower eyelid laxity or ectropion: see above management Proptosis Graves’ thyroid ophthalmopathy management (see Chapter 33, Blepharoplasty and Brow Lift) Craniofacial syndrome: frontalorbital advancement, monobloc advancement, or Le Fort III advancement as needed Trauma: reduce fractures causing proptosis

Lacrimal System Anatomy (Fig. 26.2) • Components of lacrimal system Lacrimal gland Microscopic accessory glands Punctum Canaliculi Common canaliculus Lacrimal sac Nasolacrimal duct: drains into inferior meatus

Fig. 26.2 Lacrimal system.

• Eyelid closure dynamics Lacrimal punctum closes Tears milk lateral to medial Deep heads of preseptal muscle contract Canaliculi shorten Ampulla closes Negative pressure created Lacrimal sac opens • Eyelid reopening dynamics Lacrimal diaphragm returns to relaxed position Creates sufficient pressure to propel tears into nasolacrimal duct Canaliculi reopen to collect more tears

Lacrimal System Reconstruction • Epiphora (excess tearing) Congenital Traumatic: due to injury or edema to the lacrimal system Blepharoplasty complication • Diagnosis Jones tests Probe Dacryocystography • Jones Tests Jones 1: instill drops and check dye coming out of nose Jones 2: do if failed Jones 1, inject dye forcefully

• Dacryocystorhinostomy Reconstructs lower lacrimal system burring a hole in the lacrimal fossa Connects nasolacrimal sac to nasal cavity • Canaliculodacryocystorhinostomy Reconstructs the upper canaliculus obstruction Also called conjunctivodacryocystorhinostomy • Congenital epiphora management Massage and antibiotic drops until 12 months Probing of the duct Silastic intubation Dacryocystorhinostomy

• Dry eye management Eye drops and lubrication Punctal occlusion: treats dry eye caused by increased exposure not treatable by eye drops and lubrication

Suggested Reading Codner MA, McCord CD, Mejia JD, et al. Upper and Lower Eyelid Reconstruction. Plast Reconstr Surg 126(5): 231e-245e, 2010 Glat PM, Jelks GW, Jelks EB, et al. Evolution of the Lateral Canthoplasty: Techniques and Indications. Plast Reconstr Surg 100: 1396-1405, 1997

Jelks GW, Glat PM, Jelks EB, et al. The Inferior Retinacular Lateral Canthoplasty: A New Technique. Plast Reconstr Surg 100: 12621270, 1997 Liu TM, Totonchi A, Katira K, et al. Outcomes of Mild to Moderate Upper Eyelid Ptosis Correction Using Muller's Muscle-Conjunctival Resection. Plast Reconstr Surg 130: 799e-809e, 2012 Newman MI, Spinelli HM. Reconstruction of the Eyelids, Correction of Ptosis, and Cantoplasty. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams &

Wilkins; 2006: 397-416 Spinelli HM, Jelks GW. Periocular Reconstruction: A Systematic Approach. Plast Reconstr Surg 91(6): 1017–1024, 1993 Thornton JF, Kenkel JM. Eyelid Reconstruction. Selected Readings in Plastic Surgery. 10(8): 1-51, 2005 Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press, 1985 Zoumalan CI, Lisman RD. Evaluation and Management of Unilateral Ptosis and Avoiding Contralateral Ptosis. Aesthet Surg J 30(3): 320328, 2010

Section III Breast and Cosmetic Surgery

27 Anesthesia Reviewed by Derek M. Steinbacher

Local Anesthesia • Classes of local anesthetics (Table 27.1) • Mechanism of action: block voltagegated sodium channels preventing depolarization of neurons • Lidocaine peak absorption 12 hours in trunk for liposuction 6 hours in face (2× faster than in trunk), therefore liposuction the face first • Local anesthesia toxic doses (Table

27.2) Practice toxic dosage calculations Maximum dose of 1% lidocaine for 70 kg patient: (70 kg × 5 mg/kg)/(10 mg/mL) = 35 mL Maximum dose of 2% lidocaine for a 70 kg patient: (70 kg × 5 mg/kg)/(20 mg/mL) = 17.5 mL • Lidocaine toxicity (Table 27.3) • Pharmacokinetics of local anesthetics p Ka: affects onset of action. When the pH = p Ka of the drug, half of drug is in uncharged anionic active form. Higher p Ka = slower onset. Add bicarbonate to speed the onset. Table 27.1 Classes of local anesthetics

Class

Examples

Metabolism

Ester

Tetracaine, procaine, cocaine

Metabolized to paraamino benzoic acid (PABA) in plasma

Ami de

Li docai ne, bupi vacai ne Cleared in (ami des have liver 2 i's)

Table 27.2 Local anesthesia toxic doses

Medication Toxic dose

Notes

Cocaine

1.5 mg/kg

Bupivacaine 2.5 mg/kg (Marcaine)

Lidocaine

Only local with sympathomimetic action Can cause heart block Most cardiotoxic (ventricular tachycardia or fibrillation)

1% has 10 5 mg/kg in mg/mL lidocaine, subcutaneous 2% has 20 tissue mg/mL lidocaine 1:1,000,000 epinephrine in 7 mg/kg in tumescence subcutaneous injected into hypovascular

with tissue 35–55 epinephrine mg/kg liposuction tumescence

space, 20% sucked out, long peak time; 1:200,000 epinephrine in local anesthesia

Table 27.3 Lidocaine toxicity

Symptoms

Central nervous system excitatory (seizures with muscle twitches), arrhythmias (sinus tachycardia), no effect on blood pressure, metallic taste in mouth, tinnitus, numbness

in lips and tongue

Prevention of toxicity

Add epinephrine to solution (decreases systemic dose), give benzodiazepine premedication to raise seizure threshold), sodium bicarbonate, test dose, give lowest dose and concentration possible, check Bier block cuff and reinflate Stop injecting, check composition infiltrate, assess for intravenous

Treatment for toxicity

(IV) injection, do not cardiovert unless hypotensive, normalize heart rate (beta-blockers, calcium blockers, procainamide), IV thiopental, IV vasopressors, establish airway, give oxygen, ventilate

Lipid solubility: affects potency Protein binding: affects duration of action • EMLA cream EMLA = Eutectic Mixture of Local Anesthetic

Combination of lidocaine and prilocaine Minimal time to effect: 60 minutes Apply and keep in place with Tegaderm (3M, St. Paul, MN) or Opsite dressing (Smith & Nephew, Andover, MA) • Methemogloblinemia Idiosyncratic reaction to local anesthesia Symptoms: tachycardia, cyanosis, palpitations, headache, lightheadedness Treatment: antidote is methylene blue; can also give oxygen • Ketamine Sedative: useful with pediatric procedures

Intravenous (IV) administration: less vomiting, faster onset, shorter duration, less laryngospasm compared with intramuscular administration

Regional Anesthesia • Brachial plexus block: resolve within 6 hours postop • Radial sensory nerve block: inject along styloid process of radius • Median nerve block: inject between palmaris longus and flexor carpi radialis • Finger blocks with epinephrine Inject around A-1 pulley 1:200,000 epinephrine decreases

bleeding Contrary to dogma, research shows that epinephrine can be used safely in fingers (half-life of epinephrine is 60 to 90 minutes; finger amputations survive after 24-hour ischemia) Epinephrine-induced ischemia is reversed with phentolamine injection (alpha antagonist) Warm compresses treat hypothermically induced ischemia

General Anesthesia • Malignant hyperthermia Rare life-threatening inherited myopathy secondary to

inhalational agent or depolarizing muscle relaxant (succinylcholine) Symptoms: sweat, tachycardia, rigidity, cyanosis, can lead to death Treatment: stop surgery and anesthesia, administer dantrolene (muscle relaxant), 100% oxygen, call for help, treat hyperkalemia • Benzodiazepine half-lives Short (midazolam) Intermediate (lorazepam) Long (diazepam). Note: diazepam is teratogenic • Postop nausea and vomiting (PONV) Medication with minimal PONV: propofol

Medications with higher PONV: nitrous oxide, opioids, inhalational anesthetics Risk factors for PONV: female gender, history of motion sickness, use of postop opioids, history of PONV, nonsmoking status • Minimal ambient temperature in the operating room (OR) OR temperature should be kept above 70°F (21.1°C) to reduce coagulopathy Prewarm patients with bedwarmer in preanesthesia room is the best adjunctive measure Bear-huggers Warmed IV fluids for patients undergoing liposuction with

tumescence • Radial nerve palsy Secondary to ischemia from pressure below tourniquet cuff, faulty pressure gauges Occurs in 1/5,000 to 8,000 patients, unable to extend fingers/wrist, resolves within 6 months • Stop drugs that can cause bleeding Garlic: stop 7 days preop Aspirin: stop 7 to 10 days preop Clopidogrel Warfarin Heparin drip: can be shut off hours before surgery

Deep Vein Thrombosis (Table 27.4) • Fatal pulmonary embolism (PE) Deep vein thrombosis (DVT): can lead to potentially fatal PE Abdominoplasty: most common ambulatory procedure associated with fatal PE • Risk factors for DVT Immobilization Long procedure duration Obesity Smoking Use of oral contraceptives • DVT prophylaxis (Table 27.5) Sequential compressive devices

(SCDs): all patients should get SCD Early ambulation Heparin subcutaneous Elastic stockings Stop oral contraceptives, estrogen, and smoking • Factor V Leiden Most common genetic hypercoagulability disorder (3 to 7% population) Clotting factor V resistant to inactivation by activated protein C • PE differential diagnosis Congestive heart failure: chest Xray with venous congestion, history of hypertension, left

ventricular hypertrophy on electrocardiogram (EKG), can be exacerbated with several liters of intravenous fluid Acute coronary syndrome: elevated ST segment on EKG, chest pain Wernicke encephalopathy: mental status changes, malnutrition; treat with thiamine Table 27.4 Deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosis

Symptoms/Signs Workup

DVT

Leg edema, calf tenderness, palpable cords

Ultrasound

Chest pain, respiratory distress, anxiety, tachypnea, shortness of breath

Chest computed tomographic scan (or VQ scan)

Table 27.5 DVT risk level and prophylaxis

Risk level

Clinical criteria

Low

Sequential < 40 years old, minor compressive procedure (< 30 min) device (SCD

Prophylaxi

Unfractiona > 40 years old, under heparin, low general anesthesia >

Moderate 30 min, taking estrogen

High

molecular weight heparin, SCD

> 60 years old, long operation, immobilization, Heparin cancer, subcutaneou hypercoagulable state, three times prior deep vein day, SCD thrombosis/pulmonary embolism

Suggested Reading Horton JB, Janis JE, Rohrich RJ. MOCPS (SM) CME article: patient safety in the office-based setting. Plast Reconstr Surg 2008;122(3,

Suppl):1–21 Iverson RE; ASPS Task Force on Patient Safety in Office-Based Surgery Facilities. Patient safety in officebased surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg 2002;110(5):1337–1342, discussion 1343–1346 Lipshitz AH, Kenkel JM. Local Anesthetics. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2007:1–32. Selected Readings in Plastic Surgery; vol 10, issue 18 Mustoe TA, Buck DW II, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg

2010;126(4):165e–176e Seruya M, Baker SB. MOC-PS (SM) CME article: venous thromboembolism prophylaxis in plastic surgery patients. Plast Reconstr Surg 2008;122(3, Suppl):1–9 Taub PJ, Bashey S, Hausman LM. Anesthesia for cosmetic surgery. Plast Reconstr Surg 2010;125(1):1e–7e Thorne AC. Local Anesthesia. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:91–95

28 Breast Augmentation, Mastopexy, and Reduction Reviewed by Luis O. Vasconez

Breast Anatomy • Breast location: between ribs 2 and 6 in nonptotic state • Blood supply Internal mammary artery perforators: account for majority (60%) of breast blood supply Branches from axillary artery Lateral branches from the third, fourth, and fifth posterior intercostal arteries

Thoracoacromial artery: lies deep to pectoralis muscle, preserved during submuscular augmentation • Innervation Anterior lateral cutaneous branches of T2–T6 intercostal nerves supply the breast T4 branch supplies the nipple Do blunt dissection along lateral border of pectoralis major to avoid injuring nerves • Average male nipple Oval 3 cm diameter Fourth to fifth intercostal spaces • Cooper ligaments Suspensory ligaments of the breast

Stretch over time, causing ptosis

Congenital Breast Anomalies (Table 28.1) • Tuberous breast deformity Also called constricted breast syndrome, characterized by herniation of breast tissue into nipple areolar complex, breast hypoplasia, large areola, narrow base, asymmetry Treatment: periareolar submuscular augmentation, glandular scoring with radialreleasing incisions, reduction of herniated tissue, mastopexy with areolar reduction, inferior

mammary fold lowering Table 28.1 Congenital breast anomaly word soup

Deformity

Breast

Nipple

Amastia

Absent

Athelia

Present

Absent

Amazia

Absent

Present

Two-stage procedure: tissue expander placement followed by exchange for permanent implant in (1) patients with severely deficient skin envelope and (2) adolescent patients whose contralateral breast

has not reached maturity • Poland syndrome Most common finding is absence of sternal head of pectoralis major Absent or hypoplastic breast, latissimus dorsi (LD), ribs, serratus, nipple, sternum, shoulder girdle anomalies Brachysyndactyly is most common limb abnormality, may also have atypical cleft hand Treatment during puberty: tissue expander initially, exchange for permanent prosthesis after contralateral breast stops growing, avoid LD flap with expander because can attenuate muscle Treatment in adulthood:

submuscular implant and LD • Jeune syndrome: narrow immobile breast, renal disease • Benign premature thelarche: formation of breasts before formation of puberty elsewhere (no pubic hair or vaginal mucosal thickening) • Accessory mammary tissue Supernumerary breast: along embryonic milk line (axilla to groin) Ectopic breast: outside of embryonic milk line (example: in thigh)

Breast Augmentation • Pocket selection

If superior pole pinch test > 2 cm: retromammary If superior pole pinch test < 2 cm: submuscular • Silicone implant generations (Table 28.2) • Baker classification of capsular contracture (Table 28.3) Table 28.2 Silicone implant generations

Generation

Characteristic

1st

Hard shell

2nd

Soft shell, leaked Internal barrier

3rd

coating

4th

Cohesive gel (semisolid) with increased crosslinking

Classes III and IV require management with capsulectomy Textured implants Subglandular pocket: has less contraction than smooth implants

(leads to disorganized periprosthetic collagen formation) Subpectoral pocket has no effect on contraction rate compared to smooth implants Textured implants can form seromas early and late post insertion • Saline implant complications Statistics based on 13-year study by Cunningham published in 2000 25% reoperations 20% contracture (MC complication and reason for reoperations) 3% hematoma: treatment is evacuation, puts patient at risk for infection, do not do needle

aspiration because may injure implant 1% infection 1% annual deflation rate: easy to tell because saline is absorbed in the body, notice wrinkling and a smaller breast Ruptures can be due to underfilling because rippling induces stress (lower fill, not underfill, can result in more sloping and softer breasts) • Silicone implant complications Statistics based on 6-year studies by Cunningham published in 2009 and Spear in 2007, and on a 10year study by Spear in 2014 Rupture: 1.1% (Cunningham), 5.5% (Spear 2007), 9.3% in MRI

cohort (Spear 2014) Contracture: 9.8% (Cunningham), 14.8% (Spear 2007), 18.9% (Spear 2014) Infection: 2.2% (Courtiss 1979) Reoperation: 36.1% (Spear 2014) Implant removal with replacement 18.6% (Spear 2014) There is no increased risk for rheumatologic disease There is no increased amount of silicone in breast milk of implanted patients versus controls • Silicone implant ruptures Over time the silicone shell weakens, leading to rupture (loss of biomechanical strength)

Hard to tell if there is a rupture because breast retains volume, may notice subtle softness or slight decrease in upper-pole fullness Rupture may be intracapsular (silicone within capsule), or extracapsular (out of the capsule) Screening magnetic resonance imaging (MRI) recommendations for silicone implant rupture: do MRI 3 years postop, then every 2 years MRI is the most sensitive radiological test to detect rupture Diagnose with linguini sign on MRI or snowstorm sign on ultrasound (multiple echogenic lines)

Silicone granuloma: common response to foreign material, rare in breast augmentation, should resect to rule out carcinoma or if symptomatic • Minimum age requirement for silicone gel implant placement: 22 years old • Breast pocket irrigation Bacitracin 50,000 U, Ancef 1 g, and gentamicin 80 mg in 500 mL normal saline Previous combination was Betadine (Purdue Pharma, L.P., Stamford, CT), Ancef, and gentamicin Betadine is contraindicated unless it is used and then washed out with

irrigation • Double bubble Results from implant riding below the inframammary fold (IMF), or if native glandular tissue falls over and below the lower pole of the implant Treatment: change location of prosthesis • Eklund displacement or compression mammograms Breast cancer screening method displaces implant away from compressed breast tissue Cannot do if contraction (class III or IV) Better view if implant is subpectoral

Size of implant has no effect on mammogram Bad views if small breast • Change in nipple sensitivity Based on prosthesis volume Not based on implant pocket placement or incision location • Symmastia Soft tissue connection between two breasts Congenital or iatrogenic from breast augmentation • Galactorrhea Uncommon complication after breast augmentation Related to pregnancy, menstruation, medications (TCA, fluoxetine),

thyroid disease, and pituitary tumors (check prolactin level, if elevated obtain an MRI scan) Treatment: bromocriptine • Implant exchange for larger implant: leads to increased thinning, stretching, palpability, rippling, sagging, and an unnatural appearance • Rippling: change pocket from subglandular to subpectoral • Infected implants: Severe infection: remove implant, irrigate, antibiotics, debride capsule, delayed reinsertion several months later Mild infection (with or without exposure): can attempt salvage, remove implant, irrigate, debride

capsule, antibiotics, and immediate reinsertion of new implants Threatened exposure, no infection: excise skin and primary closure Tuberculosis (Mycobacterium tuberculosis): remove implants for at least 6 months, 6 months of antituberculosis medication Nontuberculous Mycobacterium: remove implants for at least 6 months, 6 months of ciprofloxacin and bactrim • Fat grafting Unpredictable: 50% resorption May lead to calcification • Anaplastic large-cell lymphoma Increased risk of non-Hodgkin

lymphoma in patients with breast implants Rare: 0.1 to 0.3/100,000 patients with implants If asymptomatic no need to remove implant

Mastopexy • Periareolar mastopexy Most common complication: widening of areola Can avoid areola widening with a nonabsorbable purse-string stitch • Vertical mastopexy: postop pseudoptosis is a common complaint over time • Ptosis classification and management

(Table 28.4)

Mastopexy with Augmentation • Increases upper pole volume more than mastopexy alone • Use < 350 mL implant: less likely to cause recurrent ptosis and thinning • Staging mastopexy and augmentation Can stage to avoid risk of nipple loss If staging, do augmentation first followed by mastopexy because will know where to tailor tack to find out how much skin resection is needed

Caution in patients undergoing augmentation first followed by staged mastopexy with inferior pedicle technique: augmentation first may cause thinning and atrophy of inferior pole of augmented breast compromising inferior pedicle in secondary mastopexy Table 28.4 Ptosis classification and management

Regnault staging

Characteristic Management

Periareolar

1st degree

Nipple at level of inframammary fold (IMF)

2nd degree

Nipple below level of IMF

3rd degree

Nipple at Wise incision lowest point of mastopexy breast

Breast (not Pseudoptosis nipple) below (glandular IMF (increased ptosis) nipple to IMF distance)

mastopexy, interlocking Gore-Tex keeps areola from stretching Vertical incision mastopexy

IMF wedge excision when nipple to IMF distance > 6 cm

Breast Reduction • Indications: shoulder, neck, back pain secondary to trapezius strain; cosmesis; intertrigo • Pedicles used: superior, inferior, supero-medial • Skin incisions used: inverted-T (anchor), short-scar techniques (vertical circumareolar) • Juvenile breast hypertrophy Bilateral breasts are affected Due to increased end organ responsiveness to estrogen Treatment

Bilateral breast reduction, not hormones Timing: once breasts have stopped growing for 1 year • Rapid growth of 1 breast In children: giant fibroadenoma In adults: phyllodes tumor • Free nipple grafts Indications Nipple to sternal notch distance: > 40 cm Nipple to inferior mammary fold distance: > 20 cm Cannot lactate afterward • Breast cancer and breast reduction Rate of cancer found in reduction sample: 0.2%

If location known within specimen: do radiation therapy If location unknown: do completion mastectomy • Breastfeeding after breast reduction: 70% can breastfeed, 30% want to breastfeed • Complications: wound healing, scar, asymmetry, infection, hematoma (related to surgical technique, intraoperative hypotension), nipple loss/sensitivity (if pedicle undermined or free nipple graft not used when indicated)

Gynecomastia • Age groups

Newborn Puberty: most common hyperplastic breast anomaly in childhood Elderly • Diagnosis If prepubescent or adult male with unilateral gynecomastia, work up for other causes Work up: liver function tests, urine studies, testicle exam, endocrine studies (thyroid, adrenal), rule out Klinefelter syndrome, cancer, marijuana use, use of new medications • Treatment Wait 12 months prior to considering surgery

Liposuction with or without staged excision Liposuction of internal mammary fold will help redrape excess skin and possibly eliminate need for surgery • Adolescent breast cancer incidence: 1% • Klinefelter syndrome Males have extra X chromosome (47, XXY) 50% of cases have gynecomastia Increased ER/PR, decreased testosterone Increased risk of breast cancer compared with idiopathic gynecomastia

Suggested Reading Adams WP Jr, Conner WC, Barton FE Jr, Rohrich RJ. Optimizing breastpocket irrigation: the post-betadine era. Plast Reconstr Surg 2001;107(6):1596–1601 Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg 2012;130(4):597e–611e Alpert BS, Lalonde DH. MOC-PS (SM) CME article: breast augmentation. Plast Reconstr Surg 2008;121(4, Suppl):1–7 Brzozowski D, Niessen M, Evans HB, Hurst LN. Breast-feeding after inferior pedicle reduction mammaplasty. Plast Reconstr Surg

2000;105(2):530–534 Courtiss EH, Goldwyn RM, Anastasi GW. The fate of breast implants with infections around them. Plast Reconstr Surg 1979;63(6):812–816 Cunningham B. The Mentor Core Study on Silicone MemoryGel Breast Implants. Plast Reconstr Surg 2007;120(7, Suppl 1):19S–29S, discussion 30S–32S Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg 2000;105(6):2143–2149, discussion 2150–2151 Hall-Findlay EJ. Vertical reduction mammaplasty. In: Thorne CH,

Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:604–615 Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for control of areolar diameter and shape. Plast Reconstr Surg 2007;119(3):804–809 Hammond DC, Loffredo M. Breast reduction. Plast Reconstr Surg 2012;129(5):829e–839e Handel N. Secondary mastopexy in the augmented patient: a recipe for disaster. Plast Reconstr Surg 2006;118(7, Suppl):152S–163S, discussion 164S–165S, 166S–167S Harris L, Morris SF, Freiberg A. Is

breast feeding possible after reduction mammaplasty? Plast Reconstr Surg 1992;89(5):836–839 Karp NS. Gynecomastia. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:616–620 Karp NS. Mastopexy and mastopexy augmentation. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:585–592 Khosla RK. Augmentation Mammaplasty. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2008:1–43. Selected Readings in

Plastic Surgery; vol 10, issue 21 Lemmon J A. Reduction Mammaplasty and Mastopexy. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2008:1–55. Selected Readings in Plastic Surgery; vol 10, issue 19 Macadam SA, Mehling BM, Fanning A, et al. Nontuberculous mycobacterial breast implant infections. Plast Reconstr Surg 2007;119(1):337– 344 Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg 2011;127(4):91e–102e Nahai FR, Nahai F. MOC-PSSM CME article: Breast reduction. Plast Reconstr Surg 2008;121(1,

Suppl):1–13 Noone RB. An evidence-based approach to reduction mammaplasty. Plast Reconstr Surg 2010;126(6):2171–2176 Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of boardcertified plastic surgeons 2002. Plast Reconstr Surg 2004;114(7):1724–1733, discussion 1734–1736 Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classification and management of gynecomastia: defining the role of ultrasoundassisted liposuction. Plast Reconstr

Surg 2003;111(2):909–923, discussion 924–925 Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 2005;115(3):743– 751, discussion 752–754 Slavin SA, Greene AK. Augmentation mammoplasty and its complications. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:575–584 Spear SL. Breast reduction: inverted-T technique. In: Thorne CH, Beasley

RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:593–603 Spear SL, Boehmler JH IV, Clemens MW. Augmentation/mastopexy: a 3year review of a single surgeon's practice. Plast Reconstr Surg 2006;118(7, Suppl):136S–147S, discussion 148S–149S, 150S–151S Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg 2004;113(6):1634–1644 Spear SL, Murphy DK, Allergan Silicone Breast Implant U.S. Core

Clinical Study Group. Natrelle Round Silicone Breast Implants: Core Study Results at 10 Years. Plast Reconstr Surg. 133(6): 13541361, 2014 Spear SL, Murphy DK, Slicton A, Walker PS; Inamed Silicone Breast Implant U.S. Study Group. Inamed silicone breast implant core study results at 6 years. Plast Reconstr Surg 2007;120(7, Suppl 1):8S–16S, discussion 17S–18S Spear SL, Rottman SJ, Glicksman C, et al. Late Seromas After Breast Implants: Theory and Practice. Plast Reconstr Surg 130(2): 423-435, 2012 Stevens WG, Freeman ME, Stoker DA,

Quardt SM, Cohen R, Hirsch EM. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg 2007;120(6):1674–1679 Tebbetts JB. Achieving a zero percent reoperation rate at 3 years in a 50consecutivecase augmentation mammaplasty premarket approval study. Plast Reconstr Surg 2006;118(6):1453–1457 Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg 2005;116(7):2005–2016 Thorne CH. An evidence-based

approach to augmentation mammaplasty. Plast Reconstr Surg 2010;126(6):2184–2188

29 Breast Reconstruction Reviewed by Stephen Vega

Breast Anatomy • See additional information on breast anatomy in Chapter 28 • Axillary dissection nerves Medial pectoral nerve Thoracodorsal nerve: latissimus dorsi muscle weakness if injured (affects arm extension and adduction) Lateral pectoral nerve Long thoracic nerve: serratus anterior muscle weakness (winged scapula) if injured

Intercostobrachial nerve: injury leads to numbness of the medial upper arm

Breast Cancer • Risk factors BRCA Age Family history Previous breast biopsy Early menarche Late menopause Nulliparity Previous breast radiation Ductal carcinoma in situ (DCIS): < 2% recurrence risk over 4 years

Lobular carcinoma in situ (LCIS) Sex: women have 100× risk of breast cancer compared with men • BRCA 5 to 10% of familial breast cancers are associated with BRCA Women BRCA1 Breast, cervical, uterine, pancreatic, colon 85% risk of breast cancer BRCA2: pancreatic, stomach, gallbladder, bile duct, melanoma Men BRCA1: breast, pancreatic, testicular, prostate BRCA2: breast, pancreatic,

prostate (more strongly associated with BRCA2) 6% risk of breast cancer • Incidence Incidence is 1 in 8 women 1% of breast cancers occur in men 1% of breast cancers are sarcomas, 99% are carcinomas • Diagnosis Physical exam Self-exam monthly Annual physician breast exam after 40 Mammogram Annual beginning age 40 Ultrasound Fine-needle aspiration

Biopsy • Prognostic factors Size Lymph node status Estrogen receptor status Histological grade • Breast cancer staging (Table 29.1) • Treatment Prophylactic mastectomy: done for patient wishes, BRCA+, family history, previous biopsy, dense breasts Modified radical mastectomy Lumpectomy and radiation therapy Nipple-sparing mastectomy Used in negative intraoperative retroareolar frozen sections

Tumor < 3 cm Tumor > 2 cm from nipple Not multicentric No lymph node involvement Skin-sparing mastectomy: has 2% recurrence rate Chemotherapy Radiation therapy • Indications for postmastectomy radiation therapy Tumor > 5 cm Four or more positive lymph nodes Close margins Table 29.1 Breast cancer staging

Stage

Description

In situ (ductal carcinoma in situ, lobular carcinoma in situ)

Tumor < 2 cm; no lymph node spread

IIA

Tumor 2–5 cm without nodes; tumor < 2 cm with nodes

IIB

Tumor > 5 cm without nodes; tumor 2–5 cm with nodes

IIIA

Tumor > 5 cm with nodes; tumor with

fixed nodes

IIIB

Inflammatory cancer; peau d'orange; chest wall, skin, internal mammary nodes

Distant metastasis: lymph nodes (most common), lungs, bone, liver, brain

Benign Breast Disease • Rapid unilateral breast growth Fibroadenoma Children and young women < 25 years old

Benign Phyllodes tumor Adults 85% benign, 15% malignant Nonepithelial Treatment: local excision, annual surveillance • Rapid bilateral breast growth Juvenile breast hypertrophy Young females during puberty Due to increased end organ responsiveness to estrogen Bilateral breast reduction after 1 year of growth cessation • Burn contracture breast Release to allow expansion Integra Dermal Regeneration

Template (Integra LifeSciences Corp., Plainsboro, NJ) and splitthickness skin graft Hard to find sufficient donor site for full-thickness skin graft

Breast Reconstruction • Principles (rule of thumb) Early-stage I to II breast cancer patients can undergo immediate reconstruction Later-stage III to IV breast cancer patients should consider adjuvant therapy first (chemotherapy, radiation therapy) before reconstruction • Implant reconstruction

Tissue expander Muscle coverage using pectoralis and serratus muscle/fascia May use autologous dermal flap in ptotic or macromastic patient instead of acellular dermis Acellular dermal matrix with tissue expander Increases initial fill volume of expander May allow more skin capture in skin-sparing mastectomy Consider immediate prosthetic reconstruction without need for expander Questions regarding seroma and infection risks remain

Tissue expander combined with latissimus dorsi flap Useful in patients who have been radiated or have compromised mastectomy skin with no autologous tissue donor sites (i.e., fitness instructors) • Autologous Pedicled flap options Transverse rectus abdominis muscle (TRAM) flap Shorter operating room (OR) time, decreased total flap loss, and increased fat necrosis and partial flap loss compared with free TRAM Delayed pedicled TRAM: transect deep inferior

epigastric artery several weeks prior to surgery Perfusion zones (angiosomes) Zone I: ipsilateral, directly over blood supply, best perfusion Zone II: contralateral, immediately across midline Zone III: ipsilateral, lateral to Zone I Zone IV: contralateral, lateral to Zone II, farthest from blood supply, worst perfusion Based on superior epigastric artery, which enters rectus abdominis muscle on its posterior and medial side

Latissimus dorsi Extended flap by taking more subscarpal fat has more tissue than standard flap and may not need implant Useful in very obese patients with excess back fat as flap only reconstruction without implant Serratus branch of thoracodorsal artery: if using thoracodorsal artery as recipient for free-flap breast reconstruction, divide thoracodorsal artery proximal to serratus branch to preserve retrograde flow to latissimus dorsi muscle, allowing harvest

in the future Free flap options Abdominally based free flaps Free TRAM: longer OR time, ease of shaping and insetting, decreased hernia and abdominal wall weakness compared with pedicled TRAM Muscle-sparing free TRAM: more muscle spared than free TRAM, dominant blood supply of deep inferior epigastric vessels maintained; as more muscle is spared, less abdominal morbidity Deep inferior epigastric artery perforator (DIEP) flap: no

muscle removed; higher incidence of fat necrosis if wrong perforator selected; more tolerant of higher ischemia times with less muscle; spares the abdominal wall while taking dominant blood supply of rectus abdominis muscle Superficial inferior epigastric artery (SIEA) flap Least abdominal wall morbidity; highest complexity of abdominal free flaps; look for arterial diameters greater than 1.4 mm. Only consider for hemiabdominal flap

Superior gluteal artery perforator (SGAP) flap Second-line donor site after abdominal free flaps Requires molding gluteal fat No gait dysfunction, but possible contour deformity Can hide donor site scar Transverse upper gracilis (TUG) flap Second-line donor site after abdominal free flaps Best for small to medium breasts Hidden donor site Less skin available for delayed cases, but excellent tissue for

breast molding Hidden donor site Less skin available for delayed cases, but excellent tissue for breast molding • Radiation therapy and breast reconstruction Mechanism of action: damage DNA leading to cell death If radiotherapy already administered avoid implant reconstruction and use autologous tissue If need for postoperative radiation therapy, strongly consider delayed autologous reconstruction Avoid tissue expansion in patients because of risk of contraction and

infection If tissue expander is in place, and radiotherapy indicated, either fully expand and wait to reconstruct (> 6 months), or remove and use autologous tissue • Complications Tissue expander complications Threatened exposure, no infection Excise necrotic or compromised mastectomy flaps, close primarily If implant is submuscular can treat with local wound care and allow skin flap to slough Exposure: antibiotics, remove implant, delayed reinsertion

Infection Mostly staphylococcal gram positive organisms Less severe infections or infected seroma (usually Staphylococcus epidermidis): treat with antibiotics, salvage implant More severe infections (usually Staphylococcus aureus): treat with antibiotics, remove implant, delayed reconstruction Pain during expansion Confirm not due to hematoma or infection Withdraw fluid from tissue expander because pain may be

due to rapid expansion and tissue ischemia If pain does not improve with fluid withdrawal, give pain meds and warm compresses In cases of encapsulation or poor expansion consider capsulotomy/capsulectomy or other reconstruction Pectoralis torque strength reduction: due to subpectoral implants Fat necrosis Nontender hard lump presenting approximately 6 weeks postop If small: manage conservatively with massage If larger (> 2 cm) or bothersome

to patient: remove if persistent or problematic at 6 to 12 months If large and/or associated with partial flap loss: debride and treat with antibiotics Abscess: tender, firm Hematoma: tender, firm Infection No evidence postop antibiotics or antibiotics for drains reduce infection Preop, intraop, and postoperative antibiotic prophylaxis is recommended Seroma: soft consistency (35 to 60% of latissimus dorsi flaps) Abdominal wall hernia (rectus abdominis flaps)

Umbilical necrosis Arterial supply: bilateral deep inferior epigastric arteries, ligamentum teres Arterial supply after bilateral TRAM: only ligamentum teres Smoking-related complications Hernia, skin and abdominal flap necrosis No increased risk of microvascular complications

Suggested Reading Beckenstein MS. Nipple reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed.

Philadelphia, PA: Lippincott Williams & Wilkins; 2006:657–661 Carlson GW. Breast cancer for the plastic surgeon. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:621–624 Disa JJ. Breast reconstruction: prosthetic techniques. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:625–633 Elliott LF. Breast reconstruction: free flap techniques. In: Thorne CH, Beasley RW, Aston SJ, et al, eds.

Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:648–656 Hammond DC. Latissimus dorsi flap breast reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:634–640 Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of the literature. Plast Reconstr Surg 2009;124(2):395–408 Namnoum JD. Breast reconstruction: TRAM flap techniques. In: Thorne CH, Beasley RW, Aston SJ, et al,

eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:641–647 Saint-Cyr M, Schaverien M. Breast Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2008:1–57. Selected Readings in Plastic Surgery; vol 10, issue 20 Selber JC, Samra F, Bristol M, et al. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function? Plast Reconstr Surg 2008;122(2):348–355 Serletti JM, Fosnot J, Nelson JA, Disa

JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg 2011;127(6):124e–135e Sigurdson L, Lalonde DH. MOC-PSSM CME article: Breast reconstruction. Plast Reconstr Surg 2008;121(1, Suppl):1–12 Slezak S. An evidence-based approach to breast reconstruction. Plast Reconstr Surg 2010;126(6):2177– 2183 Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg 2008;122(3):702–709

30 Body Contouring, Abdominoplasty, and Liposuction Reviewed by Jeffrey A. Gusenoff

Body Contouring • Photography parameters Used to maintain constant width/height of picture For body and breast: camera 35 mm, focal length 55 mm, distance from patient 5 to 6 feet For face, head, and neck: camera 35 mm, focal length 90 to 105 mm, shorter distance (< 3 feet)

Hold camera with the flash on the side of camera that you are taking profile picture of to prevent shadows • Brachioplasty Goal: corrects posteromedial arm ptosis caused by weight loss, age, gravity, loosening of clavipectoral fascia Clavipectoral fascia: lies deep to pectoralis major muscle, extends from clavicle to dome of axillary fascia, attaches to superficial fascia and soft tissue of posteromedial arm Resuspend superficial fascia of arm flap to axillary fascia Complications: scarring (most

common), medial antebrachial cutaneous nerve injury (most common nerve injury, travels with basilic vein superficial to deep fascia, treated with time, massage, and gabapentin), medial intercostobrachial nerve injury, basilic vein injury (not cephalic vein), lymphedema (often temporary, but may be chronic), horizontal furrows, recurrent skin laxity Liposuction upper arm: useful in mild to moderate arm fat with good skin tone, beware liposuction of thin skin of medial distal upper arm because can lead to contour irregularity

• Medial thigh lift Crescent incision Limited to deformities of the upper third of the thigh Risks of skin pleating and vulvar distortion Medial longitudinal incision Can be short if addressing upper and middle thirds of the thigh Full-length to the knee for skin laxity of the entire medial thigh Risks include delayed wound healing, seroma, lymphedema, and vulvar distortion Avoid lymphedema: by superficial dissection around the femoral triangle (bordered by inguinal ligament, sartorius, and adductor

longus) Fascial anchoring: anchor the inferior thigh flap fascia to Colles fascia Colles fascia: deep layer of superficial perineal fascia continuous with superficial fascia layer (Scarpa fascia) of anterior abdominal wall, high in elastin content gives yellow hue compared with nearby white muscular fascia (note: superficial layer of superficial thigh fascia is thin, loose, areolar) • Lower body lift Goal: corrects ptosis of buttock and thigh Is based lower than a belt

lipectomy and gives better control of the buttock and thigh contour Allows for autoaugmentation of the buttocks using local tissue Can combine with liposuction Most common complication: delayed wound healing • Belt lipectomy Circumferential excision is based higher than a lower body lift to address buttock, thigh, and abdominal ptosis Better for addressing flank lipodystrophy; less control of the buttocks and thighs Most common complication: seroma (37.5%) • Monsplasty

Lower incision of abdominoplasty should be 5 to 7 cm above vulvar commissure Liposuction or direct excision of the excess mons tissue with resuspension of the mons to abdominal wall fascia • Labiaplasty Most common preop complaints: painful intercourse, painful exercise, cosmetic concerns Labia majora: longitudinal resection Labia minora: longitudinal or wedge resection Most common postop complaint: incomplete correction • Gluteal autoaugmentation

Use gluteal tissue flaps Fat grafting has unpredictable graft take Silicone (gel or solid) is palpable, increases risk of infection, and can cause granulomas • Mastopexy and autoaugmentation of breasts after massive weight loss Breast appearance after massive weight loss: medialized nipples, axillary fat roll, flat upper pole, lower inferior mammary fold due to deflation Treatment: dermal suspension, parenchymal reshaping Breast augmentation with implants has a higher risk of implant malposition or recurrent ptosis in

massive weight loss patients • Gastric bypass procedures Malabsorptive: biliopancreatic diversion Restrictive: gastric banding Combination of malabsorptive and restrictive: Roux-en-Y (most common) • Nutrition in massive weight loss patient Dietitian preoperative evaluation: protein and vitamin deficiency due to aversion to animal proteins, malabsorption, or dumping syndrome may result in poor wound healing after body contouring surgery • Protein minimum pre- and

postoperative levels: 70 to 100 g/d • Vitamins: correct for iron (most common deficiency), calcium (fatsoluble vitamin D not absorbed), folate, and vitamin B12 • Body contouring complications in massive weight loss patients Rate: 50% Wound dehiscence: most common 30% Early dehiscence: secondary to patient movement Late dehiscence: after immediate postop period, secondary to seroma Seroma: second most common complication, prevented by securing flaps with quilting

sutures, maintaining lymphatic containing tissues deep to Scarpa's fascia inferior to the umbilicus, adequate use of drains • Mesotherapy Nonsurgical body contouring Variety of medications (e.g., isoproterenol, phosphatidylcholine) injected into mesoderm (fat layer) to induce lipolysis Not Food and Drug Administration (FDA) approved • Pseudogynecomastia (Table 30.1) Predominately excess loose skin and subareolar fat in men after massive weight loss Different from gynecomastia which

is characterized by excess of glandular tissue

Abdominoplasty • Aging abdomen in men Wide upper rectus muscle diastasis Thicker skin less prone to laxity and striation Fat accumulates more centrally and intra-abdominally • Aging abdomen in women Wide lower rectus muscle diastasis Fat accumulates more peripherally below iliac crest Striae common after pregnancy Table 30.1 Pseudogynecomastia classification

Grade

Characteristics Treatment

Minimal excess skin and fat, minimal alteration nipple Liposuction areola complex, normal inframammary fold (IMF)

NAC/IMF descended

Pedicled nipple flap

III

NAC/IMF descended, upper abdominal laxity

Wedge excision, free nipple graft

•

Selection of proper surgical procedure depends on deformity Abdominal skin Abdominal fat Status musculofascial support (rectus diastasis?) • Miniabdominoplasty Lower abdominoplasty Suprapubic skin excision without translocation umbilicus; umbilicus can be floated and sutured into place, but will be lower on the abdomen Plication infraumbilical rectus muscle Can add suction lipectomy if excess fat involved

Useful for young, thin, postpartum female with excess skin, striae, and diastasis • Abdominoplasty Panniculectomy plus plication and/or transposition of the umbilicus Major undermining Plication above and below umbilicus: bulge in upper abdomen after abdominoplasty can be due to incomplete plication Relocate umbilicus in midline at level of anterosuperior iliac spine • Wedge resection Single, transverse, elliptical wedge excision with no undermining Safest approach for high-risk

patient with obesity, massive panniculus (patient cannot exercise and is prone to infection) • Nerves injured during abdominoplasty Lateral femoral cutaneous nerve: most common nerve injured causes meralgia paresthetica with anterior lateral thigh burning, tingling, and numbness Iliohypogastric: innervates suprapubic region Ilioinguinal: innervates skin along inguinal ligament, medial groin, labia majora, scrotum, inner thigh Note: genitofemoral nerve is not injured, it originates from L1–L2, courses deep to wall

Diagnosis: injection of local anesthetic, short-acting nerve block Treatment: neurectomy • Arterial supply to abdominoplasty flap Lateral intercostal perforators Preexisting abdominal scars (cholecystectomy right subcostal, paramedian supraumbilical) predispose to wound complications because decreased blood flow to flap: when operating, avoid undermining above these scars Infraumbilical scars and previous liposuction do not cause complications: can add suction

lipectomy to blend area of resection and sculpture • Seroma Most common complication in abdominoplasty Management algorithm: aspiration, closed suction drains, sclerosing agent, excision of seroma cavity Table 30.2 Tumescence techniques

EBL (% aspirate volume)

Technique

Infiltrate

Tumescent

3 mL infiltrate to 1 1% mL aspirate

Superwet

1 mL infiltrate to 1 1% mL aspirate

Wet

200–300 mL infiltrate per 4–30% area

Dry

No infiltrate

20–45%

Liposuction • Tumescence (Table 30.2) Components: normal saline or lactated Ringer solution, epinephrine, lidocaine (70% infiltrate remains postop) • Suction lipectomy fluid management

Combination of infiltrate + intravenous fluid (IVF) = 2× aspirate removed Do not liposuction > 5 L aspirate (fat and fluid) in an outpatient setting (according to American Society of Plastic Surgeons Committee on Patient Safety, 2004) Large-volume liposuction (e.g., 5 L aspirate) can cause fluid overload and lidocaine toxicity with tumescent technique (3 mL infiltrate to 1 mL aspirate); therefore, consider using superwet technique (1 mL infiltrate to 1 mL aspirate) Perform in appropriate facility to

monitor postop vital signs and urine output (Foley catheter for large volume liposuction) Signs of volume overload: hypertension, jugular venous distention, full bounding pulses, cough, dyspnea, lung crackles, pulmonary edema, change in urine output Do not combine large-volume liposuction with additional procedures • Ultrasound-assisted liposuction Piezoelectric quartz crystal or ceramic transducers transform electrical into mechanical vibrations, producing ultrasound waves

Disrupts adipocyte cell membrane via microbubble formation and rupture within cell membrane Fat is liquefied, causing cavitation, leaving behind fibrous septations Tumescent fluid infiltration minimizes thermal injury Dysesthesia postop may be due to myelin injury to nerves by ultrasonic energy Increased risk of seroma compared with suction-assisted liposuction May induce some degree of skin tightening • Suction-assisted lipectomy complications Surface irregularity: most common complication (20%), prevent by

cross-tunneling from two separate sites at right angles, use a small cannula in the deep fat, do not liposuction in zones of adherence (inferolateral IT band area, lateral gluteal depression, gluteal crease, distal posterior thigh, midmedial thigh) Thromboembolism: most common cause of death (1 in 5,000 procedures) Fatalities: thromboembolism 23%, abdominal wall perforation 15%, anesthesia 10%, fat embolism 8%, infection 5% Risks for complications: aspiration excess tissue (do not liposuction > 5 L in office), increased volume

tumescence, procedures

concomitant

Suggested Reading Aly A. Abdominoplasty and lower truncal circumferential body contouring. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:542–550 Buck DW II, Mustoe TA. An evidencebased approach to abdominoplasty. Plast Reconstr Surg 2010;126(6):2189–2195 Friedland JA, Maffi TR. MOC-PS (SM) CME article: abdominoplasty. Plast

Reconstr Surg 2008;121(4, Suppl):1–11 Gingrass MK. Liposuction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:533–541 Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight loss: detectability of technique, patient satisfaction, and classification. Plast Reconstr Surg 2008;122(5):1301–1311 Iverson RE, Lynch DJ; American Society of Plastic Surgeons Committee on Patient Safety. Practice advisory on liposuction.

Plast Reconstr Surg 2004;113(5):1478–1490, discussion 1491–1495 Iverson RE, Pao VS. MOC-PS (SM) CME article: liposuction. Plast Reconstr Surg 2008;121(4, Suppl):1–11 Koltz PF, Chen R, Messing S, Gusenoff JA. Prospective assessment of nutrition and exercise parameters before body contouring surgery: optimizing attainability in the massive weight loss population. Plast Reconstr Surg 2010;125(4):1242–1247 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg

1995;96(4):912–920 Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 1988;82(2):299–304 Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The zones of adherence: role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Sur g 2001;107(6):1562–1569 Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J 2006;26(2):214–222 Shermak MA. Body contouring. Plast Reconstr Surg 2012;129(6):963e– 978e

Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg 2008;122(1):280–288 Trussler A. Body Contouring. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2008:1–52. Selected Readings in Plastic Surgery; vol 10, issue 22 Wells JH, Hurvitz KA. An evidencebased approach to liposuction. Plast Reconstr Surg 2011;127(2):949– 954

31 Facelift and Neck Rejuvenation Reviewed by Val Lambos

Facelift • Anatomy (Table 31.1) Facial nerve Acronym for facial nerve branches Ten zillion bucks means cash Temporal (frontal), zygomatic, buccal, mandibular, and cervical Innervates superficial facial muscles on their deep surface

Innervates only three deep facial muscles on their superficial surface Mentalis Buccinator Levator anguli oris Pitanguy line: frontal nerve courses from 0.5 cm below tragus to 1.5 cm above lateral eyebrow Facial blood supply Superficial temporal artery: deep to plane of dissection, supplies scalp and forehead Transverse facial artery: branch of superficial temporal artery, arises medial to plane of dissection, undermined in

facelift skin flap, preauricular skin

supplies

Facial, labial, angular, ophthalmic, and infraorbital arteries: arise more medially and contribute to vascular arcade of facelift skin flap Retaining ligaments (Table 31.2) Support facial skin in position

relative to deep fixed underlying structures Loosening of zygomatic ligaments leads to prominent nasolabial folds Loosening of masseteric ligaments leads to jowls • Patient assessment One looks at nearly all the aspects of the face and how it has aged from brow position to the lower lid fat to skin quality and apparent excesses or deficiencies of skin, fat, and muscle Youthful face: egg or cone shape with wider side superior Aging face: midface descends, creating jowls and nasolabial

folds (there is controversy about this) • Techniques Subcutaneous facelift Can include superficial musculoaponeurotic system (SMAS) modifications (SMASectomy, SMAS-plication, SMAS-stacking, MACS lift) Sub-SMAS (deep-plane) facelift Subperiosteal facelift Added volume in the face with fat or fillers Incision placement: pre- versus posttragal, pre- versus posthairline • Complications Hematoma

Most common facelift complication (4%) May compromise airway or skin flap viability Risk factors High blood pressure: most important risk factor to control Blood thinners, including ginkgo, garlic, and vitamin E Cough, pain, anxiety, vomiting Lack of gentle compression dressing or suction drains Table 31.2 Retaining ligaments

Ligament

Attachment Zygomatic arch and

Zygomatic

malar eminence periosteum

Masseteric

Anterior border masseter muscle

Parotid

Parotid gland

Mandibular

Anterior mandible (parasymphysis) periosteum

Treatment Return to operating room (OR) for evacuation of hematoma if large, rapidly expanding, and painful; otherwise will have firmness, irregularity, and skin discoloration for months

(often there is no active bleeding) 5 days postop, hematoma may be solid: release sutures and evacuation of hematoma 7 to 10 days postop, hematoma may have liquefied: aspirate the hematoma Skin slough Second most common facelift complication (2%) Clinically important ones are in the front of the ear Associated with cigarette smoking Management: local wound care with antibacterial ointment, frequent postop visits, allow to

heal by secondary intention Nerve injury Third most common facelift complication (1%) Greater auricular nerve Most common nerve injured in facelift Originates from C2–C3 Crosses sternocleidomastoid muscle 6 cm inferior to the tragus Supplies sensation to inferior ear Frontal nerve Injury results in weakness in eyebrow elevation Can be injured with any

facelift, though not as common as with subperiosteal Buccal nerve Most common facial nerve injured Not noticed because crossover connections Frequently improves over 4 months, but there may be residuals Marginal mandibular nerve Most common facial nerve injury noticed Affects orbicularis oris, lip depressors, and mentalis muscle Ipsilateral lip does not depress, causing an

asymmetrical smile Observe because spontaneous recovery within 6 months in 80% Treat contralateral depressor labii inferioris with botulinum toxin injection Cervical nerve Only depressors affected Usually resolves within 4 to 12 weeks Ratio of facial nerve injury with sub-SMAS dissection versus subcutaneous dissection is 4:1 Nerve repair Microsurgical repair if nerve transection identified in the OR

Distal end of transected nerve can be identified by nerve stimulation for up to 72 hours after injury Infection Rare complication (0.18%) Staphylococcus aureus is most common pathogen Hairline distortion Most common complication of secondary facelift Hairline shaft injury, sideburn elevation (this has to do with poor incision placement) • Male facelift Thick skin obscures results Increased risk for hematoma

compared to female facelift patients because higher blood pressure (unless blood pressure controlled) and greater blood supply Bald patients require different incisions Retrotragal incision leads to posteriorly displaced beard over tragus Sideburns are an advantage in men because superiorly displaced beard can grow as a new sideburn • Skin diseases Cutis laxa Etiology: nonfunctional elastase inhibitor, premature degeneration of elastin fibers

Skin laxity, does not recoil when pulled Facelift may address associated wrinkling Increased risk for ventral hernias Ehlers–Danlos syndrome Collagen disorder: lysyl oxidase enzyme deficiency Hyperextension of joints, skin recoils, subcutaneous hemorrhages Avoid cosmetic surgery because poor wound healing Elastoderma Localized skin laxity Avoid cosmetic surgery because poor wound healing

Progeria (Hutchinson–Gilford syndrome) Autosomal dominant disorder Childhood-onset premature aging Do not get facelifts because suffer from early cardiac death Werner syndrome Autosomal recessive disorder Adult-onset premature aging Do not get facelifts because suffer from early cardiac death

Neck Rejuvenation • Patient assessment: youthful neck Cervicomental angle 105 to 120 degrees

Thyroid bulge Subhyoid depression Distinct mandibular border Nasolabial chin plane (NLCP): chin projection should be 3 mm posterior to NLCP (line dropped from midpoint of nasal length through upper and lower lip vermilion) Youthful neck has no playsmal bands, and minimal pre- and subplatysmal fat • Neck rejuvenation treatment algorithm (Table 31.3) Table 31.3 Neck rejuvenation treatment algorithm

Presentation

Treatment

Lateral platysmal Increased skin laxity advancement and plication Ultrasound and Excellent skin tone, suction assisted lipodystrophy liposuction Wide medial Medial release, platysmal bands (> 2 lateral closed cm) approach Medial Narrow medial release/plication, platysmal bands (< 2 open submental cm) approach

Suggested Reading Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83(1):11–16 Gonyon DL, Barton FE. The Aging Face: Rhytidectomy and Adjunctive Procedures. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–41. Selected Readings in Plastic Surgery; vol 10, issue 11 Guyuron B. An evidence-based approach to face lift. Plast Reconstr Surg 2010;126(6):2230–2233 Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck rejuvenation revisited. Plast Reconstr Surg 2006;118(5):1251–1263

Stuzin JM. MOC-PSSM CME article: Face lifting. Plast Reconstr Surg 2008; 121(1, Suppl) 1–19 Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89(3):441–449, discussion 450–451 Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989;83(2):265–271 Thorne CH. Facelift. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery.

6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:498–508 Tonnard PL, Verpaele A, Gaia S. Optimising results from minimal access cranial suspension lifting (MACS-lift). Aesthetic Plast Surg 2005;29(4):213–220, discussion 221 Warren RJ, Aston SJ, Mendelson BC. Face lift. Plast Reconstr Surg 2011;128(6):747e–764e

32 Rhinoplasty Reviewed by Ali Totonchi

Nasal Anatomy • Basics of nasal anatomy Two nasal bones Two upper lateral cartilage Two lower lateral cartilage One septum Six turbinates • Arterial supply (Fig. 32.1) External carotid artery supplies the facial artery, which branches to become angular artery and superior labial artery (travels

between orbicularis oris and oral mucosa) Superior labial artery supplies the columellar artery Angular artery supplies the lateral nasal artery, which anastomoses with dorsal nasal artery from ophthalmic artery from internal carotid artery Nasal septum perfused by anterior and posterior septal arteries as well as anterior and posterior ethmoidal arteries • Innervation from cranial nerve (CN) V1 Anterior ethmoid nerve: external branch supplies midvault and tip

Fig. 32.1 Vascularization of the external nasal pyramid. (From Huizing BH, de Groot J. Functional Reconstructive Nasal Surgery. Stuttgart, Germany: Thieme; 2003. Used with

permission.)

Supratrochlear and supraorbital nerves: supply cephalic nose Infratrochlear nerve: supplies cephalic sidewalls and radix • Innervation from CN V2 Infraorbital nerve: supplies lateral walls, ala, and columella Pterygopalatine nerve: lateral branch supplies upper and middle turbinates, medial branch supplies septum Nasopalatine nerve: terminal branch of pterygopalatine nerve innervates maxillary incisors, gingival, and palate • Muscles of the nose

Innervation: CN VII Transverse nasalis: contracts the nostril Depressor septi nasi: depresses nasal tip, narrows columellolabial angle Procerus: moves eyebrows caudally Levator labii superior alaeque nasi: dilates the nares

Nasal Airway Obstruction • Etiology Hypertrophic inferior turbinate: most common cause of nasal airway obstruction Internal and external valve

obstruction Deviated septum: treat with septoplasty Infectious rhinitis: treat with decongestant • Hypertrophic inferior turbinate Most common cause of nasal airway obstruction Treatment of the enlarged turbinate is done by partial resection of the mucosa and/or bony reduction Do not completely resect the inferior turbinate because can cause airway dryness, sensitivity to cold, or paradoxical sensation of nasal obstruction Submucosal resection can leave behind hypertrophic soft tissue

Anterior or posterior partial resection of the inferior turbinate leads to compensatory hypertrophy later in remaining portion • Internal valve Junction between upper lateral cartilage (ULC) and septum: 10 to 15 degrees is normal Narrowing of the internal valve can be secondary to nasal bone infracture Cottle maneuver: traction lateral on cheek skin diagnoses internal valve obstruction if improves airway • Treatment of internal valve collapse Spreader grafts: placed between ULC and septum in

submucoperichondrial pocket • ULC fold-in flap: this flap becomes available after resection of a sizable dorsal cartilaginous hump Butterfly graft: conchal cartilage placed on top of ULC to lateralize ULC Splay graft: conchal cartilage placed under ULC • External valve External opening of the nostril Collapse of lateral crura can be treated with lateral crural strut graft (batten graft) Collapse of alar rim can be treated with alar rim graft Seasonal allergic rhinitis

Mediated by immunoglobulin E (IgE) Symptoms involve sneezing and itching Treatment is decongestant and steroids

Nasal Dorsum • Nasal hump deformity on profile view < 3 mm: rasp without creating open roof > 3 mm: component dorsal hump reduction, may create open roof deformity • Component dorsal hump reduction Emphasizes integrity of ULC by

stepwise approach Separate ULC from septum, reduce septum, reduce ULC if needed, spreader graft if needed • Osteotomies: reduce wide nasal dorsum on frontal view (Table 32.1) • Osteotomy techniques Stay subperiosteal with anterior to posterior osteotomy to avoid injury to lateral nasal artery Choose low to low or high to low lateral osteotomy based on desired anatomical change and position of inferior turbinates If inferior turbinates are anteriorly located, do a high to low osteotomy to avoid medializing the inferior turbinate and decreasing

the airway space Lateral external perforating osteotomies can injure lateral nasal arteries and contribute to tip loss in open rhinoplasty where columellar artery already cut Low to high osteotomy can lead to a step deformity cephalically (rocker deformity)

Rocker deformity: nasal bone infracture rocks lateral portion out

laterally During lateral osteotomy preserve Webster triangle (caudal aspect of lateral osteotomy attaches to ULC) to avoid destabilizing ULC and causing internal valve collapse • Dorsal grafts Dorsal onlay grafts Correct localized dorsal depressions Autologous cartilage is preferred: diced septal, conchal, or costal cartilage, wrapped by fascia Spreader grafts: straighten deviated high dorsal septum, improve dorsal aesthetic lines Dorsal sidewall onlay grafts:

correct lateral asymmetries

Nasal Tip • Anatomical landmarks Transverse landmarks: domes Vertical landmarks: supratip and columellar breakpoint (junction of middle and medial crura) Lobule to nostril ratio: 1:2 (Fig. 32.2) • Angle of divergence (Fig. 32.3) Angle between columellar breakpoint and dome-defining points 30 to 60 degrees: normal > 60 degrees: tip appears boxy

< 30 degrees: tip appears narrow • Boxy tip Type 1: wide angle of divergence (> 60 degrees), treat with interdomal sutures

Fig. 32.2 Triangular shape of the lobule. (From Huizing BH, de Groot J. Functional Reconstructive Nasal Surgery. Stuttgart, Germany: Thieme; 2003. Used with permission.)

Fig. 32.3 Angle of divergence.

Type 2: normal angle of divergence (30 to 60 degrees) but lateral crus more cephalad; treat with caudal rotation of lateral crura or with cephalic trim of cephalic portion of lateral crura • Sutures for tip rhinoplasty

Transdomal suture: placed within the dome, to narrow a wide dome Interdomal suture: placed between domes, to narrow distance between domes Tip rotation suture: placed between cephalic margin of medial crura and the anterocaudal septum; rotates the tip cephalically and increases the columellolabial angle • Columellolabial angle Males: 94 to 97 degrees Females: 97 to 100 degrees • Techniques for cephalic tip rotation Tip rotation suture Columellar strut graft

Cephalic trim lower lateral cartilage (LLC) Anterocaudal septum resection • Tip graft Used to improve the tip shape or add height to the lobule part of the nose Different types and and shapes reported Most common complication: visibility • Columellar strut graft Maintains tip support and adds height to collumellar part of the nasal projection Increases columellolabial angle • Hanging columella management

Resection caudal septum (overresection can cause retraction of columella) Fred technique: advancement of medial crura and footplates over caudal septum

Nasal Ala • Flaring ala Treatment: Weir excision (wedge resection) of alar bases to reduce flaring • Alar retraction/collapse Due to LLC, which is overresected, concave, or malpositioned Treatment: alar contour graft

and/or alar batten graft Alar contour (rim) graft: placed in subcutaneous pocket immediately above and parallel to alar rim Alar batten graft (lateral crus graft): placed in pocket from piriform aperture to lateral crus

Rhinoplasty in Particular Patient Populations • Advancing age rhinoplasty Drooping, elongated tip complex Loss of intrinsic LLC support Weakening suspensory ligament support Loss of medial crural support

Prominent cartilages due to thickening and ossification Bulky tip due to thickened subcutaneous tissue and skin Maxillary alveolar hypoplasia with divergence of medial crural feet and columellar shortening • Male rhinoplasty Beware if requests just nasal tip aesthetic refinement instead of airway issues and gross concerns • Asian rhinoplasty Alar flaring: treat with alar base narrowing, alar rim graft, and excision of soft tissue triangle Bulbous nasal tip: treat with tip graft, columellar graft, cephalic trim LLC

Wide, flat dorsum: treat with dorsal augmentation using costal cartilage (autologous graft preferred over silicone implant), nasal osteotomies if needed Thick subcutaneous tissue • Thick skin rhinoplasty Thick sebaceous skin will cause decreased likelihood of optimal results with nasal tip work Treatment: retin-A, defat the tip, supratip suture to eliminate dead space and improve tip definition • Secondary rhinoplasty Wait 1 year after primary rhinoplasty prior to doing secondary rhinoplasty

Complications • Inverted V deformity After infracturing nasal bones with medialization of upper lateral cartilages, or after overresection of cartilaginous dorsal hump reduction, there may be a collapse of the upper lateral cartilages with visibility of inverted V-shaped nasal bones at the keystone area (junction of upper lateral cartilage, nasal bones, and perpendicular plate of ethmoid bone) Treat with spreader grafts between upper lateral cartilages and cartilaginous septum • Open book deformity

After reduction of overprojected bony dorsum there may be a broad flat dorsal defect with exposed mucosa or nasal cavity Treat by infracturing nasal bones, and placement of spreader grafts to avoid inverted V deformity • Saddle nose deformity Dorsal collapse and over-rotation of tip Secondary to septal hematoma or L strut smaller than 1 cm Treatment: onlay graft if mild deformity, more severe deformity requires L strut reconstruction with costal cartilage graft • Polly beak (supratip) deformity Convexity cephalad to nasal tip

From aggressive reduction rhinoplasty, overresection of supratip structures without elimination of dead space with supratip suture can lead to blood filling this space and fibrofatty deposition: can prevent with supratip suture and tape; if still less than 3 months after surgery can inject steroids Under-resection of supratip septum and under-rotation of tip: treat with resection of anterocaudal septum, rotation of tip; may need to trim, overlay, or reorient LLC • Toxic shock syndrome Seen with use of nasal packs Patient presents with fever,

hypotension, erythroderma Treat with antibiotics for Staphylococcus aureus and packing removal • Periostitis Erythema and hump after dorsal hump reduction because rasped bone is not irrigated out Treatment: antibiotics and surgically excise in 8 to 12 months • Nasal surgery olfactory dysfunction 7 to 9% of patients after nasal surgery have change in taste • Gustatory rhinorrhea Clear rhinorrhea when eating Secondary to anomalous nerve regeneration after septoplasty or

septorhinoplasty Similar to Frey syndrome Treatment: atropine

Suggested Reading Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican American nose. Plast Reconstr Surg 2003;112(1):244– 256, discussion 257–258 Daniel RK. The nasal tip: anatomy and aesthetics. Plast Reconstr Surg 1992;89(2):216–224 Gunter JP, Landecker A, Cochran CS. Frequently used grafts in rhinoplasty: nomenclature and analysis. Plast Reconstr Surg

2006;118(1):14e–29e Guyuron B. Alar rim deformities. Plast Reconstr Surg 2001;107(3):856– 863 Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991;88(6):970–978, discussion 979 Guyuron B. Rhinoplasty. New York: Elsevier Saunders; 2012 Guyuron B. Soft tissue functional anatomy of the nose. Aesthet Surg J 2006;26(6):733–735 Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg 2003;111(7):2449–2457, discussion 2458–2459

Guyuron B, Behmand RA. Nasal tip sutures part II: the interplays. Plast Reconstr Surg 2003;112(4):1130– 1145, discussion 1146–1149 Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg 2000;105(3):1140– 1151, discussion 1152–1153 Guyuron B, Michelow B, Thomas T. Gustatory rhinorrhea—a complication of septoplasty. Plast Reconstr Surg 1994;94(3):454–456 Ha RY, Meade RA. Rhinoplasty. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2007:1–60. Selected Readings in Plastic Surgery; vol 10, issue 18 Harshbarger RJ, Sullivan PK. The

optimal medial osteotomy: a study of nasal bone thickness and fracture patterns. Plast Reconstr Surg 2001;108(7):2114–2119, discussion 2120–2121 Janis JE, Rohrich RJ. Rhinoplasty. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:517–532 Matarasso A, Greer SE, Longaker MT. The true hanging columella: simplified diagnosis and treatment using a modified direct approach. Plast Reconstr Surg 2000;106(2):469–474 Ponsky D, Eshraghi Y, Guyuron B. The

frequency of surgical maneuvers during open rhinoplasty. Plast Reconstr Surg 2010;126(1):240– 244 Rohrich RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg 2001;107(7):1849–1863, discussion 1864–1868 Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg 2011;128(2):49e–73e Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg 2002;110(6):1509–1523, discussion

1524–1525 Rohrich RJ, Hollier LH Jr, Janis JE, Kim J. Rhinoplasty with advancing age. Plast Reconstr Surg 2004;114(7):1936–1944 Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg 2003;112(4):1071–1085, quiz 1086 Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique. Plast Reconstr Surg 2001;108(7):2122– 2130, discussion 2131–2132 Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg

2003;111(3):1322–1339, discussion 1340–1341 Rohrich RJ, Muzaffar AR, Gunter JP. Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg 2000;106(7):1640– 1641 Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 2004;114(5):1298– 1308, discussion 1309–1312 Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg

2002;109(7):2495–2505, discussion 2506–2508 Sajjadian A, Guyuron B. An algorithm for treatment of the drooping nose. Aesthet Surg J 2009;29(3):199–206 Sajjadian A, Naghshineh N, Rubinstein R. Current status of grafts and implants in rhinoplasty: Part II. Homologous grafts and allogenic implants. Plast Reconstr Surg 2010;125(3):99e–109e Sajjadian A, Rubinstein R, Naghshineh N. Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg 2010;125(2):40e–49e Sheen JH. Achieving more nasal tip projection by the use of a small

autogenous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg 1975;56(1):35– 40 Sheen JH. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg 2000;105(5):1820– 1852, discussion 1853 Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF Jr. Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg 1996;122(1):24–34

33 Blepharoplasty and Brow Lift Reviewed by Oren Tepper

Eyelid Anatomy (Fig. 33.1) • Anterior lamella Skin Orbicularis oculi muscle: innervated by cranial nerve (CN) VII to close eye (blink) • Posterior lamella Tarsoligamentous structures Conjunctiva: palpebral conjunctiva lines posterior aspect of eyelid, bulbar conjunctiva lines globe

Fig. 33.1 Eyebrow and eyelid anatomy. (From Chen W. Oculoplastic Surgery: The Essentials. New York: Thieme; 2001. Used with permission.)

Lid retractors Intraorbital fat • Orbital septum Divides anterior and posterior lamella Originates from arcus marginalis of the lower eyelid (point of confluence onto the periosteum) Join the capsulopalpebral fascia (lower eyelid) or levator aponeurosis (upper eyelid) prior to inserting into tarsal plate • Tarsoligamentous structures (Fig.

33.2) Tarsus Attach to orbital walls via medial and lateral canthal tendons Lid retractors attach to superior and inferior borders of tarsal plates Orbicularis oculi attaches to tarsal plates anteriorly Conjunctiva attaches to posterior edge of tarsal plates Superior tarsus: ~ 10 mm in height Inferior tarsus: ~ 6 mm in height Canthal tendons Medial canthal tendon

Posterior limb (PL): attaches to posterior lacrimal crest on lacrimal bone Anterior limb (AL): attaches to anterior lacrimal crest on frontal process of maxilla Lateral canthal tendon: superior and inferior limbs (SL, IL) attach to Whitnall tubercle on zygomatic bone inside lateral orbital rim (approximately 10 to 11 mm within rim) Canthal tilt: relationship of lateral and medial canthus. Lateral canthus is typically 1 to 2 mm superior to medial canthus (“positive canthal tilt”) versus level (“neutral tilt”) or inferior

(“negative tilt”)

Fig. 33.2 Canthal tendons. AL, anterior limb; LCT, lateral canthal tendon; MCT, medial

canthal tendon; PL, posterior limb.

Lockwood ligament Suspensory ligament to globe Arises from capsulopalpebral fascia off lower eyelid retractors Medial attachment is posterior lacrimal crest Lateral attachment is Whitnall tubercle Invests inferior oblique and inferior rectus muscles Whitnall ligament Lateral horn of the fascial condensation of levator aponeurosis Contributes to the lateral

retinaculum Stabilizes eye Lateral retinaculum Composed of Lateral canthal tendon Whitnall ligament lateral horn Lockwood ligament Whitnall tubercle: lateral retinaculum attachment inside orbital rim on zygomatic bone • Lid retractors Upper eyelid Levator palpebral muscle: originates from sphenoid bone, striated muscle, innervated by oculomotor nerve (CN III) Levator aponeurosis:

continuation of levator palpebral muscle, attaches to tarsal plate and eyelid skin Müller muscle: innervated by sympathetic nervous system Lower eyelid Capsulopalpebral fascia: analogous to levator aponeurosis • Periorbital fat Upper eyelid Two postseptal fat pads Nasal and central fat pads Lacrimal gland occupies space where lateral fat pad would be Nasal fat pad color is more pale than central fat pad

Anterior to upper eyelid retractors Retro-orbicularis oculi fat (ROOF): preseptal, posterior to orbicularis oculi Eisler fat pocket: bordered by lacrimal gland, orbital rim, orbital septum, lateral canthal tendon Lower eyelid Three postseptal fat pads Nasal, central, and lateral fat pads Anterior to lower eyelid retractors Medial/nasal fat pad color is most pale Suborbicularis oculi fat (SOOF):

preseptal, posterior orbicularis oculi

Blepharoplasty • Patient assessment (see additional details in Chapter 26, Eyelid and Lacrimal System Reconstruction) Visual acuity exam Schirmer test Malar support (vector analysis) Upper and lower lid position Skin excess Fat protrusion Ptosis (eyelid and/or brow) Levator excursion Lower eyelid snap-back test

Lower eyelid distraction test Evaluate for lateral upper eyelid fullness Prominent superolateral orbital rim Brow ptosis Excess ROOF Lacrimal gland ptosis Do not resect because can cause dry eye Resuspend pseudocapsule to the periosteum of lateral orbital rim Excess periorbital fat • Upper eyelid blepharoplasty Caudal incision along the upper eyelid crease

Cephalic incision based on excess skin pinched in supine position Skin only is excised in most cases If muscle is performed, must be careful not to injure levator aponeurosis Nasal and central fat compartments are excised through cephalic incision to avoid injury to levator aponeurosis • Lower eyelid blepharoplasty Transconjunctival incision Incision below tarsus through conjunctiva and capsulopalpebral fascia Dissection between orbicularis oculi and orbital septum No external scar

Decreased risk of eyelid retraction compared to external subciliary approach Addresses lower eyelid fat compartments Does not address excess lower eyelid skin and muscle Subciliary incision Incision below ciliary margin Can remove excess skin and muscle in addition to addressing lower eyelid fat compartments Increased risk of eyelid retraction compared with transconjunctival approach Fat repositioning Reposition lower eyelid

periorbital fat to the tear trough deformity along the lid–cheek junction Requires release of arcus marginalis and incision of septum; orbital fat repositioned • Prominent eye blepharoplasty Scleral show: eyelids do not overlap corneal–scleral junction Negative vector: globe position is anterior to malar region predisposing to lower eyelid malposition after blepharoplasty Need variation in blepharoplasty technique Conservative skin and muscle resection to prevent ectropion Canthoplasty or canthopexy to

reposition lateral canthus more superior and lateral in orbit to prevent lower eyelid retraction below the limbus Graves thyroid ophthalmopathy Etiology: autoantibodies stimulate thyroid to produce excess thyroid hormone resulting in intraorbital soft tissue enlargement Presentation: bilateral prominent eyes, proptosis, eyelid retraction, dry eye, conjunctival injection Treatment: steroids, radiation therapy, orbital decompression, modified blepharoplasty techniques to decrease risk of

lid malposition • Asian eyelid Characteristics Lack of supratarsal fold 50% lack levator aponeurosis insertion into dermis Fusion of orbital septum to levator aponeurosis more caudad Levator fibers insert more caudad into canthus Increased appearance of ROOF Prominent epicanthal fold Creation of prominent crease: levator aponeurosis fixation to underlying dermis • Blepharoplasty complications

Malposition: most common Lower eyelid malposition Risk factors Negative vector (e.g., proptosis, Graves thyroid ophthalmopathy) Lower eyelid laxity Midface descent Scarring between septum and capsulopalpebral fascia causing vertical restriction Excess scleral show after blepharoplasty May need to perform canthopexy or canthoplasty if lower eyelid needs tightening

Upper eyelid malposition Ptosis Lagophthalmos: inability to close eyelids completely Extraocular muscle injury Superior oblique muscle injury Most common extraocular muscle injured Inferior oblique muscle injury Second most common extraocular muscle injured Found between medial and central fat compartments Injury caused by bovie injury, scarring, or suturing can result in strabismus or diplopia Visual loss

Retrobulbar hematoma Presentation: pain, exophthalmos, ecchymosis, worsening vision, which can lead to blindness Associated with hypertension and anticoagulant use Treatment: emergent lateral canthotomy at the bedside to decompress Medical treatment to decrease intraorbital pressure: mannitol, acetazolamide, dexamethasone Ectropion intraop Due to overresection Place portion of excised skin as skin graft

Chemosis Swelling of conjunctiva secondary to disrupted lymphatics Separates lower lid from sclera, exposing conjunctiva and causing swelling, irritation, itchiness Early postoperative complication Treatment: dexamethasone ophthalmic ointment, eye lubricants, patch eye, temporary tarsorrhaphy (if no improvement) Cadaveric (hollowed out) appearance Due to excessive removal of

periorbital fat Epiphora Excessive tearing secondary to edema, chemosis, temporary paralysis of orbicularis oculi muscle Treatment Reassure and observe Evaluate for lacrimal system injury if no improvement

Brow Lift • Brow anatomy Arteries Superficial temporal artery Supratrochlear artery

Supraorbital artery Forehead muscles (Table 33.1) Nerves Sensory (trigeminal nerve) Supratrochlear nerve

Medial to supraorbital nerve Supplies radix and central forehead Passes through corrugator supercilii muscle Supraorbital nerve Lateral to supratrochlear nerve Superficial branch

• Supplies central forehead • Courses superficial to frontalis muscle Deep branch • Supplies frontoparietal scalp • Courses deep to frontalis muscle immediately medial to the superior temporal fusion line Motor Frontal branch of facial nerve: travels deep to superficial temporal fascia along the Pitanguy line (0.5 cm below tragus to 1.5 cm superior to lateral eyebrow) • Patient assessment

Ideal eyebrow position Medial eyebrow: at level of alar base Eyebrow peak: between lateral limbus and lateral canthus Lateral eyebrow: along plane of alar base and lateral canthus Women: eyebrow arches above supraorbital rim Men: eyebrow at the level of supraorbital rim without significant peaking Brow ptosis Lateral upper eyelid hooding Narrow brow–lash distance Transverse brow furrows: due to compensatory brow elevation

Independently evaluate upper eyelid and brow position Brow can have compensatory elevation when eyes are opened Ask patient to close eyes and relax brow Ask patient to slowly reopen eyes (watch for absence of compensatory brow elevation) to independently evaluate brow and upper eyelid positions Botox injections can also be used preoperatively to eliminate effects of compensatory brow elevation • Nonsurgical intervention Botulinum toxin Useful for patients who are not

interested in undergoing browlift surgery Food and Drug Administration approved to treat glabellar and crow's feet rhytids Brow lift surgical techniques (Table 33.2) Coronal incision Endoscopic Pretrichial incision Transpalpebral: upper blepharoplasty incision • Lateral brow elevation Release orbital retaining ligament between superficial temporal fascia and bone of the lateral orbital rim

Suspend lateral brow with fixation techniques laterally • Medial brow elevation Resection of corrugator supercilii muscle elevates medial brow and addresses vertical glabellar wrinkling Avoid release of periosteum medially to prevent overcorrection Avoid injury to supratrochlear nerve Replace excised corrugator with fat graft (from upper eyelid or temporal fat pad) to avoid contour deformity and reattachment of corrugator to bone Transpalpebral corrugator resection: corrugator resection can

be approached via upper blepharoplasty incision • Endoscopic approach Plane of dissection Central forehead: subperiosteal Lateral forehead: between deep and superficial temporal fascia Table 33.2 Brow lift surgical approach

Forehead shape

Forehead Surgical measurement approach

Short

< 6 cm

Coronal incision

Normal

6–10 cm

Endoscopic

Long

> 10 cm

Pretrichial incision

Fixation techniques Lateral fascial suspension suture: superficial temporal fascia sutured to deep temporal fascia Bone tunnel Drill two small holes at 45degree angles and 3 mm apart to pass suture through Cheaper than anchor and screws For bone fixation medial to the deep temporal fascia Mitek anchors (DePuy Mitek, Inc., Raynham, MA) Endotine anchor: do not use in

patients with thin skin < 5 mm because 3.5 mm tines can be palpable External screws: remove 2 weeks postop (unlike Mitek and Endotine anchors, which remain as buried foreign bodies) Endoscopic approach does not allow for skin resection • Brow lift complications Overcorrection, undercorrection, or asymmetry Nerve injury Alopecia Infection or hematoma

Suggested Reading

Bahn RS. Graves’ ophthalmopathy. N Engl J Med 2010;362(8):726–738 Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term results. Plast Reconstr Surg 2006;117(4):1137–1143, discussion 1144 Codner MA, Fored DT. Blepharoplasty. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:486–497 Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow lift. Plast Reconstr Surg 2010;126(1):1e–17e Friedland JA, Lalonde DH, Rohrich RJ.

An evidence-based approach to blepharoplasty. Plast Reconstr Surg 2010;126(6):2222–2229 Guyuron B. Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards. Plast Reconstr Surg 2006;117(4):1121–1133, discussion 1134–1136 Knize DM. Forehead lift. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:509–516 Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg 2010;125(3):1007–1017 Marten TJ. Closed, nonendoscopic,

small-incision forehead lift. Clin Plast Surg 2008;35(3): 363–378, discussion 361 Potter JK, Janis JE, Clark CP. Blepharoplasty and Browlift. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–37. Selected Readings in Plastic Surgery; vol 10, issue 10 Trussler AP, Rohrich RJ. MOC-PSSM CME article: Blepharoplasty. Plast Reconstr Surg 2008;121(1, Suppl):1–10 Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven; 1985

34 Otoplasty Reviewed by Gaby Doumit

Incidence of Promiment Ears • 5% of population has prominent ears • Underdeveloped antihelical fold: most common cause of prominent ears • Prominent concha and protruding earlobe cause prominence in the middle and lower third of the ear, respectively

Otoplasty Anatomical

Measurements • Cephaloauricular angle Normal: 20 degrees Conchal valgus male: > 25 degrees Conchal valgus female: > 21 degrees • Conchal depth Normal: 10 mm Abnormal: > 1.5 cm • Helical rim protrusion norms Apex: 10 to 12 mm Midpoint: 16 to 18 mm Lobule: 20 to 22 mm Think: 10, 15, 20 mm to remember apex, midpoint, lobule protrusion • Helical rim height: 7 mm (10% of vertical height)

• Conchoscaphoid angle Normal: 90 degrees Effacement of scapha: > 90 degrees • Ear height: 5.5 to 6 cm is double the width • Ear width: 3 to 4.5 cm

Otoplasty Techniques • Mustarde sutures 4-0 permanent sutures are placed to create an antihelical fold Sutures placed between the scapha and the concha (to create lower and middle third fold), and/or between the scapha and the triangular fossa (to create upper

third fold) Sutures should go through the full thickness of cartilage to include the anterior perichondrium Three or four horizontal mattress sutures are usually necessary to create the antihelical fold Avoid penetrating the lateral ear skin All sutures are placed before tying • Stenstrom technique Abrade the antihelical fold cartilage anteriorly to bend it posteriorly (Gibson principle) • Furnas sutures Conchomastoid sutures between conchal cartilage and mastoid fascia treat prominent ear caused

by conchal valgus Can also excise conchal cartilage from posterior incision to reduce conchal height • Luckett procedure Excision of posterior ear skin • Webster technique Corrects prominent helical tail by fixation to concha • Gosain earlobe technique Excision of medial earlobe skin Earlobe is then partially attached to inferior surface of the concha during closure • Graham and Gault technique Endoscopic scoring of posterior cartilage

Otoplasty Complications • Recurrence Most common complication (8 to 33%) Cause of recurrence in upper half of ear: inadequate placement sutures to create antihelical fold Cause of recurrence in lower half of ear: inadequate resection of excess concha or failure to reposition the earlobe Adults have less pliable cartilage and may need rasping of the cartilage • Hematoma Severe unilateral pain < 24 hours postop

Need urgent evacuation • Keloids and hypertrophic scarring • Cellulitis • Otitis externa Starts > 24 hours postop • Chondritis Starts days postop, uncommon Pain, swelling, tenderness Treatment: intravenous (IV) antibiotics, do incision and drainage if suppurative • Excessively tight dressing Pain starts immediately postop in bilateral ears when patient wakes up Postoperative dressing should initially be noncompressive and

bulky for a few days, then switched to a loose headband worn at night for six weeks • Skin necrosis • Greater auricular nerve injury Dysesthesias noted weeks later • Telephone ear deformity Secondary to overcorrection of concha reduction or inadequate reduction of upper/lower poles of ear during otoplasty

Otoplasty Timing • Neonatal molding timing Neonatal prominent or lop ears are most moldable during the first few weeks of life secondary to

increased circulating maternal estrogens Treatment with splints or molding devices should last approximately 2 to 3 months Splints and tape should be replaced when they become loose Skin needs to be examined regularly for ulceration • Otoplasty timing 4 to 6 years of age, before school At 6 years of age, ears are within 7 mm of final vertical height

Suggested Reading Davis J. Prominent ears. Clin Plast Surg 1978;5(3):471–477

Gosain AK, Recinos RF. A Novel Approach to Correctin of the Prominent Lobule during Otoplasty. Plast Reconstr Surg 112(2): 575– 583, 2003 Ha RY, Hackney F. Plastic Surgery of the Ear. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1–36. Selected Readings in Plastic Surgery; vol 10, issue 9 Stal S, Klebuc M, Spira M. An algorithm for otoplasty. Oper Tech Plast Reconstr Surg 1997;4:88–103 Thorne CH. Otoplasty and Ear Reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott

Williams & Wilkins; 2006:297–312 Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg 2012;129(4):701e–716e

35 Chemical Peels Reviewed by David J. Rowe

Peel Classification (Table 35.1) • Superficial Peels Retin-A Use for 3 to 4 months before effect is seen Side effects Erythema: most common complaint Photosensitivity: apply at night Glycolic acid Alpha hydroxyl acid

Strengths 50 to 70% for deeper peels 30% peel has depth to stratum corneum Maintenance therapy with monthly treatments Neutralize or wash off with water Jessner solution Stronger than glycolic acid Use before trichloroacetic acid (TCA) Components 14% resorcinol 14% salicylic acid 14% lactic acid Salicylic acid

Indication: acne Table 35.1 Peel classification

Classes

Indications Examples

Superficial wrinkles, Superficial acne scars, peels uneven pigmentation

Medium peels

Retin-A, glycolic acid, Jessner solution, salicylic acid

Moderate rhytides, failed superficial peels

Trichloroacetic acid (TCA)

Coarse rhytides,

Phenol, Baker–

Deep peels severe sun damage

Gordon formula

• Medium Peels: TCA Concentration 10 to 25% Light peel of superficial epidermis Lower concentration for neck, chest, hands to avoid hypertrophic scarring, which may occur in these areas 30 to 35% Intermediate peel to papillary dermis Most common strength 50 to 60%

Deep peel through the papillary dermis Only half penetration and neocollagen formation of phenol Pretreat Degrease with Jessner solution or alcohol Remove surface oils, which reduce absorption and result in uneven peel Variables that affect depth of treatment Time Number of coats Concentration Pretreatment

Clinical changes related to depth Superficial peels: sparse and pinkish-white changes Intermediate to deep peels: dense white frosting No systemic toxicity Neutralized in superficial dermis by protein keratin No systemic toxicity as with phenol Side effects Erythema Scarring Infections Pigmentary changes Acne • Deep Peels

Phenol Comparison with TCA Double penetration/depth Double neocollagen formation Longer recovery time More risk of pigmentary changes Mechanism of action Carbolic acid Protoplasmic toxin Disrupts cell walls and denatures proteins Rapid dermal absorption Penetrates into the upper reticular dermis Half-life 3.5 hours Most secreted unchanged in

urine (eliminated by kidneys) Can conjugate with glucuronic and sulfuric acids within 1 to 2 days May be combined with Croton oil: skin irritant Soap Glycerin or Septisol (Steris Corp., Mentor, OH) Acts as surfactant to lower surface tension Acts as emulsifier to aid in penetration H20 Side effects Cardiac toxicity Monitor with

electrocardiography (EKG) for arrhythmias Stop application until normal sinus rhythm IV hydration to promote excretion Anti-arhythmia medication Skin depigmentation Bleaching Baker–Gordon formula Peel in 15 to 20 minute intervals Effects: neocollagen formation, scarring, skin tightening Composition 3 mL phenol 2 mL tap H2O 8 drops Septisol

3 drops croton oil

Pretreatment • Antivirals All patients should receive pretreatment History of herpes simplex virus (HSV) No pretreatment: 50% herpes outbreak Pretreatment: 8% herpes outbreak No history of HSV No pretreatment: 6.6% herpes outbreak • Retin-A (tretinoin) Epidermal hyperproliferation

Decreases thickness of epidermis Increases peel permeability

Skin Lighteners • Hydroquinone Most commonly used bleaching agent for management of hyperpigmentation (i.e., melasma) Tyrosinase inhibitor: blocks conversion of dopa to melanin Often used in conjunction with chemical peels • Kojic acid: tyrosinase inhibitor

Dermabrasion • Indications

Perioral wrinkles, acne, scars Avoid around the eyes • Mechanism Motor-driven diamond fraise or steel brush sands down entire epidermis and upper/mid dermis Reepithelialization from residual hair follicles, sebaceous glands, and sweat ducts Less bleaching than phenol Good for darker complexions

Suggested Reading Baker TJ, Stuzin JM, Baker TM. Facial Skin Resurfacing. St. Louis, MO: Quality Medical Publishing; 1998 Herbig K, Trussler AP, Khosla RK,

Rohrich RJ. Combination Jessner's solution and trichloroacetic acid chemical peel: technique and outcomes. Plast Reconstr Surg 2009;124(3):955–964 Nguyen AT, Ahmad J, Fagien S, Rohrich RJ. Cosmetic medicine: facial resurfacing and injectables. Plast Reconstr Surg 2012;129(1):142e– 153e Perrotti JA. Cutaneous resurfacing: chemical peeling, dermabrasion, and laser resurfacing. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:459–467

Rubin MG. Manual of Chemical Peels: Superficial and Medium Depth. Philadelphia, PA: Lippincott Williams & Wilkins; 1995

36 Fillers and Injectables Reviewed by Ivona Percec

Fillers (Table 36.1) • Hyaluronic acid fillers Filler formulation used today is trademarked as NASHA (nonanimal stabilized hyaluronic acid) Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Juvederm Voluma, and Belotero Indications: deep rhytids, nasolabial folds, marionette lines, scars, lips, cheeks, and fine wrinkles

• Radiesse Microspheres of biodegradable calcium hydroxylapatite suspended in an aqueous gel carrier, form scaffold for tissue infiltration Visible on X-ray • Sculptra Poly-L-lactic acid (PLLA), similar to Vicryl Biostimulator Indications HIV lipoatrophy: inject SQ in cheeks, subperiosteal in temples Cosmetic: helps correct nasolabial wrinkles and folds Requires injections every 4 to 6 weeks for several months (results

not immediate) • ArteFill Permanent filler 20% polymethylmethacrylate (PMMA), 80% bovine collagen Requires pretesting Approved for use in nasolabial folds Table 36.1 Filler classification

Type

Duration

Examples

Temporary

Hyaluronic 6 months to 2 acid fillers, years Radiesse, Sculptra

Permanent

ArteFill

Volumizers

Hyaluronic Up to 1 year acid fillers, Radiesse

Up to 2 years, effect increases over time Biostimulators because Sculptra attract water and stimulate collagen production

Fat Grafting • Indications

Contour irregularities Cosmetic deformities Possible stem-cell effect: scar therapy, correction of deformities secondary to radiation • Technique Aspiration Process lipoaspirate Balanced centrifugation Gravity sedimentation: takes longer than centrifuge technique Telfa processing Washing Injection Inject from multiple sites Fanning in different planes Average survival of fat grafts: 50%

take at 3 months May require multiple attempts to correct deformity

Filler Complications • Under-correction: most common complaint (not a complication) • Over-correction • Visible irregularities • Donor site problems (fat grafting donor site) • Migration of fat • Infection • Introduction of a foreign body • Ischemia Arterial injection can cause skin

necrosis Treat with immediate aspiration when see blanching May require hyperbaric oxygen therapy, hyaluronidase (if hyaluronic acid filler), steroid injections, surgical debridement and antibiotics Prevent by using small needles, inject as withdraw, inject minimum quantity needed to achieve result • Blindness Rare complication From fat embolism into ophthalmic artery Avoid by retrograde injection and use of blunt cannula • Venous congestion

Excess injection can cause venous congestion Delayed presentation not amenable to immediate aspiration Treat with warm compresses, nitroglycerin paste, hyaluronidase injection for hyaluronic acid fillers, may require operative debridement • Palpable nodules Excess injection under thin superficial skin (i.e., eyelids) Dissolution unless injected Radiesse, Sculptra, or ArteFill May require steroid injection, incision and drainage instead of observation because not in a vascular layer where it will be

easily metabolized Prevent by injecting subperiosteally in tear trough deformity

Neuromodulators • BOTOX (onabotulinumtoxinA) Mechanism: inhibits acetylcholine release at neuromuscular junction FDA-approved uses Glabellar lines Crow's feet: lateral orbicularis oculis Hyperhidrosis Cervical dystonia Migraines

Off-label uses Forehead lines: frontalis muscle Perioral, mentalis, neck regions, other sites Technique On average 20U injected to 5 brow depressors: procerus (transverse bunny line wrinkles), corrugators supercilii (vertical lines), and depressor supercilii Inject approximately 2.5U per site into muscle belly Paralysis occurs within 3 to 7 days and lasts 3 to 4 months Effects are potentiated by calcium channel blockers, aminoglycosides, and

penicillamine Side effect of postinjection ptosis Most common cause is secondary to primary treatment of glabellar region with injection of corrugators supercilii injection and diffusion to levator Less likely to affect Muller's muscle deep to levator Frontalis muscle injection when brow elevator compensating for ptosis may unveil ptosis Do not massage because can cause diffusion Treat with alpha adrenergic sympatheticomimetic (Iodipine) to stimulate Muller muscle

(smooth muscle) to elevate eyelid 2 mm • Dysport (abobotulinumtoxinA) FDA approved for glabellar lines • XEOMIN (incobotulinumtoxinA) FDA approved for glabellar lines Does not need to be refrigerated

Suggested Reading BOTOX Cosmetic [package insert]. Irvine, CA: Allergan, Inc.; 2011 Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 2004;114(6, Suppl):1S–22S

Coleman S. Structural Fat Grafting. St. Louis, MO: Quality Medical Publishers 2004 Coleman S. Structural fat grafting. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:480–485 Kane MA. Botulinum toxin. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:475–479 Klein AW. Filler materials. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic

Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:468–474 Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg 2006;118(3, Suppl):92S–107S Nguyen AT, Ahmad J, Fagien S, Rohrich RJ. Cosmetic medicine: facial resurfacing and injectables. Plast Reconstr Surg 2012;129(1):142e– 153e Nguyen AT, Kenkel JM. Injectables. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2010:1–31. Selected Readings in Plastic Surgery; vol 10, issue 28

37 Hair Transplantation Reviewed by Alfonso Barrera

Hair Anatomy (Fig. 37.1) • Hair follicle In subcutaneous (SQ) tissue Matrix cells proliferate to produce hair and keratin • Cuticle: outer layer of hard keratin anchors to skin by interlocking scales • Shaft Visible portion of hair Composed of hard, dead keratin protein Three layers (inner cortex, middle

medulla, outer cuticle) Medulla and cortex contain pigment cells that give hair its color

Fig. 37.1 Hair anatomy.

• Infundibulum Upper portion of hair follicle above sebaceous duct Lined by surface epithelium • Inner and outer root sheath: extends from lower end of hair bulb to entrance of sebaceous gland duct • Basal layer of outer root sheath: contains inactive pigmented amelanotic melanocytes, which produce melanin after injury by peel or dermabrasion and migrate to epidermis • Hair shape Circular cross section gives rise to straight hair

Elliptical cross section gives rise to curly hair

Phases of Hair Growth (Table 37.1) Table 37.1 Hair growth phases

Phase

Anagen

Description Active growth, lasts 1000 days in men, 2-5 years longer in women, 85-90% hair in this phase, grows 1 cm/month

Catagen

Telogen

Degradation/transitional, lasts weeks, bulb atrophies Resting, 10% hair in this phase, 50–100 hairs lost per day

Male Pattern Baldness • Characteristics X-linked dominant Increased telogen phase, decreased anagen phase Increased 5-alpha reductase (converts testosterone to more potent dihydrotestosterone) Normal serum testosterone

Treatment with finasteride (Propecia, Merck, Whitehouse Station, NJ), a 5-alpha reductase inhibitor Norwood–Hamilton classification (Fig. 37.2)

Female Alopecia • Characteristics Least amenable to surgery: if chronic telogen effluvium (persistent hair shedding/telogen) More amenable to surgery: global diffuse thinning with discrete areas of alopecia, scar alopecia, frontal temporal alopecia Ludwig classification of female

alopecia (Fig. 37.3)

Hair Transplantation Techniques •

Follicular unit extraction (FUE)/punch grafting Large follicular units (> 4 follicles/unit) Unnatural doll-appearance • Micrografting Transfer micrografts (1 to 2 follicles) or minigrafts (3 to 4 follicles) with dermal elements (neurovascular bundle, sebaceous glands, piloerectile muscle) Follow angle of hair, put singles

along front Do not do in patients prone to form keloids Donor site harvest from occipital scalp if patient has thick hair

Fig. 37.2 Standards for classification of most common types of male pattern baldness. (From Buchwach KA, Konior RJ. Contemporary Hair Transplant. New York: Thieme; 1997. Used with permission.)

Fig. 37.3 Ludwig classification of female alopecia.

• Hair regrowth timeline Growth 1 month (false growth)

Hair loss 2 to 3 months (telogen phase) Normal hair growth at rate 1 cm/month Will likely require multiple procedures Wait at least 4 months before regraft

Causes of Baldness • Androgenic alopecia (thinning) Most common cause of male and female pattern baldness May be related to increased activity of 5-alpha reductase Treatment Finasteride (Propecia)

Minoxidil (Rogaine, McNeilPPC, Inc., Fort Washington, PA) Topical or oral Previously used as vasodilator to treat hypertension Potential mechanism of action: vasodilator to improve blood flow to follicles • Alopecia areata T cell–mediated autoimmune condition in genetically predisposed Treatment: Kenalog steroid injections (Bristol-Myers Squibb, Princeton, NJ) every 4 to 6 weeks leads to some regrowth Responds poorly if rapidly progressive, extensive, long-

standing Spontaneous remission possible in patients with < 40% scalp affected • Other causes of baldness Cicatricial: scarring Telogen effluvium: excess time in telogen phase Traction alopecia: pulling from barber Poor nutrition Medications: for gout, arthritis, depression, hypertension Disease: diabetes, lupus Medical treatments: chemotherapy and radiation therapy Hormonal changes: polycystic ovarian syndrome

Hair treatments Scalp infection: ringworm Trichotillomania: hair-pulling disorder

Scalp Flaps • Scalp flaps: historic interest, not frequently performed, lead to scarring, have recurrent baldness • Scalp reduction: for male pattern baldness unresponsive to medication (Fig. 37.4) • Bilateral advancement transposition (BAT) flap: two-stage, expander, hair grows anteriorly (Fig. 37.5) • Temporoparieto-occipital (Juri) flap (Fig. 37.6)

For frontal or frontoparietal hair loss Hair grows posteriorly, exposing anterior frontal scar Staged procedure with delay phenomenon • Expansion For burn scars Can expand scalp and perform rotational flaps Not a cosmetic procedure Micrografts take in scar tissue, though not as readily as in nonscarred areas Useful in patients with approximately 50% of scalp affected

Fig. 37.4 Scalp reduction for male pattern baldness.

Fig. 37.5 Bilateral advancement transposition (BAT) flap.

Fig. 37.6 Temporoparieto-occipital (Juri) flap.

• Orticochea flap: three-flap technique • Partial or total scalp loss Free flap coverage and wig No scalp transplants: not lifethreatening condition worth risks of chronic immunosuppression

Suggested Reading Janis JE, Leedy JE. Lip, Cheek, and Scalp Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2006:1–49. Selected Readings in Plastic Surgery; vol 10, issue 13 Reed ML. Hair transplantation. In:

Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:562–571 Vogel JE, Jimenez F, Cole J, et al. Hair Restoration Surgery: the State of the Art. Aesthet Surg J. 2013, 33(1): 128–151

38 Lasers Reviewed by David W. Low

Introduction • LASER = light amplification by stimulated emission of radiation • An energy source is used to excite electrons of a gas, liquid, or solid lasing medium within a laser tube (Table 38.1) • As the electrons return to their resting state, photons are released, which in turn can strike other excited electrons, causing the release of even more photons

Table 38.1 Lasers

Type

KTP

Wavelength Use (nm)

532

Pulsed dye (tunable dyes 585, 595 are no longer (most are

Superficial red capillary vessels (telangiectasias) on face light skin tones Vascular lesions with light and dark skin tones (port wine stains, macular stains, telangiectasias, spider

used)

now 595)

Intense 510–1200 pulsed light

angiomas, cherry angiomas, spider veins, hyperemic scars)

Noncoherent with broad spectrum polychromatic energy, useful for telangiectasias and dyschromias (benign melanocytic pigmentation)

Q-switched ruby 694

Black, purple, and violet tattoos, nevus of Ota, hair

Q-switched 755 alexandrite

Black, blue, and green tattoos, hair

Diode

Similar to alexandrite laser

810

Nd:YAG (neodymium: yttrium1,064 aluminumgarnet)

Deeper blue vessels on leg; hair reduction, collagen stimulation

Er:YAG (erbium:

Ablative, high affinity for

yttriumaluminumgarnet)

Carbon dioxide (CO2)

2,940

10,600

water, for skin resurfacing, lymphatic malformations Ablative, high affinity for water, for skin resurfacing, cutting, coagulation, actinic keratitis, and leukoplakia, and benign skin lesions such as epidermal nevi, warts, angiofibromas, lymphatic malformations, cutaneous

lymphatic vesicles, and angiokeratomas

• The light produced is intense, in phase, and parallel (coherent) • Selective photothermolysis: tissue injury based on wavelength specific light absorption by a target chromophore (Table 38.2) • Lasers generate heat that dissipates by conduction (thermal relaxation) • The amount of heat generated is a function of laser energy (joules), laser power (watts, or joules/sec), and/or power density (fluence, or joules/cm2)

Skin Resurfacing • High-energy lasers target water in all living cells, including skin Erbium and CO2 For acne scars, sun damage, fine periocular, perioral, and facial rhytides Uses light energy rather than dermabrasion or chemical peels to vaporize epidermis and superficial dermis layers of the skin • Erbium laser May be gentler skin resurfacing agent than CO2 because it is absorbed 10 times more readily by water and therefore penetrates less deeply (less hypopigmentation,

erythema, faster healing, faster healing, better for Fitzpatrick types V and VI) Produces a transudative wound more than CO2 laser because the depth of injury is more shallow Causes less photomechanical injury than CO2 laser resulting in less collateral damage and less collagen contraction Table 38.2 Chromophores

Laser

Chromophore

CO2 and erbium

Water; erbium has less thermal diffusion to

surrounding tissue than CO2 No specific chromophore, so it penetrates more Nd:YAG deeply into tissues, (neodymium:yttrium- but better absorbed aluminum-garnet) by dark pigments (blood vessels, red blood cells, collagen, melanin)

KTP

Oxyhemoglobin, melanin (cannot use on dark-skinned people for telangiectasia removal)

Pulsed yellow dye

Intense pulsed light

Oxyhemoglobin (capillary malformations, hemangiomas, telangiectasias, spider angiomas, spider veins, cherry angiomas, hyperemic scars, warts) Oxyhemoglobin (telangiectasias), and melanin (benign superficial or deeper pigmentation)

Melanin, dark tattoo Alexandrite and ruby pigmentation (not red)

• CO2 laser–ablative handpieces May have better effect on deep coarse wrinkles but may cause more hypopigmentation, especially in Fitzpatrick types V and VI Will tighten skin but not eliminate gross skin excess or significant soft tissue descent (need facelift) • Resurfacing treatment schedule First pass: vaporized epidermis, exposing the pink papillary dermis Subsequent passes: pink papillary dermis gives way to the yellow reticular dermis, stop now because further penetration will result in scarring

Terminate treatment: rhytides gone or yellow coloration • Fractional CO2 laser skin resurfacing Handpiece vaporizes small tunnels into the dermis separated by intact skin, resulting in faster healing and less erythema Results may be less effective than ablative laser skin resurfacing, but patients may prefer faster healing and shorter recovery • Facial resurfacing complications Hyperpigmentation and erythema (most common short-term) Hypopigmentation (most common long-term) Hypertrophic scarring (excessive

thermal damage or penetration into the reticular layer) • Ice pick acne Small, deep, jagged edges, steep sides Requires excision of deep crevices, not laser

Fitzpatrick Skin Classification (Table 38.3) • Stratifies patients according to potential for pigmentary changes (hyperpigmentation) following chemical peels and laser skin resurfacing • Best candidates for skin resurfacing have skin types I through III

• Skin type IV requires pre- and posttreatment with retinoic acid, hydroquinone, and sunscreens • Skin types V and VI are not as amenable to resurfacing Table 38.3 Fitzpatrick skin classification

Fitzpatrick Color skin type

Characteristics

White

Always burns/never tans

White

Usually burns/tans with difficulty

Sometimes

III

White

mildly burns/usually tans

Medium brown

Rarely burns/tans easily

Dark brown

Rarely burns/tans very easily

Black

Never burns/tans very easily

Pretreatments for Skin Resurfacing • Retin-A, sunscreen, glycolic acid,

and hydroquinone Used but little evidence that they prevent postinflammatory hyperpigmentation Hydroquinone is a tyrosine kinase inhibitor and may lightly bleach the skin, preventing hyperpigmentation Hydroquinone can be used for hyperpigmentation treatment Do not use Accutane (isotretinoin) within 18 months, because prevents reepithelialization and may lead to scarring • Antiviral prophylaxis All resurfacing procedures (lasers, dermabrasion, peels) have potential for herpes simplex virus

(HSV) vesicular rash, which spreads rapidly and may scar Prophylaxis with oral acyclovir (Zovirax), famciclovir (Famvir, Novartis, New York, NY), or valacyclovir (Valtrex, GlaxoSmithKline, Philadelphia, PA) for 2 days preop and 7 to 10 days postop • If herpes outbreak occurs Do Tzanck smear and send viral, fungal, and bacterial cultures Increase treatment dose of acyclovir to 800 mg 5×/day If systemic infection occurs (disseminated cutaneous lesions, shortness of breath, fever, malaise, headache, neurological changes):

admit to hospital for intravenous antiviral and antibiotic therapy • Photodynamic therapy-5aminolevulinic acid (ALA) Topical medication converted into protoporphyrin IX Releases cytotoxic radicals to treat cutaneous lesions such as actinic keratoses Activated by blue light (400 to 450 nm), pulsed-dye systems (585 to 595 nm), and photorejuvenation systems (560 to 1,200 nm) Patients are sensitive to light and must remain indoors for 2 days Erbium, phenol, and tretinoin do not activate it

Tattoos • Types of tattoos Professional tattoos: leave single depth of multiple colors, often extend deep within the dermis, larger particles (> 50 µm) require more sessions Amateur tattoos: more superficial, irregular depth, smaller pigment particles (< 5 µm) require fewer sessions Cosmetic Traumatic: (e.g., road tattoo, gunpowder tattoo [note: lasers can ignite gunpowder in the skin]) • Tattoo removal (Table 38.4) One laser not sufficient for

multiple colors Q-switched (quality switched) lasers deposit energy rapidly, causing rupture of cells containing tattoo pigment, and trigger phagocytosis and packaging of tattoo fragments for lymphatic drainage Table 38.4 Tattoo removal

Method

Use

Superficial, bright Q-switched tattoos (red, yellow, neodymium:yttriumbrown, orange) aluminum-garnet Leaves purpura for (Nd:YAG) (532 nm) 7–10 days

Q-switched Nd:YAG Darker, deeper (1,064 nm) tattoos (blue, black) Pulsed dye laser (510 nm)

Superficial, bright tattoos

Q-switched Black, blue, green alexandrite (755 nm) tattoos Q-switched ruby (694 nm)

Black, violet, purple tattoos

Salabrasion

Rubbing crystals over unanesthetized skin with moist gauze resulting in redness and scarring Traumatic tattoo in epidermis.

Dermabrasion

Unpredictable and can lead to scarring Q-switched ruby laser, Nd:YAG laser also used for traumatic tattoos

Q-switched alexandrite and ruby lasers are absorbed by melanin and leave transient hypopigmentation or permanent depigmentation, particularly in Fitzpatrick type V and VI skin types • Tattoo dyes Test laser on skin first, because if tattoo contains iron in the dye, lasers convert ferrous oxide to ferric oxide and can instantly turn

the skin black (hyperpigmentation) May contain titanium oxide, which is less common than iron but can also turn black with lasers Mercury, cobalt, and chromium are contained in tattoos but do not turn black Mercury is used for red-based tattoo inks and on dissemination may cause allergic reaction

Vascular Anomalies (Table 38.5) • Selective photothermolysis Lasers target the oxyhemoglobin in erythrocytes in blood vessels

Pulsed lasers cause vascular rupture and extravasation of blood (purpura) with limited extravascular damage (selective photothermolysis) Continuous wave lasers exceed the thermal relaxation time of blood vessels, causing more thermal damage and potential dermal scarring Table 38.5 Vascular anomaly laser treatment

Laser

Vascular anomaly target Telangiectasias, cherry angiomas,

KTP (532 nm)

Pulsed-dye laser (585, 595 nm)

pyogenic granulomas, venous malformations, but not recommended for port wine lesions due to increased risk of scarring, melanin absorption limits use in darker skin tones Best laser for port wine lesions; also used for telangiectasias, spider angiomas, cherry angiomas, spider veins, hyperemic scars, early hemangiomas, and regressed

hemangiomas with residual ectatic vessels; can use with light and dark skin (use lower fluence with dark skin)

Argon-pumped tunable dye (488, 515 nm)

First useful laser for port wine stains, absorbed by both oxyhemoglobin and melanin; continuous rather than pulsed laser energy can cause increased thermal damage with higher incidences of hypertrophic scarring, textural changes, dyspigmentation,

especially in children Telangiectasias and Copper vapour laser ectatic port wine (578 nm) stains Erbium laser (2,910 Lymphatic nm) malformations

Carbon dioxide (10,600 nm)

Lymphatic malformations, angiofibromas, also used to debulk subglottic hemangiomas (do not laser circumferential lesion because can lead to stenosis)

Laser Hair Removal • Mechanism of action Targets melanin in hair follicle during anagen (active hair growth phase) Sends hair follicles to telogen (resting phase) Must have multiple sessions to capture hair in anagen Not useful in fair-haired patients who have low levels of melanin in the hair follicles Best candidates have fair skin and dark hair, resulting in more selective hair destruction

• Laser options Q-switched neodymium:yttriumaluminum-garnet (Nd:YAG) (1,065 nm) Long-pulse ruby laser (694 nm) Alexandrite laser (755 nm) Intense pulsed light (IPL) • Complications Erythema in light-skinned patients Pigmentation changes in darkerskinned patients because targets melanin

Suggested Reading Achauer BM. Lasers in plastic surgery: current practice. Plast Reconstr Surg 1997;99(5):1442–1450

Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutaneous laser resurfacing. Plast Reconstr Surg 2002;109(1):308–316, discussion 317–318 Apfelberg DB; American Society for Aesthetic Plastic Surgery. American Society of Plastic and Reconstructive Surgeons. Summary of the 1997 ASAPS/ASPRS Laser Task Force Survey on laser resurfacing and laser blepharoplasty. Plast Reconstr Surg 1998;101(2):511–518 Burns JL. Lasers in Plastic Surgery. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2008:1–37.

Selected Readings in Plastic Surgery; vol 10, issue 23 Low DW. Lasers in plastic surgery. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:169–176 Perrotti JA. Cutaneous resurfacing: chemical peeling, dermabrasion, and laser resurfacing. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:459–467 Prado A, Andrades P, Danilla S, et al. Full-face carbon dioxide laser

resurfacing: a 10-year follow-up descriptive study. Plast Reconstr Surg 2008;121(3):983–993

Section IV Hand and Lower Extremity Surgery

39 Congenital Hand Reviewed by Phuong D. Nguyen

Embryology • Limb and hand development Limb bud forms at 3 weeks Hand recognizable by fifth week Fingers recognizable by eighth week (digital separation via apoptosis by 51 days) Apical ectodermal ridge (AER): proximal to distal axis, Wolffian ridge secretes fibroblast growth factor (FGF) Zone of polarizing activity (ZPA): anterior to posterior axis, secretes

sonic hedgehog, associated anomalies are mirror hand, ulnar duplication, and dimelia Wnt-7a: dorsal to ventral axis, associated with palmar duplication (double ventral phenotype) • Carpal bone development Capitate is the first seen on X-ray Birth to 6 months: capitate and hamate 6 months to 4 years: triquetrum 6 months to 9 years: lunate 1 to 10 years: trapezium 2 to 5 years: trapezoid 2 to 9 years: scaphoid 8 to 12 years; pisiform (last seen)

Hand Anomalies • International Federation of Societies for Surgery of the Hand (IFSSH) Classification of Congenital Hand Anomalies I. Failure formation (arrested development) a. Transverse: amelia, distal amputations b. Longitudinal: phocomelia, radial dysplasia, cleft hand II. Failure of differentiation (separation of parts): synostosis, syndactyly, contracture, trigger finger, camptodactyly, clinodactyly III. Duplication: polydactyly, triphalangeal thumb

IV. Overgrowth: macrodactyly V. Undergrowth: hypoplastic thumb brachydactyly VI. Constriction band syndrome VII. Generalized skeletal deformity: dystrophic dwarfism

Top 4 Most Common Anomalies Polydactyly • Incidence: 1/1000

Fig. 39.1 Wassel classification.

thumb

duplication

• Preaxial (thumb duplication) is most

common in whites • Postaxial (small finger duplication) is most common in African Americans and Asians Type A: broad stalk, associated with anomalies Type B: thin, narrow stalk • Wassel thumb duplication classification (Fig. 39.1 and Table 39.1) Table 39.1 Wassel thumb duplication classification

Type

Characteristic Bifid distal

No. bones affected 1

phalanx 2

Duplicated distal phalanx

Bifid proximal 3 phalanx

Most common, duplicated 4 proximal phalanx

Bifid metacarpal

Duplicated metacarpal

Delta

Triphalangism phalanx (delta phalanx also seen with clinodactyly)

Note: Remember classification based on number of bones affected.

• Treatment Must evaluate flexor/extensor integrity prior to digit deletion Usually excise radial digit (weakest), preserve ulnar thumb Maintain ulnar collateral ligament from ulnar duplicate for pinch May also be reconstructed with abductor pollicis brevis, otherwise you get a Z-deformity from pulling proximal phalanx

ulnarly, distal phalanx radially

Syndactyly (Fig. 39.2) • Conjoined fingers due to failure of differentiation Incidence: 1/2000 Male:female = 2:1 • Definitions Complete: webbing to fingertips Incomplete: webbing not to fingertips Simple: webbing soft tissue Complex: fusion of bones, joints, and nails Complicated: disorganized bones • Most common web space affected:

third (50% cases) • Second most common web space: fourth (30% of cases)

Fig. 39.2 Complex complete third web-space syndactyly with Brunner incision and dorsal web flap markings.

• Surgery Perform between 6 months and 2 years of age Operate on border digits first (6 to 9 months) because of differential growth, risk of tethering, and abnormal growth • Goals Complete separation bones and soft tissue Preservation both nerves and blood supply Develop adequate web space with flaps inset without tension

•

• • • •

Interdigitating flap over proximal interphalangeal (PIP) joint Development of distal phalanges and fingertips Perforated full-thickness skin graft (FTSG) for digital resurfacing for contracture prevention Only one side of a digit should be separated at a time for vascular safety Multiple Brunner incisions (local flaps) Dorsal web flap tucked two-thirds from metacarpal head to PIP joint Triangular flaps to cover PIP joints and break up grafted areas Full-thickness skin grafts to fill remaining defects

• Long-arm cast

Trigger Thumb • Characteristics Incidence: 1 to 6/2,000 Thumb flexed at interphalangeal (IP) joint If flexed at MCP, known as “clasped thumb” 30% resolve spontaneously by 3 years old Notta nodule: thickening of flexor pollicis longus (FPL) tendon • Treatment Observe until 3 years old, then do A1 pulley release Do not inject steroids because

needs MAC anesthesia Do not resect, aspirate, or biopsy node because it is benign

Constriction (Amniotic) Band Syndrome • Incidence: 1/15,000 • Factors associated Low birth weight Prematurity Young multigravida mother Sporadic • Treatment If less severe: observe, delayed release If severe, threatened limb loss:

surgical emergency; Z-plasty, two stages if circumferential Amputate only if failed attempts at salvage Do second toe to hand if only thumb affected, because need opposition

Other Hand Anomalies Acrocephalosyndactyly (Apert syndrome) • Characteristics Fibroblastic growth factor receptor anomaly (FGFR2 gene) Bilateral syndactyly–index,

middle, ring fingers most involved Type I: Spade (obstetrician's) hand–four fingers fused, thumb free Type II: Spoon (mitten) hand– thumb joined to thumb mass Type III: Hoof (rosebud) hand– osseous or cartilaginous fusion of thumb to finger mass • Treatment Surgical release border digits (1.5 years old) Digit reconstruction

Poland syndrome • Characteristics Unilateral chest wall hypoplasia–

absent sternocostal head of pectoralis major is most common anomaly Hypoplasia of hand and forearm Brachysyndactyly and shortening of middle fingers Etiology thought to be subclavian artery hypoplasia • Treatment Syndactyly release

Arthrogryposis • Flexion contractures multiple digits

Madelung deformity (Fig. 39.3)

• Characteristics Congenital dyschondrosis of distal radial physis Noticed during childhood and adolescence Increased radial inclination Ulna positive variance Short radius Carpal bones between radius and ulna Palmar subluxation of carpus • Treatment Observe if mild Darrach procedure (ulna shortening)

Thumb in palm deformity

• Seen in cerebral palsy patients • House classification

Fig. 39.3 Madelung deformity.

Adduction contracture, most common secondary to spasticity of adductor and first dorsal interosseous II. Type I plus flexion deformity of metacarpophalangeal (MCP) joint secondary to spasticity of FPL III. Hyperextension MCP joint, spastic extensor pollicis brevis IV. Type I and FPL contraction • Treatment Release of spastic muscles Stabilize joint

Cleft hand (ectrodactyly)

(Table 39.2) • Characteristics Partial or total absence of fingers in central hand Split hand/split foot malformation (SHFM) “Lobster claw hand” Associated with EEC syndrome: ectrodactyly, ectodermal dysplasia, cleft lip and palate Typical and atypical Table 39.2 Cleft hand (ectrodactyly)

Shape of

Typical

Atypical

V-shaped

U-shaped

deformity

missing LF ray

missing LF, IF, RF rays

Laterality

Bilateral

Unilateral

Inheritance

Autosomal dominant

Sporadic

Associated anomalies

Cleft foot, SHFM1 (split hand foot gene on chrom 7q21), EEC Poland syndrome syndrome (ectrodactyly, ectodermal dysplasia, cleft lip/palate)

Brachydactyly • Characteristics: short fingers • Treatment with lengthening procedures Nonvascularized toe to phalanx grafting Distraction

Macrodactyly • Characteristics Overgrowth of hand and fingers Secondary to lipomatous hamartoma within digital nerves • Treatment Staged debulking: skin and

subcutaneous resection Neurolysis, resection Epiphysiodesis: premature closure of growth plates Osteotomies and shortening procedures Amputation Timing: when fingers are at adult length

Camptodactyly • Characteristics Congenital flexion deformity, “bent finger” of small finger (SF) PIP joint in palmar-dorsal plane Related to abnormal insertion of lumbrical on flexor digitorum

superficialis (FDS) Most cases within first year of life Asymptomatic, painless • Treatment Observation and splinting for 6 to 12 months (majority of cases) Surgery last resort because of unsatisfactory results, stiffness, residual flexion deformity May operate if > 30 degree deformity Release accessory collateral ligament to volar plate Transfer lumbricals to extensor central slip Stabilization of MCP joint to prevent hyperextension (i.e.,

Zancolli lasso procedure, volar plate tightening) Full-thickness skin graft to volar deficient skin

Clinodactyly • Characteristics Congenital deviation in radialulnar plane, most commonly radial deviation of SF middle phalanx Delta phalanx: trapezoidal bone creates deviation of interphalangeal joint Associated with Down syndrome • Treatment: Excision and wedge osteotomy at 10 to 12 years old

Radial limb syndromes (Table 39.3) • Characteristics Insult to apical ectodermal ridge during fourth to seventh week Thumb and radius absent/hypoplastic, radial artery absent Other radial limb syndromes Nager, myositis ossificans, GI (imperforate anus), Carpenter, Apert, Rubinstein–Taybi (broad thumb, short stature), trisomy 18, hand-foot-uterus, Cornelia de Lange (low-birth weight, developmental delay, clinodactyly, small hands)

Thumb hypoplasia (Table 39.4) • Characteristics Blauth classification Incidence: 1/30,000 to 100,000 80% associated anomalies (Table 39.3) • Timing of surgery 1 year old before bad habit forms of side-to-side pinch between fingers to compensate Not before 1 year of age because need blood vessel walls to thicken and want cardiopulmonary system to be better developed Table 39.3 Radial limb syndromes

Syndrome

Characteristics

Holt–Oram

Cardiac anomalies, autosomal dominant mutation, absent thumb, radial club hand

Fanconi anemia

Autosomal recessive mutation DNA repair genes, lethal pancytopenia, diagnose with mitomycin C, hypoplastic thumb, absent radii, café au lait spots, short stature, genital abnormalities,

microcephaly, die 20–30 years old

TAR

Thrombocytopenia– absent radii, neonatal thrombocytopenia (seen later in Fanconi), no pancytopenia

Roberts

Tetraphocomelia (similar to thalidomide-induced phocomelia), brain and craniofacial abnormalities Vertebral, anal atresia, cardiac,

VACTERLS

tracheo-esophageal fistula, renal/radial anomalies, limb anomalies, single umbilical artery If total absence of radius, centralize ulna If thumb absent, do index finger pollicization If ulna > 35 degree bowing, do corrective closing wedge osteotomy

Table 39.4 Blauth's classification of thumb hypoplasia

Type

Characteristic Treatment

Small thumb with all components

No treatment

Small thumb, hypoplasia thenar muscles, ulnar collateral ligament instability

Opponensplasty (Huber transfer), thumb lengthening with web space deepening

IIIA

Intact carpometacarpal joint (CMC), Tendon type II, extrinsic transfers muscle abnormalities

Pollicization, ablation remaining thumb

IIIB

Absent CMC, instability

Pouce flottant, no metacarpal Same as IIIB

Complete absence of thumb

Pollicization

Pollicization • Transfer of index finger to thumb position • Steps

Ligate radial branch to long finger Divide finger A1 and A2 pulleys Extensor tendons mobilized by dividing juncture Shorten metacarpal by division (shaft removed) Index finger rotated 150 degrees into pronation, 40 degrees in abduction, and 70 degrees to palm • Index finger tendon new roles First dorsal interosseous reattached to radial lateral band to be abductor pollicis brevis (APB) First palmar interosseous becomes adductor pollicis (AP) Flexor digitorum profundus (FDP) becomes FPL

Flexor digitorum superficialis (FDS) becomes flexor pollicis brevis (FPB) Extensor indicis proprius (EIP) becomes extensor pollicis longus (EPL) Extensor digitorum communis (EDC) becomes abductor pollicis longus (APL)

Symphalangism • Characteristics Fused PIP joint Small finger is most common finger affected • Treatment: arthroplasty into functional position

Möbius syndrome • Cranial nerve VI, VII palsy • Cannot move facial muscles or eyes laterally • Associated with oligodactyly (missing fingers)

Kirner deformity • Palmar radial curving of small finger

Suggested Reading Choi M, Sharma S, Louie O. Congenital hand anomalies. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott

Williams & Wilkins; 2006:856–863 Desai HJ, Bidic SM. Hand: Fractures and Dislocations, the Wrist, and Congenital Anomalies. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2011:1–68. Selected Readings in Plastic Surgery; vol 10, issue 29 De Smet L; IFSSH. Classification for Congenital Anomalies of the Hand: the IFSSH classification and the JSSH modification. Genet Couns. 13(3): 331–338, 2002 Havlik RJ. Common Congenital Hand Anomalies. In: Thorne CH, Chung KC, Gosain AK, et al, eds. Grabb and Smith's Plastic Surgery. 7th ed. Philadelphia: Lippincott Williams &

Wilkins; 2013: 890–899 Oda T, Pushman AG, Chung KC. Treatment of common congenital hand conditions. Plast Reconstr Surg 2010;126(3):121e–133e Trumble TE. Congenital hand deformities. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:579–601 Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res 1969;64(64):175–193

40 Fingertip Amputations Reviewed by Fernando A. Herrera Jr.

Fingertip Anatomy (Fig. 40.1) • Nail plate and nailbed Germinal matrix Portion of nailbed proximal to lunula Produces 90% of the nail plate Lunula White portion of nailbed between sterile and germinal matrix beneath the eponychium Sterile matrix

Portion of nailbed distal to lunula Produces 10% of the nail plate Responsible for adherence of the nail plate to the nailbed Eponychium Cuticle Covers the proximal nail plate Overlies the lunula Hyponychium Fingertip keratinized soft tissue located where the sterile matrix and fingertip skin meet • Bone Distal phalanx • Tendons Flexor digitorum profundus (FDP)

tendon or flexor pollicis longus (FPL) tendon inserts Terminal tendon of digital extensor tendon or extensor pollicis longus (EPL) inserts

Fig. 40.1 Fingertip anatomy.

Nailbed Injuries

• Principles If significant crush injury or laceration, remove nail plate to evaluate nailbed Repair nailbed directly if laceration present Minimal debridement Repair with 7-0 chromic sutures Suspect distal phalanx fractures and always obtain X-rays Sterile matrix injuries are easier to repair primarily than germinal matrix injuries Nailbed injuries are grafted if they cannot be repaired directly or occupy > 50% of nailbed If chronic injury remove scar and attempt reapproximation or skin

graft if cannot reapproximate After evaluation replace nail plate to stent eponychial fold and avoid scar • Sterile matrix injury Treatment Primary repair if possible Sterile matrix split thickness graft (STG) Donor site for STG No resultant nail plate deformity at donor site if thin graft harvested Same digit or uninjured adjacent nailbed First or second toe Multidigit injury spare parts

• Germinal matrix injury Treatment Difficult to treat by primary closure like sterile matrix injuries Bipedicle germinal matrix advancement flap Germinal matrix full-thickness graft (FTG) needed if > 2 mm loss Donor site for FTG Resultant nail plate deformity at donor site First or second toe (second toe has least cosmetic deformity) Multidigit injury spare parts • Combined sterile and germinal

matrix injury Treatment Combined sterile and germinal matrix FTG • Nailbed hematoma Decompress if subungual hematoma occupies > 50% of nailbed or if painful Trephination: drainage with cautery device Suspect underlying nailbed injury

Fingertip Amputation Reconstruction • Direct closure Shorten bone and use remaining

volar or dorsal skin flap for direct closure • Healing by secondary intention Superficial pulp avulsions < 1 cm with no local skin available for direct closure and no exposed structures requiring coverage Better sensory recovery than full thickness skin graft (FTSG) • Skin grafts FTSG does not take over bone or tendon unless periosteum or peritenon are present Composite graft: for small defects on volar tip with exposed bone (best in children < 2 years of age) • Local flaps (Table 40.1)

• Regional flaps Reverse radial forearm flap: see Chapter 4 for more information Reverse posterior interosseous artery flap: pedicled fasciocutaneous flap to reconstruct volar, dorsal, and first web space wounds • Distant flap Groin flap: insensate • Free flap Venous flow through flaps: harvested from volar forearm, can be used for soft tissue coverage or revascularization of the digit, can be sensate

Fingertip Amputation Complications • Neuroma Painful digital nerve endings at amputation site Prevention: resect digital nerve proximal to amputation using traction neurectomy technique Treatment: resect neuroma, vibration, massage, electrical stimulation • Lumbrical plus Paradoxical extension of proximal interphalangeal (PIP) joint when try to form fist “FDP is too short”: due to retracted FDP from amputation site pulling

on the lumbricals, resulting in extension of the PIP Prevention: reattach torn FDP to distal interphalangeal (DIP) volar plate or A4 pulley Treatment: divide lumbricals • Quadriga Decreased flexion of uninjured digits because FDP tendons share a common muscle belly (except the index finger, which has an additional independent flexor tendon) Can be caused by over advancing FDP when repairing tendon, adhesions, suturing FDP to extensor tendons in distal amputation, or PIP arthrodesis

• Hook nail deformity: see below

Nail Plate Deformities • Pincer nail syndrome Constriction and transverse overcurvature of distal nail plate Etiology: tight shoes, osteoarthritis, beta-blockers, congenital, psoriasis, epidermoid cyst Treatment Remove constricted nail, incise sterile matrix longitudinally, elevate edges Excise lateral matrix horns, dermal graft under nail matrix • Hook nail deformity Volar-sided tissue loss, nail

follows curvature of residual nailbed over tip Treatment Remove nailbed curving around tip with additional 2 mm over dorsal distal phalanx so that healing wound will not draw nailbed around tip again Cover resulting wound with V-Y advancement flap

Suggested Reading Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg 2001;27(3):261–266 Braga-Silva J, Kuyven CR, Albertoni

W, Faloppa F. The adipofascial turn-over flap for coverage of the dorsum of the finger: a modified surgical technique. J Hand Surg Am 2004;29(6):1038–1043 Dolan M, Saint-Cyr M. Hand: Fingernails, Infections, Tumors, and Soft-Tissue Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2009:1–54. Selected Readings in Plastic Surgery; vol 10, issue 25 Krag C, Rasmussen KB. The neurovascular island flap for defective sensibility of the thumb. J Bone Joint Surg Br 1975;57(4):495–499 Kumar VP, Satku K. Treatment and

prevention of “hook nail” deformity with anatomic correlation. J Hand Surg Am 1993;18(4):617–620 Trumble TE. Fingertip and nail bed injuries. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:192–200 Tymchak J. Soft-tissue reconstruction of the hand. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:771–780

41 Mutilating Hand Injuries Reviewed by Ryan Katz

Mutilating Hand Injuries and Replantation • Reconstructive goals Sensibility Dexterity Aesthetic Painless use Prehensile function (grasp and hold) Thumb function (thumb accounts for 40 to 50% of hand function) Supple web spaces

Durable, high-quality soft tissue Two digits for pinch function Three digits for tripod function • Factors that affect successful replantation Mechanism of injury Crush, traction and avulsive mechanisms create wide zones of injury as compared to clean cut mechanisms The arterial intimal injury may be extensive and may require debridement and grafting to get outside of the zone of injury Ischemia time Amputated digits appropriately preserved by cooling have been successfully replanted after

prolonged cold ischemia times (up to 94 hrs) The amputated digit should be preserved by placing it in a waterproof container (or plastic bag) which is then placed within a separate vessel containing a cold water bath just above freezing (not be frozen or placed in direct contact with ice) Infection: minimize infection risky by thorough debridement of devitalized or contaminated tissues and use of antibiotics • Indications for replantation Thumb amputation Amputation(s) in children or musicians (nearly all parts)

Multiple digit amputations Single-digit amputation distal to flexor digitorum superficialis insertion Sharp amputation at any level with no contamination Hand and distal forearm amputation • Relative contraindications to replantation Single digit within zone II If no functional benefit offered by replantation Self-mutilation Psychotic patient Segmental, multilevel injury Crushed or mangled part(s)

Inability to tolerate a postoperative rehabilitation protocol • Contraindications to replantation Multitrauma patient with more immediate surgical needs Gross contamination > 6 hours warm ischemia time (forearm level) > 8 hours warm ischemia time (digit level) Serious comorbidities and inability to tolerate surgery Unsuitable part or recipient bed (extensive soft tissue and/or bone injury) • Order of repair Parts: “macro before micro”

Bone Flexor tendons Extensor tendons Nerves Artery (one artery is usually enough) Veins (at least two is preferable) Digits Thumb takes first priority Long finger or ring finger takes second priority In multidigit amputations, put best-quality digit in best-quality recipient bed—not every digit needs to be replaced in its original position Digit-by-digit repair versus part-

by-part repair Digit-by-digit repair rarely indicated If one digit has a prolonged warm ischemia time, consider replanting it first Part-by-part repair more suitable to the “macro before micro” philosophy All bone repairs followed by all flexors followed by all extensors followed by all nerves, arteries and veins Performing all microvascular work after all of the bone and tendon work will protect coaptations and anastomoses from inadvertent iatrogenic

trauma • Techniques to improve mutilated hand function Heterotopic replantation: consider replanting amputated adjacent digit to thumb position if amputated thumb cannot be replanted Finger transposition: index to long finger transposition at metacarpal base level or acute index finger pollicization in combined thumb/index finger injury Ectopic banking: amputated part can be banked in healthy ectopic location in the setting of unsuitable or contaminated recipient bed (i.e., amputated thumb banked on contralateral arm while thumb

stump cleaned and covered with groin flap) • Distal palm injuries Intrinsic muscles typically function poorly after replantation or repair Interossei: impaired abduction and adduction Lumbricals: impaired metacarpal flexion, proximal interphalangeal joint and distal interphalangeal joint extension Flexor tendons Flexor digitorum profundus and flexor digitorum superficialis, outside of the flexor tendon sheath at this level (Zone 3) typically function well after repair without significant

adhesions or tethering scar Extensor tendons function well after repair at this level (Zone 6) • Forearm injuries Management of exposed nerves and tendons in the forearm Cover with free fasciocutaneous flap Contraindication to forearm replantation > 6 hours warm ischemia time > 12 hours cold ischemia time Amputations proximal to digits have more muscle affected by ischemia Prophylactic fasciotomy: if forearm ischemic > 4 to 6 hours,

because postischemic swelling may cause compartment syndrome

Thumb Reconstruction • Principles Attempt to preserve length: if amputation at interphalangeal joint and flexor pollicis longus and extensor pollicis longus are avulsed, replant and fuse interphalangeal joint to preserve length (Table 41.1; Fig. 41.1) Close defect directly or cover with local flaps if available: Moberg flap or first dorsal metacarpal artery (FDMA) flaps are well suited to cover most distal thumb

wounds Avoid immediate “shorten and close” revision amputation Thumb reconstruction for unsalvageable thumb amputation (web-space deepening and metacarpal lengthening versus free toe-to-thumb transfer) • Osteoplastic thumb reconstruction Rarely indicated as terminal bone graft typically resorbs Consider other reconstructive options that could provide length, sensibility, and aesthetic (toe-tothumb transfer) Used for level C thumb amputations Combined bone graft with soft

tissue Nonvascularized iliac bone graft and groin flap Radial forearm flap, vascularized radius bone graft, and kite flap for sensate skin Table 41.1 Thumb amputation levels

Levels Landmarks

Reconstruction

Primary closure, Distal phalanx local flaps, toe distal to IP joint to thumb Web deepening Middle to distal (i.e., four-flap Z-plasty), proximal metacarpal phalanx

lengthening, toe to thumb

Toe to thumb (use less morbid ipsilateral second toe Middle based on first metacarpal to dorsal middle proximal metacarpal phalanx artery), osteoplastic thumb reconstruction Pollicization (index finger longer and Carpometacarpal improved to middle sensation metacarpal compared to

toe-to-thumb reconstruction)

Fig. 41.1 Thumb amputation levels.

Ring Avulsion Injury • Urbaniak Type I Circulation adequate Treatment: standard bone and soft tissue management • Urbaniak Type II Circulation inadequate Treatment: vessel repair, may need to use vein graft • Urbaniak Type III Complete degloving Treatment: ray amputation used to be universally recommended, but some authors would consider

replantation on a case-by-case basis

Infiltration Injury • IV infiltration injury Due to nonvesicant (nonblisterforming agent) entering surrounding tissue Physical exam Tissue loss 5 Ps Pain on passive extension: most indicative of compartment syndrome Pallor Paralysis Paresthesias

Pulselessness: late finding Check compartment pressures (> 30 mm Hg requires compartment release) The decision to release compartments should be guided by clinical exam and should not be delayed if clinical suspicion remains high despite absolute pressures less than 30 mm Hg Treatment Elevate extremity Cold and warm compresses are controversial Compartment release • Extravasation injury Due to vesicant (blister-forming agent) entering surrounding tissue

Diagnosis: same as IV infiltration injury above Treatment Local infiltration of hyaluronidase may be of benefit in decreasing the concentration of vesicant by increasing the area of diffusion Saline irrigation into the injured area through a small stab wound and allowed to flow out through another stab wound Incision/drainage Debridement of clearly necrotic tissue and resurfacing with local/regional tissue or free flap Anthracycline (i.e., doxorubicin) extravasation treatment

Topical dimethyl sulfoxide (DMSO) Delayed excision if does not heal Avoid cold or warm compresses, which may localize or spread extravasation • High-pressure injection injury Paint or organic solvents worse than air or water injections Injectate travels proximally along the neurovascular bundles Difficult to remove all particulate matter and foreign debris High rate of amputation in organic solvent injections Treatment Early surgical washout and

debridement Serial surgical debridements as needed to minimize foreign debris burden Antibiotics Elevation Early range of motion exercises

Suggested Reading An PC, Kuo YR, Lin TS, Yeh MC, Jeng SF. Heterotopic replantation in mutilating hand injury. Ann Plast Surg 2003;50(2):113–118, discussion 118–119 Bertelli G, Gozza A, Forno GB, et al. Topical dimethylsulfoxide for the prevention of soft tissue injury after

extravasation of vesicant cytotoxic drugs: a prospective clinical study. J Clin Oncol 1995;13(11):2851–2855 Brooks D, Buntic RF, Kind GM. Ring Avulsion: Injury pattern, treatment, and outcome. Clin. Plast. Surg 2007, 34(2): 187–195 del Piñal F. Severe mutilating injuries to the hand: guidelines for organizing the chaos. J Plast Reconstr Aesthet Surg 2007, 60(7): 816–827 Firat C, Erbatur S, Aytekin AH. Management of extravasation injuries: a retrospective study. J. Plast Surg Hand Surg 2013, 47(1): 60–65 Graham WC, Brown JB, Cannon B, et al. Transposition of fingers in

severe injuries of the hand. J Bone Joint Surg Am 1947;29(4):998– 1004 Jones NF. Replantation in the upper extremity. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:868–883 Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br 2001, 26(6): 572–581 Trumble TE. Replantation. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:469–477 Trumble TE. Thumb reconstruction. In:

Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:469–477 Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6(1):25–30 Wei FC, Chang YL, Chen HC, et al. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 1988, 82(2): 346–350

42 Dupuytren and Vascular Disease Reviewed by Alexander M. Spiess

Dupuytren Disease • Description Benign fibroproliferative disorder of palmar fascia, which can result in disabling finger contractures (Table 42.1) Northern European ancestry Peak age: 40 to 60 years old Men > Women Heritable and sporadic forms Heritable form: autosomal

dominant with incomplete penetrance • Phases Proliferative: increase in fibroblast conversion to myofibroblasts Involutional: alignment of myofibroblasts Residual: acellular devoid of myofibroblasts, only collagen remains (type III > type I) • Structures involved in disease Facial bands are natural structures in the hand that become diseased cords Pretendinous bands thicken to become diseased pretendinous cords Spiral bands become diseased

spiral cords Natatory ligaments pass transversely across web spaces and become diseased natatory cords (commissural cord in thumb web space) Perivascular structures Grayson ligament Volar to neurovascular bundle Involved with disease at spiral cords Cleland ligament Dorsal to neurovascular bundle Not involved in disease Ring finger: most common digit involved

Small finger Dupuytren disease: ulnar cord originates at musculotendinous junction of abductor digiti minimi • Indications for treatment Metacarpophalangeal (MCP) flexion > 30 degrees Table 42.1 Dupuytren contractures

Band

Contracture

Pretendinous

Metacarpal phalangeal (MCP) joint

Spiral

Proximal interphalangeal (PIP) joint

Natatory

Web space adduction contracture (cannot abduct)

Any proximal interphalangeal (PIP) flexion Significant web space contracture (especially thumb) Hueston tabletop test: inability to place palm flat on table is a positive test • Treatment Painful nodules: steroid injection Collagenase injection (Xiaflex): improves MCP deformity, little improvement of PIP deformity Percutaneous needle aponeurotomy

Open fasciotomy Open fasciectomy McCash procedure Excision of disease, leave skin open, or cover with skin graft Used for severe or recurrent disease • Complications Recurrence: 18 to 24% (most common complication) Reflex sympathetic dystrophy: 4 to 8% Digital nerve injury 1.5% Prevention Operate under tourniquet control and loupe

magnification Observe for digital nerve displacement both centrally and superficially by spiral cords Arterial injury < 1% If digital ischemia related to vasospasm: release incision, inject papaverine, put in flexion instead of extension splint, serially over next few days put back in extension • Long-term outcome of joints affected Age at presentation predicts outcome: younger age at diagnosis predicts worse outcome PIP

Poor outcome Poor response to therapy and splinting Early partial recurrence (1 to 3 years after surgery) Treatment of recurrent PIP disease may require more aggressive management More extensive joint release (accessory collateral ligament, palmar plate, checkrein ligament, flexor sheath) Dermatofasciectomy with fullthickness skin graft Arthrodesis: salvage procedure MCP Good outcome

• Associated diseases Ledderhose disease: fibromatosis Peyronie disease: fibromatosis

plantar penile

Vascular Disease • Hypothenar hammer syndrome Ulnar artery thrombosis or aneurysm as a result of blunt trauma to palm Seen in manual laborers Symptoms Ischemic pain and occasional digital ulcers due to relative hypoperfusion or emboli Numbness and tingling from

ulnar nerve compression in Guyon's canal Diagnosis: ultrasound or angiogram Treatment If there is decreased or no flow to digits: perform resection of thrombosed or aneurysmal segment and vein graft reconstruction If there is adequate digital flow: ligate or resect involved segment to avoid distal emboli into digits and/or vasospasm • Buerger disease Thromboangiitis obliterans in male smokers, leading to vascular obstruction of hands

Symptoms: hands may be painful, feel cold, look pale, red, or blue Diagnosis Hands may have large, red, tender blood vessels Palpable pulses may be faint or absent Ultrasound and magnetic resonance imaging (MRI) can be helpful Biopsy blood vessels Treatment Goal is to manage symptoms Avoid using tobacco and cold temperatures Warm extremity Surgical sympathectomy (cutting

nerves to blood vessels) may improve blood flow and help control pain Aspirin and vasodilators may be beneficial It may be necessary to amputate the affected limb if infected or if tissue death occurs • Raynaud disease Vasospasm in women, affecting fingers, toes, ears, and nose Precipitating factors Cold temperature Other precipitating factors: vasoconstrictive medications, arthritis, autoimmune conditions (scleroderma), smoking Symptoms: pain, tingling, color

changes (white, then blue, then red when blood flow reestablished) Confirmatory tests: ultrasound and cold stimulation test Treatment Change lifestyle, cease smoking, avoid caffeine, discontinue meds that cause vasoconstriction, avoid cold exposure, wear mittens or gloves in cold Vasodilators: topical nitroglycerin, calcium channel blockers, Viagra (Pfizer, New York), Cialis, angiotensinconverting enzyme (ACE) inhibitors Chemical (Botox) and surgical sympathectomy: improves pain

and vasospasm • Hand arteriovenous malformation (AVM) Congenital endothelialized vascular connection between artery and nearby veins Diagnosis MRI angiogram with intravenous (IV) gadolinium: accurately tells involvement of nearby soft tissue Ultrasound Treatment Selective preoperative intralesional embolization Can do several preoperative embolizations

Staged surgical resection • Radial artery pseudoaneurysm Etiology: iatrogenic trauma to artery (cannulation, gunshot wound, stab wound) Pseudoaneurysm is different from an aneurysm Pseudoaneurysm: leaking hole from artery into surrounding tissue, then forms a fibrous capsule around area of bleeding Aneurysm: all three layers of the arterial wall are present and dilated Diagnosis: ultrasound or MRI Treatment Direct repair with primary suture or patch

Vein graft: if defect is large and vessel critical to perfusion • Scleroderma Causes small blood vessel disease Localized scleroderma: affects skin, rarely internal organs Systemic scleroderma: affects skin and internal organs Limited: involves less skin and internal organs than diffuse Diffuse: more widepread skin and internal organ involvement than limited CREST Type of limited scleroderma Stands for: calcinosis, Raynaud phenomenon, esophageal

dysfunction, sclerodactyly, and telangiectasias Treatment Dorsal PIP joint skin may stretch and ulcerate, causing pain Ulcer debridement and limited bone resection may facilitate healing PIP joint arthrodesis Locally excise erosive calcium deposits from calcinosis

Suggested Reading Bidic SM, Schaub T. Hand: Extensor Tendons, Dupuytren Disease and Rheumatoid Arthritis. Dallas, TX: Selected Readings in Plastic

Surgery, Inc.; 2009:1–60. Selected Readings in Plastic Surgery; vol 10, issue 26 Brandt KE. An evidence-based approach to Dupuytren's contracture. Plast Reconstr Surg 2010;126(6):2210–2215 Freshwater MF. Dupuytren's disease. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:864–867 Swartz WM, Lalonde DH. MOC-PS (SM) CME article: Dupuytren's disease. Plast Reconstr Surg 2008;121(4, Suppl):1–10 Trumble TE. Dupuytren's disease. In:

Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:453–461 Watt AJ, Shin AY, Vedder NB, Chang J. Joint arthritis and soft-tissue problems of the hand. Plast Reconstr Surg 2010;126(6):288e–300e

43 Fractures and Dislocations Reviewed by Brent M. Egeland

Principles of Management • History and physical Metacarpal and phalangeal fractures are the most common upper extremity fractures Fifth metacarpal fracture is the most common fracture • Fracture sites (Fig. 43.1) Head: cam shaped, condyles located on head, covered by cartilage; rare, usually intra-

articular, most commonly affects index finger, often comminuted Neck (metaphysis): junction of head and shaft, frequent site of injury under compression; most commonly involves ring and small fingers; often significantly angulated Shaft (diaphysis): fractures can be transverse or oblique; scissoring often present Base: considered high energy; common thumb fracture site; evaluate for dislocation at carpometacarpal (CMC) joint; small finger (reverse Bennett's) is inherently unstable • Dislocation (Fig. 43.2)

Simple dislocation: articular surfaces in contact Complete dislocation: articular surfaces no longer in contact Dorsal versus volar dislocation: refers to location of distal bone relative to proximal bone • Imaging Plain radiographs virtually always necessary CT and MRI based on injury type and tissue involved • Treatment Treatment is specific to each site and fracture or dislocation—see below Splint/Cast: acceptable for nondisplaced fractures, consider in

minimally displaced fractures without scissoring or instability

Fig. 43.1 Metacarpal anatomy.

Fig. 43.2 Simple and complete dislocations.

Closed reduction with or without percutaneous fixation: can achieve significant improvement in alignment or rotation with minimal

soft tissue disruption Open reduction with percutaneous or internal fixation: used to achieve anatomic reduction and allow early mobilization • Hand therapy Should be considered in virtually all cases to optimize outcome

Fractures Metacarpal Fractures •

Metacarpal neck (metaphysis) fractures Most common metacarpal fracture “Boxer's fracture” results from

punching an object or person with axial load applied to metacarpal head Ulnar digits have greatest compensation for angulation due to mobility at the carpometacarpal joint Treatment Observation acceptable in most cases if no scissoring, no pseudoclawing [compensatory metacarpophalangeal (MCP) hyperextension and proximal interphalangeal (PIP) joint flexion], and angulation within tolerated limits: Small finger angulation < 40 to 45°

As go radial, reduce 5° per ray in ulnar to radial direction Closed reduction if unacceptable angulation or scissoring—Jahss maneuver Percutaneous pinning if closed reduction fails or unstable—may require open reduction • Metacarpal shaft (diaphysis) fractures Classified into four types: transverse, oblique, spiral or comminuted Transverse: usually from axial load and tend to deform with apex dorsal angulation due to pull of interosseous muscles Oblique/Spiral: usually result of

torsional forces Comminuted: usually result of direct impact or crush; can tolerate 0.5 cm shortening Unacceptable angulations requiring treatment Small finger angulation > 30° Ring finger angulation > 20° Long and index finger angulation > 10° Rotation: 5° at metacarpal can lead to 1.5 cm digital overlap Treatment Directed at fracture type, but includes percutaneous pinning, composite wiring, lag screws, and plate fixation

Transverse fracture Attempt closed reduction followed by cast immobilization Buddy taping can help control rotation Percutaneous pinning indicated when reduction unstable or if contraindication to casting (e.g., open wound) Open reduction internal fixation (ORIF) with dorsally applied plate if early motion desired Comminuted fracture ORIF with locking plate External fixation if soft tissue injury

Spiral or oblique fracture ORIF with lag screw: ideal when fracture length > 2x bone diameter ORIF with plate when fracture length < 2x width or when comminuted Open fracture with segmental defect Staged treatment—serial debridement followed by soft tissue coverage and fixation— antibiotic bone cement, iliac crest bone grafting, and vascularized bone grafting all possible, depending on specific circumstances

Thumb Fractures • 25% of metacarpal fractures occur at thumb, 80% of those at base • Bennett fracture Most common thumb metacarpal fracture Fracture dislocation of thumb CMC joint—two fragments: Shaft is laterally displaced by lateral pull of abductor pollicis longus (APL), while base attached to volar oblique ligament remains in place— often dynamically unstable Treatment Thumb is more forgiving: anteroposterior (AP) angulation

< 15 to 20° and lateral angulation < 20 to 30° are generally tolerated due to highly mobile joint Closed reduction: rarely indicated—inherently unstable Closed reduction and pinning: common treatment—use when Bennett's fragment < 15 to 20% of articular surface ORIF if closed reduction cannot reach tolerated limits, articular incongruity > 1 to 3 mm even after pinning, or if large Bennett's fragment (> 23 to 30% of articular surface) • Rolando fracture T or Y pattern fracture dislocation

of thumb CMC—three fragments Greater axial load compared to Bennett fracture—fracture is virtually always unstable Treatment: ORIF with multiple Kwires or T-shaped plate External fixator is used when fracture is very comminuted

Phalangeal Fractures and Dislocations • Tuft Distal phalanx distal fracture— frequently accompanied by nail bed injury Treatment: consider nail plate

removal and repair of nail bed laceration If nondisplaced, splint (Stax) for comfort Displaced fractures can be treated with closed reduction • Diaphysis Frequently at proximal and middle phalanx If nondisplaced or minimally displaced, closed treatment with splinting or buddy taping is preferred treatment; requires frequent surveillance X-rays to monitor possible fracture displacement If displaced > 2 mm or if rotatory deformity, reduction and pinning is

necessary ORIF with lag screw or plate: can be technically challenging due to closely adherent extensor mechanism, but allows early mobilization

Distal Interphalangeal (DIP) Joint • Mallet injury (Table 43.1) DIP flexion deformity from DIP extensor tendon injury—can be bony fracture (distal phalanx terminal tendon insertion) or softtissue only (terminal tendon avulsion) Results from laceration or

“jamming” tip of finger Swan neck deformity Complication from untreated mallet injury Results from proximal retraction of lateral bands: DIP flexion and PIP hyperextension Table 43.1 Mallet injury classification

Type

Description Treatment Extensor tendon avulsed from proximal dorsal base of distal phalanx

Splint (Stax) DIP in full extension, or percutaneous pin to work without splint

Open laceration of Tendon terminal repair and extensor splint (Stax) tendon

III

Primary tendon grafting, soft tissue coverage; can also do delayed tendon grafting

Extensor tendon avulsion and soft tissue loss

Acute: closed

reduction and longitudinal pin fixation; > 30% ORIF if articular cannot do surface distal closed phalanx reduction avulsed Chronic: Fowler tenotomy, which cuts central tendon to restore DIP extension

• Jersey finger Flexor digitorum profundus (FDP) avulsion with or without fracture

of FDP from distal phalanx due to forced DIP extension against flexion Most commonly involves ring finger because weakest FDP attachment to distal phalanx Leddy classification (Table 43.2) Treatment directed by classification X-ray: can diagnose type 2 and 3 due to visualized bone fragment location Table 43.2 Jersey finger Leddy classification

Type

Description Treatment Repair

Proximal FDP within 2 retracts to weeks to palm avoid tendon graft Proximal FDP retracts to PIP— maintained by fracture Repair fragment by within 3 A3 pulley; months to small avoid fragment may tendon graft convert to type 1 with proximal migration Proximal FDP retracts past

A4 pulley, large fracture fragment seen just proximal to DIP

ORIF anytime, even after 3 months

Proximal Interphalangeal (PIP) Fractures and Dislocations • PIP dislocation: volar Often irreducible because proximal phalanx condyle buttonholes and traps between central slip and lateral band—tightens with traction and creates noose effect May be associated with central

slip rupture Treatment: Nonoperative: if reduced and extensor mechanism intact, similar to boutonniere Operative: must relocate lateral bands and joint; central slip may require repair; percutaneous pinning to maintain reduction • PIP dislocation: dorsal Slips of flexor digitorum superficialis (FDS) or volar plate can block reduction Treatment: extension block splinting (or pinning); if unstable, may require volar plate arthroplasty with collateral ligament repair

• PIP fracture/dislocation Axial load leads to unstable comminuted intra-articular fracture of the base of the middle phalanx Treatment Re-establishment of the articular surface and autologous bone grafting to maintain reduction < 30% volar articular surface involved: extension block splinting > 30% volar articular surface involved: pinning or ORIF Other options: skeletal dynamic traction (ligamentotaxis)–Suzuki type Treatment chronic injury or > 60% volar articular surface involved

Volar plate arthroplasty After 2 weeks, begin extension block splinting After 4 weeks, begin light work with buddy taping for controlled extension Alternative treatment: arthrodesis

Pediatric Fractures • Pediatric growth plate fractures Salter Harris Classification (Table 43.3; Fig. 43.3): describes pediatric growth plate fractures involving the epiphysis Type II is most common fracture pattern

Treatment: closed reduction, casting, or pin • Extra-octave fracture Small finger proximal phalanx base fracture leading to ulnar deviation Not included in Salter Harris Classification, because does not involve growth plate • Seymour fracture Table 43.3 Salter–Harris classification of pediatric growth plate fractures

Type

Description

Epiphyseal separation

Epiphyseal separation and metaphyseal fracture

III

Articular surface fracture and epiphyseal separation

Articular surface, epiphyseal, and metaphyseal fractures

Epiphyseal plate compression

Fig. 43.3 Salter-Harris classification of pediatric growth plate fractures

Salter I or II fractures of the distal phalanx physis, with nail avulsion Mimics mallet finger due to physeal separation with differential extensor and flexor tendon insertions High rate of infection if untreated —typically requires operative treatment Requires debridement and reduction of soft tissue from

fracture and nail bed repair

Complications • PIP joint flexion contracture Early treatment Serial casting Dynamic splinting Delayed treatment Dynamic external fixator Capsulectomy: release of scarred soft tissue of capsule, volar plate, collateral ligaments, and checkrein ligaments • PIP joint posttraumatic degeneration Arthroplasty: best for radial digits Arthrodesis: best for ulnar digits

Amputation: for nonfunctional digits with neuropathic pain • Malunion Bone healed with abnormal alignment • Nonunion Fracture does not heal

Other Dislocations and Ligament Injuries • Gamekeeper's/Skier's thumb Thumb MCP ulnar collateral ligament (UCL) injury following forced abduction and hyperextension Stener lesion (Fig. 43.4): proximal

phalanx UCL fragment retracted proximal to interposed adductor aponeurosis—this blocks its ability to spontaneously relocate to normal position at base of proximal phalanx—will not improve Diagnosis Thumb MCP joint lateral laxity X-rays—may see small Stener fragment in first web space, but not always Treatment Complete tear Open reduction internal fixation if UCL instability > 30° in both flexion and extension, or if > 15 degree

differential compared to contralateral Dissection planes during operative repair: skin, extensor/adductor aponeurosis, and ulnar collateral ligament; in a Stener lesion, the displaced UCL will be encountered in the subcutaneous space (i.e., on top and proximal to the adductor)

Fig. 43.4 Stener lesion.

Repair of ligament: suture, wire, screw, or bone anchor fixation of fragment to phalanx Cast for 4 weeks then thumb spica splint for 4 weeks Partial tear If no UCL instability (i.e., 10 degree instability in flexion or extension) Immobilization with thumb spica splint for 4 weeks • Index finger MCP radial collateral ligament injury Due to forced ulnar deviation at MCP Diagnosis

Weak key pinch with pain and ulnar deviation of index finger MRI confirms diagnosis Treatment Closed reduction and immobilization Open repair if unstable after reduction • MCP dorsal dislocation Often irreducible due to interposed volar plate, lumbricals (radially), and flexor tendons (ulnarly), which lead to noose effect with longitudinal finger traction Treatment Closed reduction: flex wrist to loosen flexor tendons and apply distally and volarly directed

pressure at base of proximal phalanx Operative reduction under sedation or relaxation will loosen tendons Partial A3 pulley division allows condyle repositioning from flexor tendon Dorsal extension block splinting: prevents instability in extension

Suggested Reading Chin SH, Vedder NB. MOC-PS (SM) CME Article: Metacarpal Fractures. Plast Reconstr Surg 121(1S): 1-13, 2008 Desai HJ, Bidic SM. Hand: Fractures

and Dislocations, the Wrist, and Congenital Anomalies. Selected Readings in Plastic Surgery. 10(29): 1-68, 2011 Eaton RG, Malerich MM. Volar Plate Arthroplasty of the Proximal Interphalangeal Joint: a Review of Ten Years’ Experience. J Hand Surg Am 5(3): 260-8, 1980 Lucas GL. Fowler Central Slip Tenotomy for Old Mallet Deformity. Plast Reconstr Surg 80(1): 92-94, 1987 Friedman DW, Kells A, Aviles A. Fractures, Dislocations, and Ligamentous Injuries of the Hand. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's

Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006: 790-802 Friedrich JB, Vedder NB. An EvidenceBased Approach to Metacarpal Fractures. Plast Reconstr Surg 126(6): 2205-2209, 2010 Jones NF, Jupiter JB, Lalonde DH. Common Fractures and Dislocations of the Hand. Plast Reconstr Surg 130 (5): 722e-736e, 2012 Rockwell WB, Butler PN, Byrne BA. Extensor Tendon: Anatomy, Injury, and Reconstruction. Plast Reconstr Surg 106(7): 1592-1603, 2000 Stern PJ, Roman RJ, Kiefhaber TR, et al. Pilon Fractures of the Proximal Interphalangeal Joint. J Hand Surg

Am 16(5): 844-850, 1991 Trumble TE. Hand Fractures. In: Trumble Principles of Hand Surgery and Therapy. 1st ed. Saunders; 2000: 41-89

44 Nerves and Compartment Syndrome Reviewed by Ida K. Fox

Anatomy and Physiology • Median nerve Motor component Pronator teres (PT) Flexor carpi radialis (FCR) Flexor digitorum superficialis (FDS) Anterior interosseous nerve (AIN) Supplies: flexor pollicis longus, radial half of flexor

digitorum profundus (FDP) to the index and long fingers, and pronator quadratus Recurrent motor branch to abductor pollicis brevis (APB), opponens pollicis (OP), and superficial head of flexor pollicis brevis (FPB) Lumbricals to index and long fingers Sensory component Palmar cutaneous branch: supplies skin over thenar eminence Digital sensory nerves Supply palmar surface of thumb, index finger, and long finger, and radial half of ring

finger Provides some sensation of dorsal thumb, index finger, long finger, and radial half of ring finger from the distal interphalangeal (DIP) joint to the fingertip (see radial sensory nerve below) • Ulnar nerve Motor component Flexor carpi ulnaris (FCU) FDP to the index and small fingers Opponens digiti minimi (ODM) Abductor digiti minimi (ADM) Flexor digiti minimi (FDM) Lumbricals to the ring and small

fingers Palmar and dorsal interossei FPB deep head Adductor pollicis (terminal branch) Sensory component Dorsal cutaneous branch: supplies dorsal and ulnar distal forearm, dorsal and ulnar hand, dorsal and ulnar half of ring finger, and dorsal small finger Digital sensory nerves: supply palmar surface of small finger, palmar ulnar half of ring finger, dorsal ulnar half of ring finger distal to DIP joint, and dorsal small finger distal to DIP joint • Radial nerve

Motor component Triceps brachii Anconeus Brachioradialis Extensor carpi radialis longus (ECRL) Posterior interosseous nerve (PIN) branch Extensor carpi radialis brevis (ECRB) Supinator Digital extensors Sensory component Superficial sensory branch supplies dorsal and radial distal forearm, dorsal and radial hand, and dorsal thumb, index finger,

long finger, and radial half of ring finger • Musculocutaneous nerve Motor component Corachobrachialis Biceps brachii Brachialis Sensory component Lateral antebrachial cutaneous nerve: provides sensation to radial forearm • Axillary nerve Motor component Teres minor Deltoid Sensory component Superior lateral cutaneous nerve

provides sensation to lateral upper arm • Martin–Gruber connection Forearm level anastomosis between ulnar and median nerve Most common pattern: motor branch from median nerve innervates ulnar nerve–innervated intrinsic musculature • Nerve layers Endoneurium: surrounds individual nerve fibers Perineurium: surrounds individual fascicles (bundles of nerve fibers) Epineurium: surrounds bundles of fascicles and the entire nerve • Sensory receptors and nerve fibers

Merkel cells: static two-point discrimination (slow-adapting receptors) Meissner corpuscles: moving twopoint discrimination (quickadapting receptors) Pacinian corpuscles: vibratory light touch, unable to identify location of vibration well because supplies a broad area (quickadapting receptors) A fiber: sharp pain (nociception) C fiber: burning pain (nociception)

Nerve Injury Principles • Sunderland, Seddon, and Mackinnon classifications (Table 44.1)

Describe nerve injury, degeneration, and recovery • Wallerian degeneration Axon degeneration distal to point of nerve injury Not seen in first-degree conduction block or neurapraxia type injury Seen in second-, third-, fourth-, fifth-, and some areas of sixthdegree injuries Nerve requires time to recover but in some cases may require surgical repair • Nerve regrowth 1 in/mo (1 mm/d) Rule of 18: (no. inches from injury to muscle) + (no. months muscle denervated) should be < 18 for

nerve recovery or reconstruction to work before motor end-plate degeneration occurs • Evaluation and timing of repair Open injury Sharp nerve transection injuries are best repaired immediately Nerve transection with crush or other nonsharp-mechanism may benefit from reexploration at 2 weeks once zone of injury has been demarcated Closed (blunt, compression, crush) or gunshot-wound injury Observe and serial clinical exam Electromyography (EMG) at 6 weeks then serially If no return of function, consider

repair or nerve transfer early at 3 months

• Postoperative management Splint if simultaneous bony and tendon structures require protection Early mobilization is critical to prevent scarring and allow nerve gliding

Nerve Repair • Primary repair For sharp, acute injuries Contraindicated if large gap or tension on the repair • Nerve conduit/acellularized allograft For short gap up to 2 to 3 cm to restore noncritical sensation Contraindicated if large gap > 3 cm or motor nerve gap Material Bioabsorbable polyglycolic acid or collagen Vein Decellularized nerve allograft • Nerve graft For cases when other treatment

strategies not possible or contraindicated Shorter nerve grafts used to repair digital nerve or other short gap defects Medial antebrachial cutaneous (MABC) nerve Lateral antebrachial cutaneous (LABC) nerve Posterior interosseous nerve (PIN) Longer nerve grafts Used in a cabled fashion to repair longer nerve gaps in the major peripheral nerves such as the median, radial, ulnar, and sciatic nerves Sural nerve: harvest from

posterior calf • Nerve transfer Useful for brachial plexus injuries or other high (proximal) nerve injuries Transfer expendable donor nerve to a distal site on the recipient injured nerve Converts high (proximal) to low (distal) nerve injury Can be motor or sensory nerve Demands knowledge of intrafascicular anatomy of nerve Example Nerve transfer to correct ulnar nerve claw hand: median nerve's AIN pronator branch-to-ulnar nerve

• Bone shortening Generally contraindicated except in cases of replantation Nerve grafts are indicated if the repair cannot be done without tension • Neuroma Can occur after nerve injury and/or repair Pain and decreased nerve conduction Treatment Excision and interposition nerve grafting Excision and proximal burying: acceptable for noncritical sensory neurons

Preserve functioning fascicles

Nerve Compression • Nerve compression pathophysiology Both acute and chronic nerve compression injury have similar pathophysiology At first Local nerve ischemia prevents depolarization causing a nerve block Adenosine triphosphate (ATP) sodium/potassium (Na/K) pumps unable to export sodium to repolarize and maintain resting potential (− 90 mV) Recovery can occur as soon as

compression is released As compression continues Myelin sheath disintegrates preventing saltatory jumping between nodes of Ranvier Recovery of function may take 12 weeks More severe compression (crush injury) Leads to Wallerian degeneration Will recover at rate of 1 in/mo • Carpal tunnel syndrome (CTS) Most common compressive neuropathy Median nerve compression at the wrist Carpal tunnel contents

Median nerve 9 tendons: FDS (4), FDP (4), flexor pollicis longus (FPL) (1) FDS 3 and 4 are palmar to FDS 2 and 5 in carpal tunnel Lumbricals (attached to FDP tendons) may enter with finger flexion and can produce effortassociated CTS, especially in muscular hands Diagnosis Numbness and tingling in median nerve distribution Thenar muscle weakness can develop Tinel sign over carpal tunnel Phalen sign

Electromyogram (EMG) Fibrillations present if motor end organ affected Nerve conduction study (NCS) Increased median sensory and motor nerve latency across transverse carpal ligament Treatment Conservative Splinting Nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections, and activity modification have variable efficacy Surgical release of carpal tunnel ligament

• Median nerve compression at the forearm Sites of compression Supracondylar spur Ligament of Struthers: ligament between humeral supracondylar process and medial epicondyle Lacertus fibrosis and bicipital aponeurosis Pronator teres (PT) FDS fascial arch Vascular arcade proximal to FDS fascial arch Pronator syndrome (more proximal injury) Both motor and sensory symptoms

Aching at proximal forearm Worsened by resisted pronation Anterior interosseous nerve (AIN) syndrome (more distal injury) Pure motor symptoms: inability to pinch between thumb and index finger Diagnosis These less common areas of median nerve compression require diagnosis primarily through history and physical exam • Cubital tunnel syndrome Second most common compressive neuropathy is ulnar nerve compression at the elbow Sites of compression

Arcade of Struthers: medial intermuscular septum (fascia between triceps and biceps) Anconeus epitrochlearis (anomalous muscle) Osborne ligament: fascial band of FCU origin between olecranon and medial epicondyle Diagnosis Involvement of dorsal sensory nerve causes dorsal hand numbness in addition to volar small and ulnar ring finger digital nerve involvement Small and ring finger FDP weakness can weaken grip Intrinsic muscle (ADM, FDM,

interossei, and adductor pollicis) weakness and atrophy Tinel sign at the elbow Froment sign: on attempted pinch, see thumb interphalangeal joint flexion as flexor pollicis longus compensates for weak adductor Wartenberg sign: extensor digiti minimi (EDM) abducts small finger compensating for weak third dorsal interosseous abduction EMG may show denervation of ulnar-innervated muscles NCS: slowing across cubital tunnel Treatment

Nonsurgical: activity modification, therapy, NSAIDs, steroid injections, splints, elbow pad Surgical treatment options Cubital tunnel release (in situ decompression) Submuscular ulnar nerve transposition Subcutaneous ulnar nerve transposition Medial epicondylectomy Complications from surgical treatment Neuroma of the MABC nerve: treatment is to excise and implant proximal stump into nearby muscle

Incomplete release, tethering (in part can be due to prolonged postoperative immobilization), kinking • Guyon canal syndrome Ulnar nerve compression at the wrist Sites of compression Guyon canal between volar carpal ligament and transverse carpal ligament Deep motor branch may also be compressed by leading fibrous edge of hypothenar muscle and fascia Diagnosis Tinel sign at wrist Normal dorsal ulnar hand

sensation Abnormal small and ulnar ring finger sensation Froment sign Wartenberg sign Treatment Nonsurgical: splinting, NSAIDs, activity modification Surgical: release of Guyon canal and hypothenar fascia

Radial Nerve Compression at the Forearm • Radial nerve and its branches can be compressed in the arm, antecubital area, and forearm

• Sites of compression: “radial tunnel” includes multiple areas along course of nerve Between brachialis and biceps (medially), and brachioradialis muscle (laterally) Edge of ECRB Arcade of Fröhse: fibrous arch along superior portion of supinator Leash of Henry: radial recurrent artery and venae comitantes • PIN entrapment Pure motor syndrome Loss of finger and thumb extension • Radial sensory nerve entrapment Pure sensory syndrome Neuropathic pain and/or numbness

at distal forearm and dorsal hand

Brachial Plexus • Anatomy Composed of C5–T1 nerve roots Dorsal sensory rootlets join ventral motor rootlets to form roots that divide into trunks, divisions, cords, and branches Branches innervated by nerve roots: long thoracic (serratus anterior), dorsal scapular (levator scapulae and rhomboids) Branches innervated by nerve trunks: suprascapular nerve (supraspinatus and infraspinatus) Cords innervate most of the main

branches Medial cord innervates: median nerve, ulnar nerve, and medial antebrachial cutaneous nerve Posterior cord innervates: radial nerve, axillary nerve, thoracodorsal nerve (latissimus dorsi), and subscapular nerve (subscapularis and teres major) Lateral cord innervates: musculocutaneous nerve and median nerve • Etiology Congenital Traumatic • Injuries Can be first- to sixth-degree injury pattern with complete avulsion,

nerve interruption, or nerve incontinuity Proximal avulsion injuries No proximal stump available for direct repair Treatment Will require some type of surgery because no return of function can occur Distal nerve or tendon transfers may provide more timely return of function For other injury patterns, direct repair may be possible Serial exam and electrodiagnostic studies are critical to decision making May or may not require surgical

intervention, depending on degree of recovery Stretch injuries can resolve; degree of recovery depends on extent of nerve injury If surgery is indicated, it must be done in a timely fashion prior to terminal muscle denervation • Erb palsy (waiter's tip deformity) C5 and C6 injury Unable to abduct and externally rotate at shoulder, flex elbow, and extend wrist • Klumpke palsy C8 and T1 injury Combined median and ulnar nerve palsy

Loss of wrist, thumb, and finger flexion Loss of all intrinsic hand function

Complex Regional Pain Syndrome (CRPS) • Etiology CRPS-1 Reflex sympathetic dystrophy (RSD) Secondary to trauma (no obvious associated nerve injury) CRPS-2 Causalgia Associated with a specific nerve injury or compressive

neuropathy Risk factors include injury to brain, peripheral nerve, spinal cord, radius fracture, upper extremity injury • Symptoms Spontaneous pain Allodynia: pain secondary to nonpainful stimulus Hyperesthesia: hypersensitivity Vasospasm skin changes, swelling, stiffness, increased sweat • Diagnosis Thermography detects increased baseline temperature X-ray: detects Sudeck bone atrophy within 3 to 5 weeks

Bone scan: detects increased vasomotor and periarticular activity Stellate ganglion block (diagnostic block) • Treatment Nonoperative (medical) management: therapy, pain management (i.e., stellate ganglion block), edema management, medications (gabapentin, pregabalin, amitriptyline) Surgical management: nerve decompression or repair (CRPS2)

Acute Compartment Syndrome

• Increased compartment pressure results in muscle and nerve ischemia (irreversible damage occurs after 4 to 8 hours and can lead to Volk-mann contracture) • Etiology Trauma, crush injury, burn, reperfusion after arterial repair/thrombectomy or extravasation agent (intravenous contrast, chemotherapeutic agent, etc.) • Symptoms and findings Pain, numbness, pain with passive range of motion of involved muscle, decreased range of motion, loss of pulses (late finding)

Compartment pressure > 30 mm Hg and/or compartment pressure within 20 mm Hg of diastolic blood pressure (e.g., hypotensive patients require a lower threshold for compartment release due to their decreased perfusion pressure) • Treatment Emergent fasciotomy and nerve release • Hand compartment release Decompress the following muscles Four dorsal interossei Three volar interossei Adductor pollicis compartment Thenar compartment (ABP, FPB, OP)

Hypothenar compartment (ADM, FDM, ODM) Hand muscle release typically done using four fasciotomy incisions Two dorsal incisions over second and fourth metacarpals Two volar incisions over thenar and hypothenar compartments Decompress the median nerve within the carpal tunnel, the ulnar nerve within the Guyon canal, and the deep motor branch of the ulnar nerve • Forearm compartment release Decompress the following muscles Mobile wad proximally: consists of brachioradialis, ECRB, and

ECRL Dorsal muscles (EDC, EIP, EPL, EDQ) Superficial volar muscles (FCR, FCU, FDS) Deep volar muscles (FPL, FDP, pronator quadratus) Decompress the median nerve within the carpal tunnel, the ulnar nerve within the Guyon canal, and the deep motor branch of the ulnar nerve

Suggested Reading Cheng J, Ellison CR. Hand: Peripheral Nerves and Tendon Transfers. Dallas, TX: Selected Readings in

Plastic Surgery, Inc.; 2010:1–76. Selected Readings in Plastic Surgery; vol 10, issue 27 Effron CR, Beasley RW. Compression neuropathies in the upper limb and electrophysiologic studies. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:830–834 Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plast Reconstr Surg 2011;127(5):105e–118e Hentz VR, Lalonde DH. MOC-PS (SM) CME article: self-assessment and

performance in practice: the carpal tunnel. Plast Reconstr Surg 2008;121(4, Suppl):1–10 Mackinnon SE, Novak CB. Operative findings in reoperation of patients with cubital tunnel syndrome. Hand (NY) 2007;2(3):137–143 Rodriguez-Niedenführ M, Vazquez T, Parkin I, Logan B, Sañudo JR. Martin-Gruber anastomosis revisited. Clin Anat 2002;15(2):129–134 Shores JT, Lee WP. An evidence-based approach to carpal tunnel syndrome. Plast Reconstr Surg 2010;126(6):2196–2204 Trumble TE. Brachial plexus injuries. In: Trumble Principles of Hand

Surgery and Therapy. Philadelphia, PA: Saunders; 2000:297–312 Trumble TE. Compartment syndrome and Volkmann's contracture. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:324–341 Trumble TE. Compressive neuropathies. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:324–341 Trumble TE, McCallister WV. Physiology and repair of peripheral nerves. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:279–296

45 Tendons Reviewed by Warren C. Hammert

Tendon Anatomy •

Extensor tendon compartments (Table 45.1) • Flexor tendons Flexor digitorum profundus (FDP): inserts on distal phalanx to flex proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints Flexor digitorum superficialis (FDS) Splits into two slips (Camper chiasm) to allow passage of FDP tendon

Rotates 180 degrees to insert on middle phalanx to flex the PIP joint Flexor pollicis longus (FPL): inserts on thumb distal phalanx to flex interphalangeal (IP) joint • Annular and cruciate pulleys Five annular pulleys Three cruciate pulleys A2 pulley (proximal proximal phalanx) and A4 pulley (middle of middle phalanx) are the most important to repair after injury to prevent bowstringing • Lumbricals Intrinsic muscle originates from radial aspect of tendon and inserts on lateral bands of the extensor

mechanism Function: metacarpophalangeal (MCP) flexion, PIP extension • Anatomical snuffbox Volar border: first dorsal compartment (abductor pollicis longus/extensor pollicis brevis [APL/EPB]) Dorsal border: third dorsal compartment (extensor pollicis longus [EPL]) • Vincula: vascular supply to flexor tendons • Total active range of motion (TAM) Sum of TAM of MCP, PIP, and DIP, minus extensor lag Table 45.1 Extensor tendon compartments

Compartment

Extensor tendons

Abductor pollicis longus (APL)/extensor pollicis brevis (EPB)

Extensor carpi radialis brevis (ECRB)/extensor carpi radialis longus (ECRL)

Extensor pollicis longus (EPL): lifts thumb off tabletop Extensor digitorum

communis (EDC)/extensor indicis proprius (EIP)

Extensor digitorum minimi (EDM)

Extensor carpi ulnaris (ECU)

Normal TAM: MCP 90 degrees + PIP 110 degrees, + DIP 70 degrees = 270 degrees

Flexor Tendon Injury • Flexor tendon injury exam (Table 45.2; Fig. 45.1)

Loss of normal digital cascade: injured finger rests in extended position Table 45.2 Flexor tendon injury zones

Zone

Description

Distal to FDS insertion, FDP only

No man's land, from proximal aspect of A-1 pulley to FDS insertion, most difficult zone of injury to repair, worst outcomes

III

Distal aspect of transverse carpal ligament (TCL) to proximal aspect of A-1 pulley

Under TCL

Proximal to TCL, although good outcomes are possible, it is difficult to gain independent tendon gliding because adhesions are common

Fig. 45.1 Flexor tendon injury zones.

FDP injury Patient unable to flex DIP joint while examiner holds middle phalanx to block FDS contribution to PIP flexion FDS injury Patient unable to flex PIP joint without simultaneous DIP flexion Examiner isolates FDS by holding uninjured fingers in extension and blocking FDP • Repair Single-stage repair Direct repair Tendon graft

Release pulley or debride cut edges of flexor tendon if triggering from cut edges catching on pulley Staged reconstruction Required with insufficient quantity of flexor tendon sheath First-stage: silicone forms a new tendon sheath and pulley reconstruction Delayed tendon graft Palmaris longus (PL) tendon graft Toe extensors or flexors Plantaris tendon graft Incision anterior to medial margin of Achilles tendon

Oblique course between soleus and gastrocnemius Third stage often used to improve motion with tenolysis • Rehabilitation Dorsal extension blocking splint Best outcomes are from early active range of motion without resistance to prevent adhesions for patients with four-strand repair and who are compliant and under supervision of a certified hand therapist (level I evidence) Passive protocol for those who are noncompliant or who have twostrand repair Rupture after tendon injury repair: immediate return to the operating

room for direct repair Arthrodesis: last resort if flexor tendon injury cannot be repaired or reconstructed

Extensor Tendon Injury (Table 45.3; Fig. 45.2) • Extensor tendon injury exam May have slight flexed posture of digit distal to laceration May be able to extend distal to injury due to interconnection through juncturae tendinum • Repair Direct suture repair of injured extensor tendon if > 60% cross

section extensor tendon ruptured Table 45.3 Extensor tendon injury zones

Zone

Description (odd numbers over joints and even numbers over bones)

DIP, terminal extensor tendon insertion on base of distal phalanx, mallet injury

Middle phalanx (P2), lateral bands

III

PIP, central slip insertion on base of P2, can result in Boutonniere deformity

Proximal phalanx

MCP, fight bite

Dorsum of hand

VII

Wrist, extensor retinaculum

VIII

Distal forearm

Proximal forearm, musculotendinous junction, difficult to

repair

Fig. 45.2 Extensor tendon injury zones.

• Complications Swan neck deformity: see Chapter 43, Fractures and Dislocations, and Chapter 49, Rheumatology, for more information Boutonniere deformity: see Chapter 49, Rheumatology, for more information

Tendonitis • Trigger finger Stenosis of A1 pulley resulting in pain, triggering, or locking of digit with PIP joint flexion in fingers Tender palpable nodule at level of

A1 pulley Treatment Conservative management Splinting in extension Steroid injection A1 pulley release indications Failed conservative treatment Recurrence or incomplete resolution after steroid injection Digit locked in flexion • De Quervain disease Tenosynovitis of first dorsal compartment Diagnosis Tenderness to palpation of first dorsal compartment

Positive Finkelstein maneuver: clasped thumb ulnarly deviated causes pain Treatment Conservative management Rest Nonsteroidal antiinflammatory drugs (NSAIDs) Splint Steroid injections Surgical management Release of first dorsal compartment Decompression of subcompartment for EPB APL will have multiple slips Avoid injury to dorsal sensory

branch of radial nerve • Intersection syndrome Tenosynovitis of second dorsal compartment Inflammation due to tendon friction at intersection between first and second dorsal compartments 4 cm proximal to wrist Diagnosis: crepitus and tenderness Treatment Conservative management: rest, NSAIDs, extension splint, steroid injections Surgical: second compartment release and synovectomy at intersection point • Wartenberg syndrome (cheiralgia paresthetica)

Dorsal sensory branch of radial nerve entrapped between brachioradialis and extensor carpi radialis longus Associated with jewelry and wrist watches Diagnosis: pain, numbness, positive Tinel sign, aggravated with pronation Treatment: conservative management or surgical release Do not confuse with Wartenberg sign: ulnar nerve injury leads to extensor digiti minimi (EDM) abduction of small finger secondary to paralysis and lack of adduction by third palmar interosseous

Contractures • Contractures can be due to intrinsic joint problems or extrinsic causes Extrinsic Contracture or loss of motion is due to problem outside the joint (i.e., tendon adhesions, Dupuytren disease) Tendon adhesions Passive motion is better than active motion Treatment: tenolysis; surgically excise adhesions if stiffness persists following adequate therapy program and soft tissues are supple Intrinsic

Passive range of motion is equal to active range of motion Treatment: joint release • Ischemic forearm contracture Injury to forearm soft tissue leads to poor joint range of motion Deepest forearm structures affected most FDP, FPL, and median nerve are deep and most affected FDS, flexor carpi ulnaris (FCU), and flexor carpi radialis (FCR) are more superficial and less affected Holden classification Holden I Arterial ischemia proximal to

forearm (i.e., thromboembolism to upper extremity) Holden II Direct trauma to forearm Tsuge classification (based on extent of muscle involvement) Mild Medium Severe Treatment Initial management: Botox injections (Allergan, Irvine, CA), splinting, physical therapy Holden I or II mild: tendon lengthening Holden I moderate: muscle slide

Holden II moderate: tendon transfer Holden I or II severe: innervated free muscle transfer (i.e., gracilis) • Volkmann contracture Ischemic contracture of forearm Most common cause: supracondylar fracture Most common finding: forearm flexor fibrosis Contracture prevention: compartment release if pressure > 30 mm Hg for > 4 to 6 hours • PIP contracture (flexion) management Initial treatment is nonoperative, with therapy directed at contracture reversal

Dynamic extension splinting Serial casting If contracture remains, can consider surgical options, but maintenance of correction can be challenging Surgical release involves sequential release of affected structures until full extension Release checkrein ligaments (proximal extension of volar plate) Collateral ligament release: true collateral ligament followed by accessory collateral ligaments Capsulectomy Release oblique retinacular ligament of Landsmeer (courses volar to PIP and dorsal to DIP) if

PIP contracture after checkrein ligament release (conceptual, but true identification of this structure and surgical release is not done clinically) Soft tissue coverage of resultant defect is possible, but rarely required after release: full thickness skin graft or cross finger flap

Tendon Transfers • Indications Reconstruction after nerve injury when repair, grafting and nerve transfers are not an option Tendon ruptures: rheumatoid

arthritis, and EPL rupture following distal radius fracture Restores motor function only • Requirements Joints must be supple with good passive motion Adequate muscle strength (a transferred muscle will lose one grade of strength) Adequate excursion (3, 5, 7 rule: tendons attaching at wrist have 3 cm excursion, digital extensors have 5 cm excursion, and FDS tendons have 7 cm excursion) Must have expendable donor (must preserve one wrist/digital flexor, extensor) Straight line of pull

Good soft-tissue coverage: minimal scar and supple tissues One tendon should restore one function Synergistic transfers easier to rehab Tenodesis can be used to augment motion when donor tendon has less excursion than recipient tendon • Classification of nerve injuries High Proximal to mid forearm Reconstruction at this level will use same procedures as for low nerve palsy, plus reconstruction for the proximal deficit Low

Distal to mid forearm After innervation of extrinsic flexors and wrist extensors • High radial nerve palsy Goal is to restore wrist, finger, and thumb extension Wrist extension: pronator teres (PT) to ECRB Finger extension: FCR or FCU or FDS4 to EDC Thumb extension: PL to EPL • EPL laceration late reconstruction EIP to EPL • Low median nerve palsy Goal: restore thumb opposition Abductorplasty PL to abductor pollicis brevis

(APB) Opponensplasty EIP to APB FDS4 to APB Adductor digiti minimi (ADM) to APB (for congenital thumb hypoplasia) • High median nerve palsy Goal: restore thumb, index, and middle flexion and thumb opposition Side-to-side transfer of FDP index and middle to ring and small Brachioradialis to FPL Opponensplasty as described above • Low ulnar nerve palsy

Goal: restore pinch, MP flexion, small-finger adduction Treat claw-hand deformity Dynamic transfers: allow active MP flexion Split FDS to ring and small finger into radial lateral band of intrinsics to flex MCP and extend PIP Split ECRL with graft to radial lateral bands to prevent MP hyperextension Static transfers: block MP hyperextension Loop FDS around SF and RF A1 pulleys and suture back onto pulley Power pinch transfers to adductor

pollicis (AP) and first dorsal interosseous ECRB with tendon graft to AP and first dorsal interosseous FDS4 to AP • High ulnar nerve palsy Must have function of extrinsic flexors to develop a claw Claw hand not present, because no imbalance between intrinsic and extrinsic muscles Power pinch transfers to AP (see above) FDP2 and 3 side-to-side to FDP4 and 5 • Combined low ulnar and median nerve palsy

ECRB and tendon graft to FDP 1 to 4 Static transfers of MCP hyperextension occurs • Quadriplegia C5 tetraplegia Loss of elbow extension Reconstructive goal: wheelchair transfer Deltoid-to-triceps tendon transfer Biceps-to-triceps tendon transfer Low-level tetraplegia Loss of finger flexion and extension Reconstructive goal: key pinch • Cerebral palsy

Spasticity of flexors overpowers extensors and can result in pronation contracture of forearm, flexion contracture of wrist, and adduction contracture of thumb into palm Initial treatment is splinting and stretching Goal of tendon transfers are to improve supination and wrist, finger extension Fractional lengthening effective on flexor side, particularly when passive wrist extension past neutral and limited active extension • Stroke Repair based on level of function

and use of hand, as well as IQ If normal IQ: contracture release for function If low IQ: contracture release for hygiene Tendon transfer: FDS to FDP to lengthen and allow finger extension (this will substantially weaken the hand and typically is only used in nonfunctional hands following stroke)

Suggested Reading Bates SJ, Chang J. Repair of the extensor tendon system. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic

Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:810–816 Beasley RW. Tendon transfers. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:847–855 Bidic SM, Schaub T. Hand: Extensor Tendons, Dupuytren Disease, and Rheumatoid Arthritis. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2009:1–60. Selected Readings in Plastic Surgery; vol 10, issue 26 Cheng J, Ellison CR. Hand: Peripheral Nerves and Tendon Transfers.

Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2010:1–76. Selected Readings in Plastic Surgery; vol 10, issue 27 Lalonde DH. An evidence-based approach to flexor tendon laceration repair. Plast Reconstr Surg 2011;127(2):885–890 Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg 2011;128(1):1e–14e Lehfeldt M, Ray E, Sherman R. MOCPS (SM) CME article: treatment of flexor tendon laceration. Plast Reconstr Surg 2008;121(4, Suppl):1–12 Rockwell WB, Butler PN, Byrne BA. Extensor tendon: anatomy, injury,

and reconstruction. Plast Reconstr Surg 2000;106(7):1592–1603, quiz 1604, 1673 Soltanian H. Tenosynovitis. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:826–829 Trumble TE. Extensor tendon injuries. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:263–278 Trumble TE. Tendon transfers. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:343–360 Trumble TE, Sailer SM. Flexor tendon

injuries. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:231–262 Zidel P. Tendon healing and flexor tendon surgery. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:803–809

46 Hand Tumors Reviewed by Andrew Chen

Hand Tumors • Evaluation History and physical exam Radiological examination Ultrasound: detects cystic lesions Magnetic resonance imaging (MRI): defines soft tissue tumors and vascular anomalies X-ray and computed tomographic (CT) scan: define the bony tumors and calcified tumors in the soft tissue

Biopsy Excisional Incisional: via longitudinal incision within definitive resection • Operating room preparation Do not exsanguinate with Esmarch prior to placement of tourniquet (if malignancy) Can compress brachial artery, elevate arm for 1 minute, then apply tourniquet

Benign Soft Tissue Tumors • Giant cell tumor Most common benign soft tissue hand tumor

Usually arise from flexor tendon sheath Treatment: excision High recurrence rate: 5 to 50% • Glomus tumor Subungual tumor Digital pulp less common Diagnosis Symptoms: pain, sensitivity to cold Blue-purple mass observed Love sign: pain on direct contact Hildreth sign: ablation of pain with tourniquet Ice bath immersion provocative test MRI

Treatment: excision Recurrence: 6 to 32% • Hemangiopericytoma Benign tumor composed of vascular Zimmermann pericytes Diagnosis: biopsy Treatment: wide local resection Potential for malignant transformation • Pyogenic granuloma Nodules that grow rapidly and bleed easily Occurs in young patients after trauma or during pregnancy Histology: inflammatory granulation tissue Treatment: excisional biopsy;

silver nitrate • Keratoacanthoma Benign round, smooth nodule around a keratinous plug Appears in sun-exposed skin and immunosuppressed patients Rapidly grows over weeks Observe for potential spontaneous regression over months Excise in immunosuppressed patients because can grow and metastasize 5.7% develop into small cell carcinoma (SCC) • Digital infantile fibromatosis Rapidly growing broad nodule on dorsal lateral finger

Occurs in children, usually < 1 year old Pathology Intracytoplasmic inclusion bodies Interlacing fibroblasts Treatment Wide excision Skin grafting Local flaps • Schwannoma Neurilemmoma Most common benign nerve tumor Location: nerve sheath Diagnosis Painless proximal to wrist,

painful in fingers Tinel positive MRI Treatment Marginal excision: easy to shell out Do not need biopsy Recurrence rate: 4% • Neurofibroma Benign nerve sheath tumor Grows from within the nerve itself: not easy to shell out May require nerve graft reconstruction See Chapter 10, Skin Lesions and Soft Tissue Tumors, for additional information

• Verruca vulgaris Associated with human papillomavirus infection (types 1 to 4, 7, 10) Treatment: topical agents, cryotherapy

Malignant Soft Tissue Tumors • Squamous cell carcinoma Most common primary hand cancer Treatment Excision with 1 cm margins Mohs surgery if involves nail bed Amputate distal phalanx if

involves bone • Basal cell carcinoma Slow growing, telangiectasias, ulceration with pearly border Treatment Excision with 4 mm margins Mohs surgery if large (> 2 cm) or morpheaform • Kaposi sarcoma Bluish-reddish macule or papule Indolent 10 to 15 years Predisposing factors Human immunodeficiency virus (HIV) Human herpesvirus 8 (HHV-8) Elderly males Immunosuppression

Treatment Antiretrovirals Cryotherapy Chemotherapy Radiation therapy • Malignant melanoma Most deadly skin cancer Acral lentiginous: on palms and soles; most common melanoma in skin of color Subungual melanoma: arises in nail matrix Treatment Full thickness biopsy/excision to evaluate depth Wide local excision Sentinal node biopsy if

intermediate or thick Amputation one joint proximal to closest joint in subungual melanoma • Epithelioid sarcoma Malignant tumor of mesenchymal origin Occurs during third and fourth decades of life Diagnosis: biopsy Treatment Neoadjuvant radiation therapy to shrink tumor Neoadjuvant chemotherapy if tumor > 10 cm diameter, involves lymph nodes, or metastasis

Wide local resection • Synovial sarcoma High grade malignant tumor of mesenchymal origin Arises in proximity to joints, tendons, or bursae Diagnosis: biopsy X-rays: soft tissue calcifications in 20 to 30% Treatment Wide local resection Chemotherapy

Bone Tumors • Enchondroma Most common benign solitary

primary bone tumor Occurs during second to fourth decades of life Most common location: proximal phalanx Diagnosis Painless Pathological fracture X-ray: lucency Histology: cartilaginous Treatment Immobilize for fracture healing: closed reduction, fixation Surgery: open biopsy, curettage, bone grafting Recurrence rate: 10% Follow-up: surveillance X-rays at

6 months, 1 year, and 2 years postop • Enchondromatosis Ollier disease: multiple enchondromas under 10 years of age Maffucci syndrome: multiple enchondromas and hemangiomas Metachondromatosis: multiple enchondromas and osteochondromas • Giant cell tumor of bone Rare in hand Usually occurs in early fourth decade of life Locally aggressive: high rate of recurrence; metastatic potential

X-ray: lytic lesion with no matrix and indistinct borders Treatment: wide local excision or amputation • Aneurysmal bone cyst Rare in hand Usually occurs in second decade of life Locally aggressive: high rate of recurrence; no metastatic potential X-ray: lytic lesion with thin rim of surrounding bone Treatment: curettage and cryosurgery, or wide local excision • Osteochondroma Most common pediatric benign

bone tumor Arises near growth plate Composed of bony stalk and cartilage cap Treatment Observe if small Excise if large and symptomatic causing mass effect Potential for malignant transformation • Osteoid osteoma Benign tumor composed of osteoblasts occurring in long bones Occurs during third and fourth decades of life Symptoms: nocturnal pain

X-ray: < 1 cm diameter sclerotic nidus with surrounding halo Treatment Nonsteroidal anti-inflammatory drugs Curettage and bone grafting if refractory to medications • Osteosarcoma Rare in hand Usually occurs around the knee during first and second decades of life Treatment: wide local excision and chemotherapy

Cysts • Ganglion

Most common hand mass Etiology Idiopathic Degenerative Occurs during second to fourth decades of life Transilluminates on exam Location Scapholunate joint: most common Scaphoid–trapezium–trapezoid joint Radiocarpal joint Treatment Excision of cyst, stalk, and osteophytes if present Nonsurgical (steroid, aspiration,

rupture) have higher recurrence • Mucous cyst Nontender degenerative ganglion cyst found in distal interphalangeal joint Occurs during fifth and sixth decades of life X-ray detects degenerative joint changes Treatment: excision if symptomatic; remove any associated osteophytes • Epidermal inclusion cyst Traumatic implantation of epithelial cells into underlying dermis or bone Treatment: soft tissue excision or curettage from bone

Suggested Reading Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am 1976;1(3):228–235 Archer IA, Brown RB, Fitton JM. Epithelioid sarcoma in the hand. J Hand Surg [Br] 1984;9(2):207–209 Athanasian EA. Bone and Soft Tissue Tumors. In: Wolfe Green's Operative Hand Surgery. 6th ed. Elsevier; 2011: 2141–2195 Bednar MS, Weiland AJ, Light TR. Osteoid osteoma of the upper extremity. Hand Clin

1995;11(2):211–221 Colon F, Upton J. Pediatric hand tumors. A review of 349 cases. Hand Clin 1995;11(2):223–243 Dodge LD, Brown RL, Niebauer JJ, McCarroll HR Jr. The treatment of mucous cysts: long-term follow-up in sixty-two cases. J Hand Surg Am 1984;9(6):901–904 Dolan M, Saint-Cyr M. Hand: Fingernails, Infections, Tumors, and Soft-Tissue Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2009:1–54. Selected Readings in Plastic Surgery; vol 10, issue 25 Feldman F. Primary bone tumors of the hand and carpus. Hand Clin

1987;3(2):269–289 Gandon F, Legaillard P, Brueton R, Le Viet D, Foucher G. Forty-eight glomus tumours of the hand: retrospective study and four-year follow-up. Ann Chir Main Memb Super 1992;11(5):401–405 Idler RS. Benign and malignant nerve tumors. Hand Clin 1995;11(2):203– 209 Keith JE Jr, Wilgis EF. Kaposi's sarcoma in the hand of an AIDS patient. J Hand Surg Am 1986;11(3):410–413 Mankin HJ. Principles of diagnosis and management of tumors of the hand. Hand Clin 1987;3(2):185–195

Noble J, Lamb DW. Enchondromata of bones of the hand. A review of 40 cases. Hand 1974;6(3):275–284 Okada K, Wold LE, Beabout JW, Shives TC. Osteosarcoma of the hand. A clinicopathologic study of 12 cases. Cancer 1993;72(3):719–725 Phalen GS, McCormack LJ, Gazale WJ. Giant-cell tumor of tendon sheath (benign synovioma) in the hand: evaluation of 56 cases. Clin Orthop 1959;15(15):140–151 Trumble TE. Ganglion, mucous cyst, and carpal boss. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:462–467 Trumble TE, Berg D, Bruckner J, et al.

Benign and malignant neoplasms of the upper extremity. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:529–578

47 Hand Infections Reviewed by Devra Becker

Flexor Tenosynovitis • Description Infection of the flexor tendon sheath • Kanavel's four signs Fusiform swelling Partially flexed posturing Tenderness over flexor tendon sheath Pain with passive extension of finger • Treatment

Intravenous (IV) antibiotics Irrigation and drainage of flexor digital sheath Open drainage through Brunner incision exposing A1 to A5 pulleys Closed irrigation through separate counter incisions made over A1 and A5 pulleys If only one or two signs, do needle aspiration to detect presence of infection

Fingertip Infections • Paronychia Nail fold infection Infectious etiology

Acute disease: Staphylococcus aureus Chronic disease: Candida albicans Treatment: soaks, incision, drainage, removal of nail, antibiotics (antifungal if chronic), marsupialize if abscess forms If fails treatment (after several weeks or months): biopsy, X-ray, and rule out cancer • Felon Fingertip pulp infection Treatment: incision, drainage, antibiotics • Herpetic whitlow Etiology: herpes simplex virus (HSV) infection

Vesicular lesions can be confused with paronychia and felon Diagnosis: Tzanck smear of vesicular fluid reveals giant cells Treatment Rest, elevation, dry dressing, anti-inflammatory agents Resolves within a few weeks with conservative treatment (dry dressings) Incision and drainage should be avoided, because can cause secondary bacterial superinfection IV acyclovir if immunocompromised

Specific Pathogens • Staphylococcus aureus Gram-positive cocci Most common pathogen for hand infections, septic arthritis, and IV drug abusers Treatment: first-generation cephalosporin • Neisseria gonorrhoeae Gram-negative diplococci Septic arthritis in young patients with sexually transmitted diseases, no history of trauma Treatment: third-generation cephalosporin • Bacillus anthracis Cutaneous or inhalational spread

Results in ulcerative lesions Treatment: penicillin, ciprofloxacin, or doxycycline • Pseudomonas aeruginosa Most common gram-negative rod found in diabetic wounds (diabetic patients with renal failure have high rates of amputation) Ecthyma gangrenosum: cutaneous infection in patients with P. aeruginosa bacteremia Rapid progression, fatal in patients with febrile neutropenia, complication of chemotherapy Treatment: antipseudomonal antibiotics (piperacillin, gentamicin, ciprofloxacin, and ceftazidime)

• Candida albicans Causes chronic paronychia Diagnosis: potassium hydroxide (KOH) preparation Treatment: see above • Mycobacterium marinum Most common mycobacterial hand infection Lab tests Ziehl–Neelsen stain: detects acid-fast mycobacteria Culture on Löwenstein–Jensen agar plate at 30°C Pathology Granulomas Rice bodies: infected villous bodies on synovial surface

break off and are trapped within an inflammatory mass • HIV needle stick 0.3% conversion risk 80% conversion risk reduction with zidovudine (AZT) prophylaxis 2 hours postinjury and 4 week therapy

Bites • Cat and dog bites Pathogens: Streptococcus, Pasteurella multocida (gramnegative facultative anaerobic bacteria), and Staphylococcus aureus Treatment

Augmentin (amoxicillin and clavulanic acid) Incision/drainage if abscess If have penicillin allergy, need to treat with broad spectrum antibiotics that cover anaerobes Cat bites Seal in infection because cats have long, thin teeth, compared to dog bites, which lacerate and crush All cat bites should be considered for incision and drainage • Human (fight bite) Tooth penetrates metacarpal skin, tendon, joint capsule, and bone Layers of injury separate when

extend hand from clenched fist position Pathogens: Staphylococcus aureus (most common) and Eikenella corrodens (gram-negative anaerobic rod) Treatment: wound exploration, drainage, irrigation of joint space, antibiotics • Deer tick bite (Lyme disease) Pathogen: bacterium Borrelia burgdorferi Symptoms Erythema chronicum migrans: expanding rash resembling a bull's eye On differential for monoarthropathy because can

spread to joints Neurological problems Treatment Antibiotics

and

cardiac

Palmar Space Infections • Collar button Located between dorsal and volar hand, fingers found in abducted position Treatment: incision and drainage from dorsal and volar approaches, antibiotics • Horseshoe Between ulnar bursa, Parona space, and radial bursa

Involves flexor tendon sheaths of small finger and thumb • Parona space Distal volar forearm between pronator quadratus and flexor digitorum profundus Treatment: incision and drainage via extended carpal tunnel release • Thenar space Between thumb metacarpal, index metacarpal, and adductor pollicis • Midpalmar space Between long finger metacarpal, small finger metacarpal, interossei, and flexor tendons • Posterior adductor space Between adductor pollicis and first

dorsal interosseous

Necrotizing Soft Tissue Infections • Pathogens Type 1 Polymicrobial Anaerobic (i.e., Clostridium) and facultative bacteria Type 2 Single pathogen Group A Streptococcus (most common) • Initial presentation Pain Crepitus

Edema Erythema Fever Dishwater purulence: gray, watery discharge • Progresses to Blisters and necrotic skin Systemic disease: septic shock, liver failure, kidney failure, disseminated intravascular coagulation Death • Labs Leukocytosis Thrombocytopenia Hyperkalemia • Predisposing factors

Diabetes: most common Trauma Systemic infection Immunosuppression • Treatment Immediate debridement IV antibiotics Repeat debridement in 12 to 24 hours

Hand Infection Mimickers • Sweet syndrome Skin lesion: acute febrile neutrophilic dermatosis Histology: epidermal and dermal neutrophils without infection or

cellulitis Treatment: steroid taper (unresponsive to antibiotics) • Crystalline arthropathy (gout and pseudogout) Joints appear infected (swelling, redness, tenderness) No history of trauma See Chapter 49, Rheumatology, for additional information • Amyloidosis Can cause carpal tunnel syndrome and tenosynovitis Diagnosis: amyloid sampling

Suggested Reading Chao JJ, Morrison BA. Infections of the

upper limb. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:817–825 Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician 2003;68(2):323– 328 Kozin SH, Bishop AT. Atypical Mycobacterium infections of the upper extremity. J Hand Surg Am 1994;19(3):480–487 Lavery LA, Walker SC, Harkless LB, Felder-Johnson K. Infected puncture wounds in diabetic and nondiabetic adults. Diabetes Care 1995;18(12):1588–1591

Monstrey SJ, van der Werken C, Kauer JM, Goris RJ. Tendon sheath infections of the hand. Neth J Surg 1985;37(6):174–178 Ong YS, Levin LS. Hand infections. Plast Reconstr Surg 2009;124(4):225e–233e Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop Relat Res 1987; (220):237–240 Trumble TE, Hashisaki P. Hand infections. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:214–221 Watt AJ, Shin AY, Vedder NB, Chang J. Joint arthritis and soft-tissue

problems of the hand. Plast Reconstr Surg 2010;126(6):288e–300e

48 Wrist Reviewed by Anthony Perrone

Wrist Anatomy • Carpal bones Mnemonic: Scared lovers try positions that they can't handle Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate

• Wrist ligaments Scapholunate interosseous ligament Primary scaphoid-stabilizing ligament Injury results in dorsal intercalated segment instability (DISI) deformity Lunotriquetral interosseous ligament Injury results in volar intercalated segment instability (VISI) deformity Dorsal ligament complex Primary thumb carpometacarpal (CMC) stabilizing ligament Dorsal intercarpal ligament: between triquetrum and scaphoid

Volar beak ligament: between thumb metacarpal and trapezium Volar ligament of Testut: neurovascular conduit between radius, scaphoid, and lunate (not a true extrinsic ligament) Triangular fibrocartilage complex (TFCC) Primary distal radioulnar joint (DRUJ) stabilizer TFCC injury Pain on ulnar aspect of wrist Arthrogram can document TFCC tear Distal radioulnar shuck test: pain with movement of radius and ulna in opposite directions Treatment: debridement or

repair

Scapholunate Advanced Collapse (SLAC) • Degenerative arthritis of the wrist caused by Scapholunate injury Scaphoid nonunion advanced collapse (SNAC) wrist Kienböck disease: avascular necrosis of the lunate Rotary subluxation of scaphoid Preiser disease: avascular necrosis of the scaphoid Crystalline arthritis • Diagnosis

Scaphoid (Watson) shift test Apply pressure over the scaphoid tubercle as wrist deviates from ulnar to radial position Palpable “clunk,” pain, and laxity preventing vertical repositioning of the scaphoid If scapholunate ligament intact, the scaphoid will reposition vertically Tenderness distal to the Lister tubercle X-ray Diastasis > 2 mm of scapholunate joint (Terry Thomas sign) Scaphoid ring sign due to palmar

rotation of the distal scaphoid pole Capitate proximal migration between scaphoid and lunate • Four stages of SLAC wrist arthrosis Stage 1: arthritis between the radial styloid and the distal scaphoid (radoscaphoid) Stage 2: radial midcarpal (scaphocapitate) Stage 3: ulnar midcarpal (capitolunate) Stage 4: diffuse carpal arthritis involving the entire wrist (pancarpal) • Treatment Acute scapholunate ligament tear (within 3 months)

Dorsal approach Reduce carpal collapse with Kirschner wires Repair scapholunate ligament directly or with suture anchors Flexor carpi radialis tendon or AlloDerm (LifeCell Corp., Bridgewater, NJ) reconstruction Chronic injury Proximal row carpectomy (PRC) Effective if disease limited to radioscaphoid joint Resurface capitate if diseased Arthrodesis Less range of motion compared with PRC Scaphoid excision and four-

corner arthrodesis Arthrodesis between lunate, capitate, hamate, and triquetrum Radioscapholunate arthrodesis Effective for disease limited to radioscaphoid disease Complete wrist fusion Arthroplasty

DISI and VISI Deformities (Fig. 48.1) • DISI deformity Results from scapholunate interosseous ligament injury Diagnosis

Fig. 48.1 Normal, dorsal intercalated segment instability (DISI), and volar intercalated segment instability (VISI) scapholunate angles.

Scaphoid (Watson) shift test X-ray Normal Radiolunate angle is 0 degrees Scapholunate angle is 45 degrees (range: 30 to 60 degrees) DISI Lunate tilted with the cup facing dorsally (remember: dorsal, DISI) Increased radiolunate angle (> 15 degrees of extension)

Increased scapholunate angle (> 60 degrees) • VISI deformity Results from lunotriquetral interosseous ligament injury Diagnosis X-ray Lunate tilted with the cup facing volarly (remember: volar, VISI) Increased radioluante angle (> 15 degrees of flexion) Decreased scapholunate angle (< 30 degrees)

Basal Joint Arthritis • Joints affected

Thumb CMC joint: most common Scaphoid–trapezoid–trapezium (STT) Pantrapezial • Diagnosis Attrition of volar oblique ligament (beak ligament) Loss of thumb abduction Osteophyte migration between first and second metacarpal Subluxation of first metacarpal on trapezium CMC grind test: axial compression and rotation of thumb metacarpal against trapezium causes pain and crepitus X-rays: anteroposterior, oblique,

lateral, and Robert views • Treatment Conservative Splint Nonsteroidal anti-inflammatory drugs (NSAIDs) Steroids Surgery Trapeziometacarpal arthrodesis For young manual laborer Provides strong grip and pinch Less range of motion compared with arthroplasty Arthroplasty Ligament reconstruction tendon interposition (LRTI) Trapeziectomy

Volar beak ligament reconstruction and tendon interposition with palmaris longus, flexor carpi radialis, or abductor pollicis longus tendons Trapeziectomy (hematoma arthroplasty) Polyurethane urea (Artelon) implant joint reconstruction Degradable and more biocompatible than silicone Silicone implant joint reconstruction Complications • Displacement • Synovitis • Giant cell reaction

(granuloma)

Scaphoid Fracture • Scaphoid fracture (Fig. 48.2) Most common carpal bone fractured Triquetrum is second most common carpal bone fractured Scaphoid fracture locations Tubercle (distal) Waist Proximal pole: avascular necrosis results from interrupted retrograde blood flow

Fig. 48.2 Scaphoid tubercle, waist, and proximal pole fractures.

• Diagnosis Pain in anatomical snuffbox Plain X-rays and computed tomographic scan Magnetic resonance imaging scan can be positive for avascular necrosis of proximal pole within 24 hours of injury Reevaluate in 1 to 2 weeks if initial X-rays are negative • Treatment Nondisplaced fracture Cast immobilization 6 to 12 weeks Long arm thumb spica cast for 4

to 6 weeks, followed by short arm thumb spica cast until union is radiologically confirmed Displaced fracture Open reduction internal fixation Compression screw fixation 3 to 6 weeks of cast immobilization Nonunion Vascularized bone graft: 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) and 2,3 ICSRA graft

Perilunate Instability • Mayfield progressive perilunate instability classification

Describes progression of perilunate ligamentous injury patterns Stage I: scapholunate separation Stage II: capitolunate separation Stage III: lunotriquetral separation Stage IV: perilunate dislocation • Diagnosis Radiographs show disruption of Gilula's lines, bone fractures, and carpal gapping Greater arc injury: involves fractures of radial styloid, scaphoid (most common bone fractured), capitate, triquetrum, and/or ulna styloid Lesser arc injury: involves ligamentous injury of

scapholunate, lunocapitate, and/or lunotriquetral joints • Treatment Repair ligaments Open reduction and internal fixation

Suggested Reading Desai HJ, Bidic SM. Hand: Fractures and Dislocations, the Wrist, and Congenital Anomalies. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2011:1–68. Selected Readings in Plastic Surgery; vol 10, issue 29 Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations:

pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5(3):226–241 Mullett H, Hausman M. Fractures and ligamentous injuries of the wrist. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:781–789 Nilsson A, Liljensten E, Bergström C, Sollerman C. Results from a degradable TMC joint Spacer (Artelon) compared with tendon arthroplasty. J Hand Surg Am 2005;30(2):380–389 Sammer DM, Shin AY. Wrist surgery: management of chronic scapholunate

and lunotriquetral ligament injuries. Plast Reconstr Surg 2012;130(1):138e–156e Tomaino MM, Pellegrini VD Jr, Burton RI. Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am 1995;77(3):346–355 Trumble TE. Fractures and dislocation of the carpus. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:90–125 Trumble TE, Rafijah G, Gilbert M, Allan CH, North E, McCallister WV. Thumb trapeziometacarpal joint arthritis: partial trapeziectomy with

ligament reconstruction and interposition costochondral allograft. J Hand Surg Am 2000;25(1):61–76 Trumble T, Verheyden J. Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire. J Hand Surg Am 2004;29(3):412–417 Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9(3):358–365

49 Rheumatology Reviewed by Jennifer F. Waljee

Rheumatoid Arthritis • Patient demographics 1% population Female to male ratio is 3:1 Onset 25 to 50 years old • Rheumatoid arthritis diagnostic criteria (Table 49.1) • Arthritis Impact Measurement Scale: documents baseline disease • Exam Cervical spine involvement (in 25 to 30% of patients)

Swan neck deformity: see below Boutonniere deformity: see below Metacarpal bones angle radially Ulnar drift and subluxation of MCP joint • Labwork Anemia (in 80% of patients) Elevated erythrocyte sedimentation rate (in 90% of patients) Joint fluid aspiration to prove no infection or crystals Table 49.1 Rheumatoid arthritis diagnostic criteria

Need 4 of 7 criteria to establish diagnosis

1. Morning stiffness > 1 hour for > 6 weeks 2. 3 or more joints affected 3. Wrist, metacarpophalangeal (MCP) joints, or proximal interphalangeal (PIP) joints affected for > 6 weeks 4. Bilateral joint involvement 5. Serum rheumatoid factor (RF) elevation (in 70% of patients) 6. Rheumatoid nodules present 7. Radiographic evidence

Serum rheumatoid factor elevation Rheumatoid factor is an

immunoglobulin M (IgM) autoantibody directed against IgG antibody Deposition of antibody–antigen complexes cause pathology Also elevated systemic lupus erythematosus and scleroderma • Radiography Bony erosions • Conservative early treatment Disease-modifying antirheumatic drugs (DMARDs) Nonbiologics (i.e., methotrexate) Biologics (i.e., infliximab) Early initiation of these agents is considered standard of care, most patients who see surgeons

will be on these medications Steroids Splints • Perioperative management Collaborate with rheumatologist to manage immunosuppressive medications in the perioperative period Stop biologics according to length of time of their half life Potential need for stress dose steroids Communicate with anesthesiologist regarding airway management because these patients may have cervical spine disease (check cspine X-ray) • Surgical treatment for progression of

disease Procedures should be driven by patient symptomatology and request, the presence of deformity alone is not an indication for operation (i.e., can manage nonoperatively if patient is not having pain and not bothered by deformities) Treat proximal before distal joints May require management of the soft tissues (synovectomy, tendon rebalancing, tendon repair) Elbow arthroplasty (synovectomy can play a role in some patients in early stages of disease) Wrist arthrodesis MCP arthroplasty

• Extensor digitorum communis (EDC) ulnar sublimation Treatment: tendon rebalancing (centralize extensor tendons at the level of the MCP joint) • Intrinsic tightness Caused by intrinsic rheumatoid myositis Results in: swan neck deformity, MCP flexion, PIP extension Treatment: intrinsic release • Swan neck deformity Description: PIP extension, distal interphalangeal (DIP) joint flexion Loss of function is variable Need to distinguish flexible from fixed deformities

Etiology Terminal tendon rupture (mallet finger) PIP volar plate laxity Intrinsic tightness (decreased PIP flexion with MCP in hyperextension) Lateral bands displaced dorsally at PIP Treatment Address any MCP deformity first before undertaking reconstruction of swan neck deformity If mallet: fix mallet, splint DIP, allow PIP to be free If PIP volar plate laxity: flexor digitorum superficialis (FDS)

slip transferred to volar plate to pull the PIP from extension to flexion If intrinsic tightness: intrinsic release Oblique retinacular ligament (ORL) reconstruction (not commonly done) Lateral band mobilization if flexible deformity Arthroplasty or DIP fusion for more advanced disease • Boutonniere deformity Description: PIP flexion, DIP extension, MCP hyperextension Most patients do not have functional difficulties until late stages

Etiology Central tendon rupture due to synovial proliferation Lateral bands displace volarly at PIP ORL shortens Treatment Determine if fixed or flexible deformity As with swan neck deformity, ensure there is no proximal deformity at level of MCP or wrist to correct first Dynamic splinting: PIP in extension and leave DIP free Centralize lateral bands Extensor tenotomy at the DIP

joint Silicone arthroplasty PIP fusion (last resort) • Rheumatoid arthritis and trigger finger Treatment Steroid injection: first-line treatment Tenosynovectomy and resection of slip of superficialis tendon Excision of flexor tendon nodule Release of A1 pulley: controversial because some surgeons believe that ulnar drift may worsen • Flexor tendon adhesions PIP and DIP joint passive motion

better than active motion Treatment: tenolysis • Extensor tendon rupture Secondary to inflammatory weakening or attrition from underlying bony irregularity Caput ulnae syndrome: ulna is dorsal to carpal bones, leading to erosions and risk for extensor tendon rupture over prominent ulna Vaughan–Jackson progression: extensors rupture over damaged distal radius ulna joint starting on the ulnar side (extensor digiti minimi) and progressing radially (EDC to small finger, ring finger, then long finger) Loss of tenodesis effect where

normally flexion wrist allows extension of MCP if tendon intact Most common tendons ruptured EDC: most common Extensor pollicis longus and extensor digiti minimi Flexor pollicis longus rarely ruptured by scaphoid spur (Mannerfelt lesion) Treatment Repair needs to include tenosynovectomy, and must smooth over bony irregularities if possible (ulnar head resection, relocate the retinaculum) Repair directly: if tendon ends are close together (uncommon to

be able to do this) Tendon graft: if tendon ends are far apart and muscle is not contracted Tendon transfer: if muscle contracted Transfer extensor indicis proprius to small single small or index finger Can also recruit a slip of FDS through the interosseous if needed Darrach procedure: distal ulna resection to eliminate prominence eroding tendons • Differential diagnosis for inability to extend fingers Extensor tendon rupture

MCP dislocation Posterior interosseous nerve compression Weak finger extension Due to elbow joint swelling and compression of arcade of Fröhse Treatment: steroid injection, surgical decompression

Additional Inflammatory Arthritis Conditions • Juvenile rheumatoid arthritis Loss of wrist extension Ulnar angulation of metacarpal bones, and radial deviation of MCP joint (opposite in rheumatoid

arthritis) Loss of flexion at interphalangeal joint Swan neck and boutonniere deformities rare Tendon rupture rare Order of repair: surgically correct deformities from proximal (elbow) to distal (fingers) • Gout Uric acid joint fluid and serum elevated Podagra: big toe pain Crystals have negative birefringence on slit lamp evaluation Medical treatment: colchicine,

allopurinol, nonsteroidal antiinflammatory drugs (NSAIDs), steroids May require joint aspiration to discern from other pathologies • Pseudogout (chondrocalcinosis) Calcium pyrophosphate crystals present in joint fluid Crystals have positive birefringence on slit lamp evaluation • Septic arthritis Painful joint infection caused by bacterial, viral, or fungal infections Staphylococcus aureus is most common cause Leukocytosis and pathogens

present in joint fluid Treatment Can begin with broad spectrum antibiotics, elevation, splinting May require operative washout if fails to improve Consider arthroscopic washout if occurs in the wrist • Psoriatic arthritis Psoriatic skin lesions, arthritis, nail pitting Can present with dactylitis Can progress to significant erosive arthritis and joint loss Pencil-in-cup appearance of joint Opera glass hand Most common deformity in the DIP

joint • Reiter arthritis Triad: reactive arthritis, conjunctivitis, uveitis Precipitated by infection • Human immunodeficiency virus (HIV) infection–related arthritis Explosive onset May lead to psoriatic arthritis or reactive arthritis • Scleroderma See Chapter 42, Dupuytren and Vascular Disease, for more information on scleroderma • Systemic lupus erythematosus (SLE) Autoimmune disorder Soft tissue laxity only without bony

erosions (unless there is concomitant osteoarthritis) Also present with findings similar to rheumatoid arthritis, including MP subluxation, swan neck deformity but without bony erosions May have concomitant Raynaud phenomena (see Chapter 42, Dupuytren and Vascular Disease, for more information on Raynaud phenomena) Associated with malar rash, arthritis, kidney, and pulmonary disease • Palmar fasciitis and polyarthritis syndrome (PFPAS) Associated palmar fibromatosis,

arthritis, and neoplasm Computed tomographic scan abdomen: evaluate for ovarian cancer in women with palmar fibromatosis and arthritis

Osteoarthritis • Description Idiopathic or traumatic arthritis Causes pain and stiffness Most common joints affected: DIP joint followed by carpometacarpal (CMC) joint Women > men (particularly in the CMC joint, likely mediated by postmenopausal hormonal changes)

Fifth decade • Presentation Morning stiffness < 1 hour Worsens with activity Heberden nodules: DIP joint osteophytes (can present with mucoid cysts and nail plate changes) Bouchard nodules: PIP joint osteophytes Basal joint arthritis: for additional information see Chapter 48, Wrist Radiographic evidence of osteophytes and sclerotic changes • Treatment Nonsurgical management Tylenol

NSAIDs (topical or oral) Physical therapy Splints Steroid injections CMC joint hyaluronic acid injections Glucosamine Activity modification Surgical options DIP joint: mucoid cyst excision, DIP fusion (K wires, interosseous wires, headless compression screw) PIP joint arthroplasty: pyrocarbon vs. silicone; fusion last resort MCP joint arthroplasty:

pyrocarbon vs. silicone (much less common); fusion last resort CMC: trapeziectomy with or without interposition arthroplasty and resuspension of the joint (associated variations with abductor pollicis longus, flexor pollicis longus); implantbased reconstruction more controversial

Suggested Reading Bidic SM, Schaub T. Hand: Extensor Tendons, Dupuytren Disease, and Rheumatoid Arthritis. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2009:1–60. Selected

Readings in Plastic Surgery; vol 10, issue 26 Cook GS, Lalonde DH. MOC-PSSM CME article: Management of thumb carpometacarpal joint arthritis. Plast Reconstr Surg 2008;121(1, Suppl):1–9 Haase SC, Chung KC. An evidencebased approach to treating thumb carpometacarpal joint arthritis. Plast Reconstr Surg 2011;127(2):918– 925 Isani A. Upper limb arthritis. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:884–891

Krause ML, Matteson EL. Perioperative management of the patient with rheumatoid arthritis. World J. Orthop. 5(3): 283–291, 2014 Qureshi AA, Saavedra A. Palmar fasciitis and polyarthritis syndrome in patients with ovarian cancer-a case report and review of the literature. Hand (NY) 2011;6(2):220–223 Trumble TE, Gardner GC. Arthritis. In: Trumble Principles of Hand Surgery and Therapy. Philadelphia, PA: Saunders; 2000:401–435 Watt AJ, Shin AY, Vedder NB, Chang J. Joint arthritis and soft-tissue problems of the hand. Plast Reconstr Surg 2010;126(6):288e–300e

Wolf JM, Scher DL, Etchill EW, et al. Relationship of relaxin hormone and thumb carpometacarpal joint arthritis. Clin. Orthop. Relat. Res. 472(4): 1130–1137, 2014

50 Lower Extremity Reviewed by Hani Sbitany

Lower Extremity Nerves • Tibial nerve Branch of sciatic nerve, passes through popliteal fossa, branches to gastrocnemius, soleus, tibialis posterior, and flexor digitorum longus muscles, branches to the sural and plantar nerves Deficit: loss of plantar flexion, absent plantar foot sensation • Sural nerve Located 1 cm posterior to lateral malleolus in subcutaneous tissue

plane Composed of tibial nerve (medial sural branch) and peroneal nerve (lateral sural branch) Supplies sensation to lateral foot and ankle Ideal nerve graft up to 30 cm long and 3.6 mm wide • Plantar nerves: branches of tibial nerve Medial plantar nerve: provides sensation to medial sole; supplies flexor digitorum brevis (flexes proximal and middle phalanges toes), flexor hallucis brevis, and lumbricals Lateral plantar nerve: provides sensation to lateral plantar aspect;

supplies flexor digiti minimi brevis, interossei, lumbricals, and quadratus plantae (flexes lateral four toes through flexor digitorum longus, which is innervated by tibial nerve and not involved in tarsal tunnel) • Tarsal tunnel syndrome Nerve compression: medial and lateral plantar nerves Symptoms: tingling, numbness of plantar toes and feet, worse with activity • Deep peroneal nerve Arises from: common peroneal nerve Supplies anterior leg compartment: tibialis anterior, extensor hallucis

longus, extensor digitorum longus and brevis, peroneus tertius Supplies sensation: to the first web space Deficit: weakness of dorsiflexion (foot drop) • Superficial peroneal nerve Arises from: common peroneal nerve Supplies lateral leg compartment: peroneus longus and brevis Supplies sensation: to the lateral leg Deficit: weakness eversion, plantar flexion, and decreased sensation of lateral leg and middle of dorsum of foot • Peroneal nerve palsy

Secondary to: distal femur and proximal tibia fracture Symptoms: decreased sensation and dorsiflexion Diagnosis: nerve conduction studies Treatment: nerve decompression, nerve repair, or tendon transfer • Thigh nerves Obturator nerve: supplies medial thigh adductors (adductor brevis, longus, and magnus, gracilis, and obturator externis), and sensation to the medial thigh Femoral nerve: supplies anterior thigh muscles, iliacus, sartorius

Preoperative Workup • Clinical exam Palpable pulses: dorsalis pedis (on dorsal foot) and posterior tibialis (between medial malleolus and Achilles tendon) Handheld Doppler: if pulses not palpable Ankle brachial index (ABI): assess for peripheral vascular disease (PVD), < 0.5 to 0.6 needs revascularization Toe brachial index: assess for PVD in patients with diabetes, atherosclerosis with calcified or noncompressible vessels; < 30 mm Hg needs revascularization

•

Angiography or computed tomographic angiography (CTA) If renal problems, can perform duplex ultrasonography Peroneus magnus: anatomic single vessel supplying distal lower extremity; check vascularity of leg with angiography or CTA to avoid inducing ischemia with removal of dominant peroneal artery (peroneus magnus) • Revascularization options Angioplasty Stent Bypass graft

Proximal Third

Reconstruction • Gastrocnemius flap Muscle flap: type 1 Pedicle: sural artery (medial and lateral branches supply medial and lateral muscle heads, respectively) off the popliteal artery, in the popliteal fossa Medial muscle head: longer than lateral head, for extended flap divide origin from the medial condyle of femur Lateral muscle head: beware of common peroneal nerve, which crosses superficial to origin • Do not use: thigh muscle flaps because their proximally based

pedicles do not rotate distally

Middle Third Reconstruction • Soleus flap Muscle flap: type II Dominant pedicles: multiple perforators from popliteal artery, posterior tibial artery, and peroneal artery Minor pedicle: posterior tibial artery, can base reverse soleus off these perforators

Lower Third Reconstruction • Reconstructive options

Free flap Local fasciocutaneous flap • Reverse sural artery fasciocutaneous flap Type A: based on peroneal artery perforators Largest perforator and pivot point is 5 cm proximal to lateral malleolus Use a 2 cm wide base Thin, easier than free flap Most common complication: partial flap necrosis, likely due to venous congestion • Dorsalis pedis fasciocutaneous flap Type B septocutaneous flap: based on dorsalis pedis artery

Donor site morbidity: leave paratenon on donor site to skin graft • Lateral calcaneal fasciocutaneous flap Type B septocutaneous flap: based on peroneal artery Coverage: lateral lower extremity • Radial forearm free flap: thin and pliable with long pedicle • Do not use Tissue expansion (high infection/extrusion rate) Large bulky free flaps: rectus abdominis, latissimus dorsi Local flaps for athletes: use free flap instead to preserve lower extremity function

Foot Reconstruction • Medial plantar flap Sensate flap for plantar weight bearing portion of calcaneus Supplied by medial plantar artery and nerve • Abductor hallucis brevis: for small medial malleolus and heel flaps • Radial forearm free flap Sensate free flap for plantar wounds Supplied by radial artery and medial or lateral antebrachial cutaneous nerves

Trauma Reconstruction • Open tibial fractures (Table 50.1) Low-energy injury: due to falls, collisions from ice skating High-energy injury: due to gunshot wounds, crush injuries, motor vehicle crashes Infection risk: farm injury (most common cause of infection), injury severity, increased length of time from injury, comorbidities

Factors for persistent infection: dead space, no soft tissue coverage, nonviable muscle, devitalized bone • Contaminated Gustilo IIIB defects Initially wash out, debride, antibiotic spacers, and placement of external fixator for stabilization Delay definitive reconstruction once clean after approximately 6 weeks to prevent possible contamination of plates or free flap

Negative pressure wound therapy can be used in the interim to keep the field clean and free of contamination • Tibial defect management algorithm Defects > 6 cm: use vascularized free fibula flap (greater osteocyte viability because vascularized) Defects < 6 cm: do not need free fibula flap, can use nonvascularized cancellous bone graft (heal by creeping substitution, vascular ingrowth) Avoid using ipsilateral fibula to reconstruct tibia: ipsilateral side already weak from tibia, do not use peroneal artery in traumatized limb

• Amputation of traumatic lower extremity Gustilo injury Stabilize patient first: ABCs (airway, breathing, circulation) before amputation Indications: tibial nerve avulsion with absent plantar flexion and sensation, severe soft tissue loss, warm ischemia time > 6 hours Filet-of-foot free flap: use part of amputated lower leg to cover distal stump • Risk factors for infection Farm injury: most common Length of time from injury Severity of injury Comorbidities

• Intramedullary free fibula flap Free fibula flap placed inside medullary canal of allogeneic bone graft Used for large segmental defects of the tibia or femur in children and adolescents who need strong longterm construct Allogeneic bone graft heals more quickly by osteoinduction of free fibula graft

Ulcers • Venous stasis ulcer Chronic wound, brown red discoloration, edema, serous drainage/discharge

Treatment: Unna boot • Diabetic ulcer Secondary to diabetic neuropathy Loss of protective sensation and microvascular thrombosis leads to injury • Peripheral vascular disease ulcer Requires vascular workup Claudication and decreased ankle brachial index May need revascularization prior to reconstruction • Recurrent ulceration of a below-theknee amputation stump Treatment: sensate free flap Keep length: maintain at least 15 cm (5 cm in young patient) for best

function, do not amputate shorter or do above-the-knee amputation

Congenital •

Congenital talipes equinovarus (CTEV) Internally rotated foot: clubfoot Initial conservative treatment: conservative with casting, splints Surgical correction: need preop tissue expansion for coverage after release contracted skin

Suggested Reading Dibbell DG, Edstrom LE. The gastrocnemius myocutaneous flap.

Clin Plast Surg 1980;7(1):45–50 Ducic I, Attinger CE. Foot and ankle reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:689–706 Griffin JR, Thornton JF. Lower Extremity Reconstruction. Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2005:1057. Selected Readings in Plastic Surgery; vol 10, issue 5 Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg 2011;128(5):551e–563e Kasabian AK, Karp NS. Lower-

extremity reconstruction. In: Thorne CH, Beasley RW, Aston SJ, et al, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:676–688 Moran SL, Shin AY, Bishop AT. The use of massive bone allograft with intramedullary free fibular flap for limb salvage in a pediatric and adolescent population. Plast Reconstr Surg 2006;118(2):413– 419 McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstr Surg 1975;55(2):177–185 Medina ND, Kovach SJ III, Levin LS.

An evidence-based approach to lower extremity acute trauma. Plast Reconstr Surg 2011;127(2):926– 931 Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg 1973;26(4):313–321 Reddy V, Stevenson TR. MOC-PS (SM) CME article: lower extremity reconstruction. Plast Reconstr Surg 2008;121(4, Suppl):1–7

Index Note: Page numbers followed by f and t indicate figures and tables, respectively. A Abbe flap, 118f Abdominally based free flaps for breast reconstruction, 177 Abdominal wall – anatomy of, 34, 34f – reconstruction of, 34–35 Abdominal wall transplant, 34 Abdominoplasty, 183–185 – arterial supply to flap in, 184 – coding for, 61 – complications of, 184

– indications for, 183–184 – mini-, 184 Abductor hallucis brevis flap, 319 ABI (ankle brachial index), 318 Abobotulinumtoxin A (Dysport), 219 Accessory mammary tissue, 167 Accessory nerve injury from neck dissection, 112 Acellular dermal matrix in breast reconstruction, 176 Acellularized allograft in nerve repair, 276 Achrocordon, 51 Acinic cell carcinoma, 114t Acne, ice pick, 229 Acral lentiginous melanoma, 46, 295 Acrocephalosyndactyly, 241 Acrocephaly, 97t

Actinic cheilitis, 113 Actinic keratosis, 49 Acute compartment syndrome, 281 Adaptive immunity, 58 Adenoid cystic carcinoma, 114, 114t Adenoma, pleomorphic, 114t Adipofascial turndown flap for fingertip amputation, 250t Adult teeth, 71, 72f Advancement flap, 6–7, 7f Advancing age rhinoplasty, 197 AER (apical ectodermal ridge), 237 Aesthetic cases, 61 Afferent pupillary defect, 123 A fiber, 274 AIN (anterior interosseous nerve), 273 AIN (anterior interosseous nerve) syndrome, 278

ALA (5-aminolevulinic acid) prior to skin resurfacing, 230 Alar batten graft, 197 Alar countour graft, 197 Alar defects – partial nasal reconstruction for, 146 – rhinoplasty for, 197 Alar retraction/collapse, 197 Alar rim graft, 197 Aldara (imiquimod) for actinic (solar) keratosis, 49 Allen test, 21 AlloDerm, 27 – for abdominal wall reconstruction, 35 Allodynia, 282 Allograft, 57 Alloplastic implants, 26 Alopecia. See also Baldness

– androgenic, 223–224 – areata, 224 – female, 223, 223f – traction, 224 Alveolar bone, 72f Alveolar bone grafting, 81 Alveolar cleft, 81 Amastia, 166t Amazia, 166t Ambient temperature in operating room, 163 Ameloblastoma of mandible, 135 5-Aminolevulinic acid (ALA) prior to skin resurfacing, 230 Amniotic band syndrome, 240 Amputation – of finger, 253–254

– of fingertip, 249–250t, 249–251 – of thumb, 255, 256f, 256t – of traumatic lower extremity Gustilo injury, 320 Amputation stump, recurrent ulceration of below-the-knee, 321 Amyloidosis, 303 Anaplastic large-cell lymphoma, breast augmentation and, 170 Anastomotic coupler devices for improved flap perfusion, 23 Anatomical snuffbox, 283 ANB angle, 91f, 91t, 92 Androgenic alopecia, 223–224 Anesthesia, 161–165 – general, 163 – local, 161–162, 161t, 162t – regional, 162–163

Aneurysmal bone cyst, 296 Angle of divergence, 195, 196f Angular artery, 192, 192f Animation test, 155 Ankle brachial index (ABI), 318 Annular pulleys, 283 Anosmia, malingering for, 62 Anterior compartment of neck, 110t, 111f Anterior ethmoid foramen, 69t Anterior ethmoid nerve, 202 Anterior fontanelle, 96, 96f Anterior interosseous nerve (AIN), 273 Anterior interosseous nerve (AIN) syndrome, 278 Anterior lamella of eyelid, 201 Anterior lateral thigh flap, 18, 19t Anterior thoracic hypoplasia, 36

Anterior tibial vessels and nerve, 138f Antia–Buch flap, 131, 132f Antibodies, common side effects of, 59t Anti-CD3 (OKT3), common side effects of, 59t Anti-CD25, common side effects of, 59t Antigen, 57 Antihelix, 127, 127f Anti-inflammatory agents for improved flap perfusion, 23 Antilymphocytes, common side effects of, 59t Antimetabolites, common side effects of, 59t Antimicrobials for burns, 30, 30t Antitragus, 127, 127f Antivenom administration for snake

bites, 54, 54t Antiviral prophylaxis – prior to chemical peels, 215 – prior to skin resurfacing, 230 Antley-Bixler syndrome, 98t Apert syndrome – craniosynostosis in, 98t – hand anomalies in, 241 Apex of root of tooth, 72f Apical ectodermal ridge (AER), 237 Apical foramen, 72f Aplasia cutis congenita, 118 Apligraf, 27 Arcuate line, 34 Argon-pumped tunable dye laser for vascular anomalies, 232t Arnold nerve, 128 Arrector pili muscle, 221f

Arrhythmias due to burns, 31 Artefill, 217 Arteriovenous malformations (AVMs), 103 – of hand, 262 Arthritis – HIV-related, 314 – osteo-, 315 – psoriatic, 314 – Reiter, 314 – rheumatoid, 310–313, 310f – septic, 314 Arthrodesis for SLAC wrist, 305 Arthrogryposis, 241 Arthroplasty for basal joint arthritis, 307 Ascending palatine artery, 92, 93f Asian eyelid blepharoplasty, 205 Asian rhinoplasty, 197

Atasoy–Kleinert single V-Y flap for fingertip amputation, 249t Athelia, 166t Aural atresia repair, 129 Auricle, 127 Auricular composite graft, 143 Auriculotemporal nerve, 128 Autograft, 57 Autologous breast reconstruction, 176–178 Autologous ear reconstruction, 129, 129t Autologous tissue implants, 26 AVMs (arteriovenous malformations), 103 – of hand, 262 Axillary dissection, nerves in, 174 Axillary nerve, 274 Axonotmesis, 275t

Azathioprine (Imuran), common side effects of, 59t B Baboon ear, 130–131 Babysitter procedure for facial paralysis, 107 Baby teeth, 71, 72f Bacillus anthracis, hand infections due to, 300 BAHAs (bone anchored hearing aids), 129 Baker classification of capsular contracture, 167–168, 167t Baker-Gordon formula for chemical peel, 215 Baldness, 221–226. See also Alopecia – causes of, 223–224

– female, 223, 223f – hair anatomy and, 221–222, 221f – hair transplantation techniques for, 223 – male pattern, 222, 222f – scalp flaps for, 224–225, 224–226f Banner flap for constricted ear, 130, 131f Basal cell carcinoma (BCC), 49–50 – of hand, 295 Basal joint arthritis, 307 Basiliximab, common side effects of, 59t BAT (bilateral advancement transposition) flap for baldness, 145, 225, 225f Bazex syndrome, 50 BDD (body dysmorphic disorder), 62 Becker nevus, 51

Bell palsy, 105 Below-the-knee amputation stump, recurrent ulceration of, 321 Belt lipectomy, 182 Benign breast disease, 176 Benign premature thelarche, 167 Benign soft tissue hand tumors, 293–294 Bennett fracture, 266–267 “Bent finger,” 243–244 Benzodiazepine half-lives, 163 Bernard–Burow flap (Webster modification), 116f Biceps femoris muscle/musculocutaneous flap, innervation of, 16t Bilateral advancement transposition (BAT) flap for baldness, 225, 225f Bilateral neck exploration, 110

Bilobed flap, 9, 9f – for nasal reconstruction, 144 Binder syndrome, 100 Biobrane, 27 Biologic mesh for abdominal wall reconstruction, 35 Biomaterials, 27 Biopsy – punch, 45 – sentinel lymph node, 47 Bisphosphonate-related osteonecrosis of the jaw (BRONJ), 136, 137t Bites – cat and dog, 300–301 – deer tick, 301 – hand infections due to, 300–301 – human, 301 – snake, 54, 54t

– spider, 55 Black widow spider bites, 55 Blauth classification of thumb hypoplasia, 244, 245t Bleeding, preoperative cessation of drugs that cause, 163 Blepharochalasis, 152 Blepharoplasty, 204–206 – Asian eyelid, 205 – complications of, 205–206 – lower eyelid, 204–205 – patient assessment for, 204 – prominent eye, 205 – upper eyelid, 204 Blindness – from blepharoplasty, 206 – due to filler, 218 Blue nevus, 48

Blue rubber bleb nevus syndrome, 103 BMP (bone morphogenetic protein), 12 Body contouring, 181–183, 183t Body dysmorphic disorder (BDD), 62 Bone anchored hearing aids (BAHAs), 129 Bone conduction hearing aids, 129 Bone cyst, aneurysmal, 296 Bone dust, 12 Bone formation, 12 Bone grafts, 12 Bone morphogenetic protein (BMP), 12 Bone shortening in nerve repair, 276 Bone tumors of hand, 296–297 Borrelia burgdorferi, 301 Botulinum toxin (BOTOX, onabotulinumtoxin A), 219 – for brow lift, 208

Bouchard nodules, 315 Boutonniere deformity, 287, 312 Bowen disease, 49 “Boxer's fracture,” 265 Boxy tip, 195 Brachial arches, 74, 74t Brachial plexus, 280–281 – anatomy of, 280–281 – injuries of, 281 – palsies of, 281 Brachial plexus block, 162 Brachioplasty, 181 Brachycephaly, 97t Brachydactyly, 243 BRCA, 174 Breast(s) – anatomy of, 166, 174 – burn contracture of, 176

– congenital anomalies of, 166–167, 166t – ectopic, 167 – gynecomastia of, 171–172 – supernumerary, 167 – tuberous deformity of (constricted), 166–167 Breast augmentation, 167–170, 167t – after massive weight loss, 182 – mastopexy with, 170 Breast cancer – BRCA and, 174 – and breast reduction, 171 – diagnosis of, 175 – incidence of, 174 – lymphedema due to, 41t – prognostic factors for, 175, 175t – risk factors for, 174

– staging of, 175t – treatment for, 175 Breast disease, benign, 176 Breast expansion, 39–40 Breastfeeding after breast reduction, 171 Breast hypertrophy, juvenile, 171, 176 Breast implants, 167–170 – in breast reconstruction, 176 – and capsular contracture, 167–168, 167t – complications of, 168–170 – pocket irrigation for, 169 – pocket selection for, 167 – saline, 168 – silicone, 167t, 168–170 – textured, 168 Breast mastopexy, 170, 170t Breast reconstruction, 176–180

– autologous, 176–178 – coding for, 60 – complications of, 178–179 – free flap options for, 177–178 – with implant, 176 – pedicled flap options for, 176–177 – principles of, 176 – radiation therapy and, 178 – serratus branch of thoracodorsal artery in, 179 – tissue expander for, 176, 178 Breast reduction, 171 Brent technique for autologous ear reconstruction, 129, 129t Breslow scale for melanoma, 46 Bronchoscopy for inhalational injury, 30 BRONJ (bisphosphonate-related osteonecrosis of the jaw), 136, 137t

Brow anatomy, 201f, 206–207, 207f Brow lift, 206–209 – anatomy for, 206–207, 207f – complications of, 209 – fixation techniques for, 209 – nonsurgical intervention for, 208 – patient assessment for, 207 – surgical techniques for, 208–209, 208t Brown recluse spider bites, 55 Brow paralysis, static reconstruction for, 107 Brow ptosis, 207 Buccal nerve injury due to facelift, 189 Buccal surface of tooth, 71 Buerger disease, 261 Bupivacaine (Marcaine) for anesthesia, 161t Burn(s), 28–33

– antimicrobials for, 30, 30t – chemical, 32, 32t – complications of, 31 – contracture due to, 30 – – of breast, 176 – criteria for transfer to burn center for, 28 – degrees of, 28, 28t – of ear, 130 – electric, 31 – fluid management for, 29 – frostbite as, 31 – hypermetabolic response to, 30 – immunology of, 28 – inhalational injury due to, 30–31 – nutrition for, 29 – silver and other wound dressings for, 30, 30t

– thermal, 28–31, 28t, 29f, 30t – total body surface area of, 28, 29f Burn care, dermatologic conditions requiring, 32 Burn center, criteria for transfer to, 28 Burn shock, 31 Butterfly graft, 193 C Cadaveric appearance after blepharoplasty, 206 Café au lait spots, 51 Calcineurin inhibitors, common side effects of, 59t Calcium bone substitutes, 26 Calvarial bone graft, 12 Camptodactyly, 243–244 Canaliculodacryocystorhinostomy, 157

Canaliculus, 157f Cancellous bone grafts, 12 Candida albicans, hand infections due to, 300 Canthal tendons, 202, 202f Canthal tilt, 202 Canthoplasty, 154, 155 Capillary malformations (CMs), 103 Capsular contracture, Baker classification of, 167–168, 167t Capsulopalpebral fascia, 203 Caput ulnae syndrome, 313 Carbon dioxide (CO2) laser, 227t, 228t – for skin resurfacing, 228, 229 – for vascular anomalies, 232t Carboxyhemoglobin (COHb) in inhalational injury, 30 Carotid artery blowout, 112

Carotid bifurcation region, 110t, 111f Carotid canal, 70f Carpal bone(s) – anatomy of, 304 – development of, 237 Carpal tunnel syndrome (CTS), 277–278 Carpenter syndrome, craniosynostosis in, 98t Carpometacarpal (CMC) grind test, 307 Carpometacarpal (CMC) joint osteoarthritis, 315 Cartilage grafts, 12–13 Cat bites, 300–301 CATCH-22 syndrome, 77 Cathopexy, 154, 155 Cauliflower ear, 130 Causalgia, 282 Cavum concha, 127

Cementum, 71, 72f Central incisors, 71 Centric occlusion, 90 Centric relation, 90 Cephalic tip rotation, 196 Cephaloauricular angle, 210 Cephalometric analysis, 90–92, 91f, 91t Cerebral palsy, 291 Cerebrospinal fluid (CSF) leakage, 123–124 Cervical nerve injury due to facelift, 189 C fiber, 274 Champy principle, 124 CHARGE syndrome, 100 Charles procedure for lymphedema, 42 Checkrein ligament, 260, 270, 289 Cheilitis, actinic, 113 Cheiralgia paresthetica, 288

Chemical burns, 32, 32t Chemical peels, 213–215 – classification of, 213–215, 213t – deep, 213t, 214–215 – medium, 213t, 214 – pretreatment for, 215 – superficial, 213, 213t Chemosis after blepharoplasty, 206 Chest anomalies, 36 Chest reconstruction, 36, 36t Chimerism, 59 Chin disorders, 94–95 Chondritis after otoplasty, 211 Chondrocalcinosis, 302, 314 Chondrocutaneous composite conchal transposition flap, 131, 132f Chondrodermatitis nodularis helicis, 131

Chromophores, 228, 228t Chylous leak from neck dissection, 111–112 Cicatricial ectropion, 154–155 Cigarette smoking, impaired wound healing due to, 4 Clark's mnemonic for melanoma, 46 Clasped thumb, 240 Clavipectoral fascia, 181 Claw-hand deformity, 290 Cleft hand, 242, 243t Cleft lip, 77–79 – prenatal diagnosis of, 77 – repair of, 77–79, 78f Cleft lip and palate (CLP), 75–82 – alveolar cleft in, 81 – classification of, 75, 75f, 75t – embryology of, 75–76

– epidemiology of, 76, 78t – orthognathic surgery for, 81, 88 – syndromes associated with, 76–77 – velopharyngeal insufficiency in, 81 Cleft palate, 79–80 – palatal anatomy and, 79, 80f – primary vs. secondary, 79 – submucous, 80 – surgical repair of, 80 – terminology for, 79 Cleft rhinoplasty, 79 Cleland ligament in Dupuytren disease, 259 Clinodactyly, 244 CLP. See Cleft lip and palate Clubfoot, 321 CM(s) (capillary malformations), 103 CMC (carpometacarpal) grind test, 307

CMC (carpometacarpal) joint osteoarthritis, 315 CMN (congenital melanocytic nevi), giant, 40, 47–48 CO2 laser. See Carbon dioxide laser Cobb syndrome, 104 Cocaine for anesthesia, 161, 161t Coding, 60–61, 60t COHb (carboxyhemoglobin) in inhalational injury, 30 Collagen in wound healing, 3–4, 3t Collar button infection, 301 Colles fascia, 181–182 Columella, hanging, 196 Columellar artery, 202f Columellar strut graft, 196 Columellolabial angle, 196 Combined low ulnar and median nerve

palsy, 291 Compartment syndrome, acute, 280 Complex regional pain syndrome (CRPS), 282 Complications, medicolegal aspects of, 61 Composite tissue allotransplantation, 57 Compound nevus, 48 Comprehensive plastic surgery, 1–62 – burns in, 28–33 – flaps and microsurgery in, 14–25 – immunology and transplantation in, 57–63 – implants and biomaterials in, 26–27 – local tissue rearrangement in, 6–10 – lymphedema and pressure sores in, 41–44 – skin, bone, and cartilage grafts in,

11–13 – skin lesions and soft tissue tumors in, 45–53 – soft tissue infection in, 54–56 – tissue expansion in, 39–40 – trunk reconstruction in, 34–37 – wound healing in, 3–5 Computer simulation surgery in mandible reconstruction, 139–140 Concha, 127, 127f Conchal depth, 210 Conchoscaphoid angle, 210 Condylar neck fracture, bilateral, 124 Congenital melanocytic nevi (CMN), giant, 40, 47–48 Congenital midline nasal lesions, 86–87 Congenital talipes equinovarus (CTEV), 321

Conjunctiva, 201 Conjunctivodacryocystorhinostomy, 157 Conotruncal anomaly face syndrome, 77 Consent, informed, 62 Constricted breast syndrome, 166–167 Constricted ear, 130, 131f Constriction band syndrome, 240 Contractures, 288–289 – due to burns, 30 Cooper ligaments, 166 Copper vapor laser for vascular anomalies, 232t Coronal suture, 96, 96f Corrugator supercilii muscle, 207t Cortical bone grafts, 12 Cosmetic surgery, 181–233 – abdominoplasty as, 183–185 – blepharoplasty as, 204–206

– body contouring as, 181–183, 183t – brow lift as, 206–209, 207t, 208t – chemical peels as, 213–216 – facelift as, 187–190, 187t, 188t – fat grafting as, 218 – fillers as, 217, 217t, 218–219 – hair transplantation as, 221–226 – injectables as, 219 – lasers for, 227–233 – liposuction as, 185–186, 185t – neck rejuvenation as, 190–191, 191t – otoplasty as, 210–212 – rhinoplasty as, 192–200 Cottle maneuver, 193 Cranial bones and sutures in newborn, 96–97, 96f Cranial fossa, 69 Cranialization, 124

Cranial nerve, free flap to ipsilateral, for facial paralysis, 106 Cranial nerve transfers for facial paralysis, 107 Cranial shapes, 97t Craniofacial anomaly, orthognathic surgery for, 88 Craniofacial microsomia, 99 – orthognathic surgery for, 88–89 Craniofacial syndrome, 99–101 Craniomaxillofacial surgery, 65–154 – for cleft lip and palate, 75–82 – for craniosynostosis and craniofacial syndromes, 96–101 – for ear reconstruction, 127–133 – for eyelid and lacrimal system reconstruction, 150–158 – for facial paralysis, 105–107

– head and neck anatomy for, 67–74 – for head and neck tumors, salivary gland tumors, lip and scalp, 108–119 – for hemangiomas and vascular malformations, 102–104 – for mandible reconstruction, 136–139 – for maxillofacial trauma, 120–126 – for nasal reconstruction, 142–149 – orthognathic, temporomandibular joint and chin, 88–95 – for Tessier clefts, 83–87 Cranioplasty, pediatric, 12 Craniosynostosis, 96–99 – defined, 96 – diagnosis of, 97–98, 97t – normal anatomy and, 96–97, 96f – orthognathic surgery for, 88 – principles for treatment of, 98–99

– syndromic, 98, 98t – unilateral coronal, 98 Creeping substitution, 12 Cribriform plate, 69t, 70f Cross-face nerve graft for facial paralysis, 106 Cross finger flap for fingertip amputation, 249t Crouzon syndrome, craniosynostosis in, 98t Crown of tooth, 71, 72f CRPS (complex regional pain syndrome), 282 Cruciate pulleys, 283 Crura of antihelix, 127f Cryptotia, 130 Crystalline arthropathy, 302 CSF (cerebrospinal fluid) leakage,

123–124 CTEV (congenital talipes equinovarus), 321 CTS (carpal tunnel syndrome), 277–278 Cubital tunnel syndrome, 278–279 Cup ear, 130, 131f Cusp of tooth, 72f Cutaneous groin flap, vascular supply to, 17f Cutaneous horn, 49 Cuticle of hair, 221 Cutis laxa, facelift for, 190 Cyclosporine, common side effects of, 59t Cylindroma, 52 Cymba concha, 127, 127f Cyst(s) – aneurysmal bone, 296

– epidermal inclusion, 51, 297 – ganglion, 297 – of hand, 297 – mucous, 297 – nasal dermoid, 86 D Dacryocystorhinostomy, 157 Dacryon, 84 Dapsone for brown recluse spider bites, 55 Deciduous teeth, 71, 72f Deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction, 177 Deep peels, 213t, 214–215 Deep peroneal nerve, 317 Deep vein thrombosis (DVT), 163–164,

164t Deer tick bite, 301 Delta phalanx, 244 Deltopectoral flap, 18, 19t Dental anatomy, 71–73, 72f Dentin(e), 71, 72f Dentofacial imbalance, orthognathic surgery for, 89 Depressor septi nasi muscle, 203 Depressor supercilii muscle, 207t De Quervain disease, 287 Dermabrasion, 216 – for tattoo removal, 231t Dermatochalasis, 152 Dermatofibroma, 52 Dermatofibrosarcoma protuberans, 52 Dermatologic conditions requiring burn care, 32

Dermatosis papulosa nigra, 50–51 Dermoid cyst, nasal, 86 Descending palatine artery, 92, 93f Dextran for improved flap perfusion, 23 Diabetic ulcer, 321 DIEP (deep inferior epigastric artery perforator) flap for breast reconstruction, 177 DiGeorge syndrome, 77 Digit(s). See Finger(s) Digital infantile fibromatosis, 294 Diode laser, 227t Direct fasciocutaneous flaps, 19t, 20f Disease-modifying antirheumatic drugs (DMARDs), 311 DISI (dorsal intercalated segment instability), 304, 305–306, 306f Distal interphalangeal (DIP) joint

– fractures and dislocations of, 267–268, 268t – osteoarthritis of, 315 Distally based radial forearm pedicled flap, 22, 22f Distal palm injuries, 255 Distal surface of tooth, 73 Distant flap, 10 – for fingertip amputation, 249 Distraction osteogenesis, 92 Distraction test, 154 DMARDs (disease-modifying antirheumatic drugs), 311 Doctor-patient relationship, 61 Dog bites, 300–301 Dorsal grafts, 195 Dorsal intercalated segment instability (DISI), 304, 305–306, 306f

Dorsal intercarpal ligament, 304 Dorsalis pedis fasciocutaneous flap, 19t, 319 Dorsal ligament complex of wrist, 304 Dorsal nasal artery, 202f Dorsal nasal flap, 145, 146f Dorsal onlay grafts, 195 Dorsal sidewall onlay grafts, 195 Double bubble with breast implant, 169 Down syndrome, 100 Dry eye management, 157–158 Dupuytren disease, 259–260, 259t DVT (deep vein thrombosis), 163–164, 164t Dysport (abobotulinumtoxin A), 219 E Ear(s)

– anatomy of, 127–128, 128f – burned, 130 – cauliflower, 130 – constricted (lop, cup), 130, 131f – prominent, 210–212 – Stahl (Spock, baboon, Vulcan, satyr), 130–131 – telephone, 212 Ear avulsion, 130 Ear keloid, 5 Earlobe, 127f Ear reconstruction, 127–133 – Antia–Buch flap for, 131, 132f – autologous, 129, 129t – chondrocutaneous composite conchal transposition flap for, 131, 132f – for chondrodermatitis nodularis helicis, 131

– for congenital deformities, 130–131, 131f – ear anatomy and, 127–128, 127f – for microtia, 128–129 – for middle third helical rim defect, 131 – for traumatic deformities, 130 – for upper third helical rim defect, 131 Ear width, 210 Ecthyma gangrenosum, 300 Ectopic banking for replantation, 254 Ectopic breast, 167 Ectrodactyly, 242, 243t Ectropion, 154–155 – during blepharoplasty, 206 EDC (extensor digitorum communis) ulnar sublimation, 311 Ehlers-Danlos syndrome, facelift for,

190 Eisler fat pocket, 203 Eklund displacement or compression mammograms, 169 Elastoderma, facelift for, 190 Elderly, rhinoplasty in, 197 Electric burns, 31 EM (erythema multiforme), 32 Embolism, pulmonary, 163–164, 164t EMLA (eutectic mixture of local anesthetic) cream, 162 Enamel, 71, 72f Encephalocele, 86 Encephalopathy, postoperative, 164 Enchondral bone formation, 12 Enchondroma, 296 Enchondromatosis, 296 Endoneurium, 274

Endoscopic approach for brow lift, 208–209 Enophthalmos, 122 Entropion, 155 Envenomation – due to snake bites, 54, 54t – due to spider bites, 55 Ephelis, 51 Epiblepharon, 155 Epidermal inclusion cyst, 51, 297 Epidermis, layers of, 45 Epinephrine – finger blocks with, 162–163 – lidocaine with, 161t Epineurium, 274 Epiphora, 157 – after blepharoplasty, 206 Epithelioid sarcoma, 295

Epitope, 57 Eponychium, 247, 247f Equine antivenom, 54, 54t Erbium:yttrium-aluminum-garnet (Er:YAG) laser, 227t, 228t – for skin resurfacing, 228 – for vascular anomalies, 232t Erb palsy, 281 Erythema chronicum migrans, 301 Erythema multiforme (EM), 32 Erythroplasia of Queyrat, 49 Estlander flap, 115f Ethmoid bone, 67, 67f Eutectic mixture of local anesthetic (EMLA) cream, 162 Excisions, 6 Extensor digitorum communis (EDC)

ulnar sublimation, 311 Extensor digitorum longus muscle, 138f Extensor hallucis longus muscle, 138f Extensor tendon compartments, 283, 283t Extensor tendon injury, 285–287, 286f, 286t Extensor tendon rupture, 312–313 External auditory canal, 127f External carotid artery – in blood supply to external nasal pyramid, 192, 192f – in blood supply to maxilla, 92, 93f – injury from neck dissection of, 112 External ear – anatomy of, 127, 127f – arteries of, 127 – embryology of, 128

– nerves of, 127–128 External oblique muscle/musculocutaneous flap, 16t – vascular supply to, 18f External valve obstruction, 194 Extra-octave fracture, 269 Extraocular muscle(s), 67, 68t – injury from blepharoplasty of, 206 Extravasation injury, 257–258 Eyebrow(s) – anatomy of, 201f, 206–207, 207f – ideal position of, 207 Eyebrow lift. See Brow lift Eyelid(s) – anatomy of, 201–203, 201f, 202f – malposition after blepharoplasty of, 205 Eyelid defect

– ectropion as, 154–155 – entropion as, 155 – evaluation of, 150 – lagophthalmos as, 155–156 – of lateral canthus, 151 – lower, 151 – lower lid malposition as, 154–156, 157f – of medial canthus, 151 – periocular, 151 – ptosis as, 152–153, 153t – reconstructive algorithm for, 150–151, 150f – upper, 150–151 F Face – anatomy of, 187–188, 187t, 188t

– blood supply to, 187–188 – retaining ligaments of, 188, 188t – youthful vs. aging, 188 Facelift, 187–190 – anatomy for, 187–188, 187t, 188t – complications of, 188–190 – male, 190 – patient assessment for, 188 – for skin diseases, 190 – subcutaneous, 188 – subperiosteal, 188 – sub-SMAS (deep-plane), 188 – techniques for, 188 Facial artery, 92, 93f, 202f Facial clefts, rare, 83, 84f Facial fractures. See Maxillofacial trauma Facial height, 120

Facial nerve, 187 – injury due to facelift of, 189 Facial paralysis, 105–107 – dynamic reconstruction (facial reanimation) for, 106–107 – etiology of, 105–106 – principles of, 105 – static reconstruction for, 107 Facial reanimation, 106–107 Facial width, 120 Factor V Leiden, 164 Fanconi anemia, hand anomalies in, 245t Fasanella–Servat procedure, 153 Fascial bands in Dupuytren disease, 259, 259t Fasciocutaneous flaps, 18–22, 19t, 20–22f Fasciotomy for snake bites, 54

Fat grafting, 218 – for breast implant, 169–170 Fat necrosis with breast reconstruction, 178 FDMA (first dorsal metacarpal artery) flap for fingertip amputation, 250t FDP tendon. See Flexor digitorum profundus tendon FDS (flexor digitorum superficialis) tendon – anatomy of, 283 – injury of, 285 Felon, 299 Female alopecia, 223, 223f Femoral nerve, 318 FH line, 91f, 91t, 92 Fibroadenoma, 176 Fibromatosis, digital infantile, 294

Fibrous dysplasia, 101 Fibula muscle/musculocutaneous flap, 16t Fibula osteoseptocutaneous flap, 139–140 Fight bite, 301 Filariasis, lymphedema due to, 41t Fillers – classification of, 217, 217t – complications of, 218–219 – medicolegal aspects of, 61 Finasteride (Propecia) – for androgenic alopecia, 224 – for male pattern baldness, 222 Finger(s) – amputation of, 253–254 – “bent,” 243–244 – conjoined, 239–240, 239f

– duplication of, 237–239, 238f, 238t – Jersey, 268, 268t – overgrowth of, 243 – short, 243 – transposition of, 254 – trigger, 287 – – rheumatoid arthritis and, 312 Finger blocks with epinephrine, 162–163 Fingertip(s) – anatomy of, 247, 247f – infections of, 299 – nailbed injuries of, 248 – reconstruction for amputated, 249–250t, 249–251 First-degree burns, 28, 28t First dorsal metacarpal artery (FDMA) flap for fingertip amputation, 250t

First molars, 71 Fitzpatrick skin classification, 229, 229t FK-506 (tacrolimus), common side effects of, 59t Flag flap for constricted ear, 130, 131f Flap(s) – advancement, 6–7, 7f – bilobed, 9, 9f – distant, 10 – failure of, 22–23 – fasciocutaneous, 18–22, 19t, 20–22f – improving perfusion of, 23–24 – interposition, 9 – island, 10 – monitoring of, 22 – muscle/musculocutaneous, 14, 14–16t, 17f, 18f, 19t, 20f – random cutaneous, 6

– rhomboid (Limberg), 8, 8f – rotation, 6, 6f – transposition, 7–9, 8f, 8t, 9f – venous flow through, 24 – vomer, 80 – v-Y, 7, 7f Flaring ala, 197 Flexor digitorum longus muscle, 138f Flexor digitorum profundus (FDP) tendon – anatomy of, 283 – avulsion of, 268, 268t – injury of, 285 Flexor digitorum superficialis (FDS) tendon – anatomy of, 283 – injury of, 285 Flexor hallucis longus muscle, 138f

Flexor pollicis longus (FPL) tendon, 283 Flexor tendon(s) – adhesions of, 312 – anatomy of, 283 – injury of, 284–285, 284f, 284t Flexor tenosynovitis, 299 Floor of orbit, 67 Fluid management – for burns, 29 – with suction lipectomy, 185 5-Fluorouracil (5-FU) for actinic (solar) keratosis, 49 Follicle papilla of hair, 221f Follicular unit extraction (FUE), 223 Foot reconstruction, 319 Foramen cecum, 69t Foramen lacerum, 69t, 70f Foramen magnum, 69t, 70f

Foramen ovale, 69t, 70f Foramen rotundum, 69t, 70f Foramen spinosum, 70f Forearm – injuries of, 255 – ischemic contracture of, 288–289 – median nerve compression at, 278 – radial nerve compression at, 279 Forearm compartment release, 280 Forehead expansion, 39 Forehead flap for nasal reconstruction, 144–145, 144f, 145f Forehead muscles, 206, 207t FPL (flexor pollicis longus) tendon, 283 Fractional CO2 laser skin resurfacing, 229 Franceschetti–Klein syndrome, 100 Fred technique for hanging columella,

196 Free fibula flap for mandible reconstruction, 138–139, 138f Free flaps – for abdominal wall reconstruction, 34 – for breast reconstruction, 177–178 – coding for, 60 – failure of, 22–23 – for fingertip amputation, 249 – monitoring of, 22 Frey syndrome, 114 Froment sign, 278 Frontal bone – anatomy of, 67, 67f – pediatric fractures of, 125 Frontalis muscle, 207t Frontalis sling, 153 Frontal nerve injury due to facelift, 189

Frontal sinus fractures, 123–124 Frostbite, 31 FUE (follicular unit extraction), 223 5-FU (5-fluorouracil) for actinic (solar) keratosis, 49 Full-thickness burns, 28, 28t Full-thickness skin graft (FTSG), 11–12 – for nasal reconstruction, 143 Furlow palatoplasty, 80, 81 Furnas sutures, 211 G Galactorrhea after breast augmentation, 169 Gamekeeper's thumb, 271–272, 271f GAN (greater auricular nerve) – anatomy of, 127 – injury due to facelift of, 189

Ganglion, 297 Gastric bypass procedures, 182 Gastrocnemius muscle, 138f Gastrocnemius muscle/musculocutaneous flap, 15t, 318 Gender reassignment, 62 General anesthesia, 163 Genioplasty, 94 Germinal matrix – anatomy of, 247, 247f – injury of, 248 Giant cell tumor – of bone, 296 – of hand, 293 – of mandible, 135–136 Giant congenital melanocytic nevi, 40, 47–48

Gillies approach to zygoma fractures, 121 Gillies fan flap, unilateral, 117f Gingival margin, 72f Gingivoperiosteoplasty for alveolar cleft, 81 Glioma, 86 Global period, 61 Glomus tumor, 293 Gluteal autoaugmentation, 182 Gluteus maximus muscle/musculocutaneous flap, 16t Glycolic acid – for chemical peel, 213 – prior to skin resurfacing, 230 Gnathion, 91f, 91t Goldenhar syndrome, 99–100 Gonion, 91f, 91t

Gore-Tex (polytetrafluoroethylene) mesh for abdominal wall reconstruction, 35 Gorlin syndrome, 50 Gosain earlobe technique, 211 Gout, 302, 314 Gracilis muscle/musculocutaneous flap, 15t – for abdominal wall reconstruction, 34 – innervation of, 16t – vascular supply to, 17f Grafts – alar, 197 – allo-, 57 – auricular composite, 143 – auto-, 57 – bone, 12 – – alveolar, 81 – butterfly, 194

– cartilage, 12–13 – columellar strut, 196 – dorsal, 195 – fat, 169–170, 218 – iso-, 57 – lateral crus, 197 – micro-, 223 – nerve, 276 – – cross-face, 106 – punch, 223 – skin, 11–12, 11t – splay, 194 – spreader, 193, 195 – tip, 196 – xeno-, 57 Graham and Gault technique, 211 Granuloma – pyogenic, 52, 294

– silicone, 168 Graves thyroid ophthalmopathy, 205 Grayson ligament in Dupuytren disease, 259 Greater auricular nerve (GAN) – anatomy of, 127 – injury due to facelift of, 189 Greater palatine artery, 80f Greater palatine foramen, 70f Groin flap, 19t Growth plate fractures, 269, 270f, 270t Gustatory rhinorrhea after rhinoplasty, 198 Gustilo classification of open tibial fractures, 319–320, 320t Guyon canal syndrome, 279 Gynecomastia, 171–172 – pseudo-, 183, 183t

H Hair anatomy, 221–222, 221f Hair follicle, 221 Hairline distortion due to facelift, 190 Hair regrowth time, 223 Hair removal, laser, 232–233 Hair shaft, 221, 221f Hair shape, 221f, 222 Hair sheath, 221f, 222 Hair transplantation, 221–226 – causes of baldness and, 223–224 – for female alopecia, 223, 223f – hair anatomy and, 221–222, 221f – for male pattern baldness, 222, 222f – scalp flaps for, 224–225, 224–226f – techniques for, 223 Halo nevus, 48 Hamulus, 80f

Hand(s) – claw, 290 – cleft, 242, 243t – embryology of, 237 – hoof (rosebud), 241 – “lobster claw,” 242 – overgrowth of, 243 – spade (obstetrician's), 241 – spoon (mitten), 241 Hand anomalies, 237–246 – acrocephalosyndactyly (Apert syndrome) as, 241 – arthrogryposis as, 241 – brachydactyly as, 243 – camptodactyly as, 243–244 – classification of, 237 – cleft hand (ectrodactyly) as, 242, 243t – clinodactyly as, 244

– constriction (amniotic) band syndrome, 240 – Kirner deformity as, 246 – macrodactyly as, 243 – Madelung deformity as, 241, 242f – in Möbius syndrome, 246 – most common, 237–240 – other, 241–246 – in Poland syndrome, 241 – polydactyly as, 237–239, 238f, 238t – radial limb syndromes as, 244, 245t – symphalangism as, 246 – syndactyly as, 239–240, 239f – thumb hypoplasia as, 244–246, 245t – thumb in palm deformity as, 241–242 – trigger thumb as, 240 Hand compartment release, 280 Hand dislocations

– complete, 264 – distal interphalangeal (DIP) joint, 267–268, 268t – dorsal vs. volar, 264 – MCP dorsal, 272 – phalangeal, 267 – principles of management of, 264–265, 265f – proximal interphalangeal (PIP), 269 – simple, 264 Hand fractures, 264–270 – complications of, 270 – distal interphalangeal (DIP) joint, 267–268, 268t – metacarpal, 265–266 – pediatric, 269–270, 270f, 270t – phalangeal, 267 – principles of management of, 264–265,

264f – proximal interphalangeal (PIP), 269 – site of, 264, 264f – thumb, 266–267 Hand infections, 299–303 – due to bites, 300–301 – of fingertips, 299 – flexor tenosynovitis as, 299 – mimickers of, 302–303 – necrotizing soft tissue, 302 – of palmar space, 301 – specific pathogens in, 300 Hand injuries, 253–258 – of distal palm, 255 – of forearm, 255 – infiltration injury as, 257–258 – reconstructive goals for, 253 – replantation for, 253–254

– ring avulsion injury as, 257 – techniques for improving function with, 254 – thumb reconstruction for, 255, 256f, 256t Hand ligament injuries – gamekeeper's/skier's thumb as, 271–272, 271f – of index finger MCP radial collateral ligament, 272 Hand surgery, 235–316 – for congenital anomalies, 237–246 – for Dupuytren disease, 259–260, 259t – for finger amputations, 247–252 – for fractures and dislocations, 264–272 – for infections, 299–303 – for mutilating hand injuries, 253–258

– for nerve disorders and compartment syndrome, 273–282 – for rheumatologic disorders, 310–316 – for tendon disorders, 283–292 – for tumors, 293–298 – for vascular disease, 261–262 – for wrist disorders, 304–309 Hand tendons, 283–292 – anatomy of, 283–284, 283t – contractures of, 288–289 – extensor tendon injury of, 285–287, 286f, 286t – flexor tendon injury of, 284–285, 284f, 284t – nerve injuries affecting, 290–291 – tendonitis of, 287–288 – tendon transfers of, 289–290 Hand tumors, 293–298

– benign soft tissue, 293–294 – of bone, 296–297 – cysts as, 297 – evaluation of, 293 – malignant soft tissue, 295–296 – operating room preparation for, 293 Hanging columella, 196 Harlequin deformity, 98 Head anatomy, 67–74 – brachial arches in, 74, 74t – dental, 71–73, 72f – mandible in, 69, 71t – orbital, 67, 67f, 68t – scalp, 68 – sinus, 68 – skull base in, 69, 69t, 70f – tongue in, 73, 73f Head and neck reconstruction, 112–113

Head and neck tumors – classification and staging of, 108, 109t – neck dissection for, 109–112, 110t, 111f – pediatric, 118 – reconstruction for, 112–113 Health Insurance Portability and Accountability Act (HIPAA), 62 Hearing aids for microtia, 129 Hearing in microtia, 129 Heberden nodules, 315 Helical advancement flaps, bilateral, 132f Helical rim defect – middle third, 131 – upper third, 131 Helical rim height, 210 Helical rim protrusion, 210

Helix, 127, 127f Hemangiomas, 102 Hemangiopericytoma, 293 Hematoma – due to facelift, 188–189 – of nailbed, 248 – after otoplasty, 211 – retrobulbar, 206 – septal, 122 Hemifacial microsomia, 99 – orthognathic surgery for, 88–89 Heparin for improved flap perfusion, 23 Hering's law of equal innervation, 153 Hering test, 153 Herpes outbreak prior to skin resurfacing, 230 Herpetic whitlow, 299 Hertel exophthalmometry, 154

Heterotopic replantation, 254 High median nerve palsy, 290 High-pressure injection injury, 258 High radial nerve palsy, 290 High ulnar nerve palsy, 291 Hildreth sign, 293 HIPAA (Health Insurance Portability and Accountability Act), 62 Hirudo medicinalis for improved flap perfusion, 23 Histocompatibility, 58 HIV (human immunodeficiency virus) needle stick, 300 HIV (human immunodeficiency virus)related arthritis, 314 HLAs (human leukocyte antigens), 58 Holden classification of ischemic forearm contractures, 288

Hollowed out appearance after blepharoplasty, 206 Holoprosencephaly, 100 Holt–Oram syndrome, 245t Hoof hand, 241 Hook nail deformity, 251 Horner syndrome, ptosis due to, 152 Horseshoe infection, 301 Human bites, 301 Human immunodeficiency virus (HIV) needle stick, 300 Human immunodeficiency virus (HIV)related arthritis, 314 Human leukocyte antigens (HLAs), 58 Hurley staging of hydradenitis suppurativa, 55t Hutchinson–Gilford syndrome, facelift for, 190

Hutchinson sign, 47 Hyaluronic acid fillers, 217 Hydradenitis suppurativa, 55–56, 55t Hydrofluoric acid burns, 32t Hydroquinone – as skin lightener, 215 – prior to skin resurfacing, 230 Hyperesthesia, 282 Hypermetabolic response to burns, 30 Hypertelorbitism, 84–86, 85f Hyperthermia, malignant, 163 Hypertrophic inferior turbinate, 193 Hypertrophic scars, 5 Hypoglossal canal, 69t, 70f Hypoglossal nerve injury, 112 Hyponychium, 247, 247f Hypothenar hammer syndrome, 261

I Ice pick acne, 229 IFSSH (International Federation of Societies for Surgery of the Hand) Classification of Congenital Hand Anomalies, 237 Iliac osseomusculocutaneous flap, 15t – vascular supply to, 17f Iliohypogastric nerve during abdominoplasty, 184 Ilioinguinal nerve during abdominoplasty, 184 Imiquimod (Aldara) for actinic (solar) keratosis, 49 Immunity, innate vs. adaptive, 58 Immunology – of burns, 28 – of transplantation, 57–59, 58t, 59t

Immunosuppressive agents, 58, 58t – common side effects of, 58, 59t – impaired wound healing due to, 4 Implants, 26 – breast, 167–170 – Medpor mandibular angle, 92 – osseointegrated dental, 137 Imuran (azathioprine), common side effects of, 59t Incisive canal, 70f Incisive foramen, 80f Incisors, 71 Incobotulinumtoxin A (Xeomin), 219 Index finger MCP radial collateral ligament injury, 272 Infection(s) – of breast implant, 169 – with breast reconstruction, 179

– with burns, 31 – due to facelift, 190 – hand, 299–303 – impaired wound healing due to, 4 – of open tibial fractures, 319–320 – soft tissue, 54–56, 54t, 55t Inferior alveolar nerve, 69 Inferior crus, 127 Inferior meatus, 157f Inferior oblique muscle, 68t Inferior orbital fissure, 67, 67f, 69t Inferior rectus muscle, 68t Inferior turbinate, hypertrophic, 193 Infiltration injury, 257–258 Inflammatory phase of wound healing, 3t Informed consent, 62 Infraorbital artery, 202f Infraorbital nerve, 203

Infratrochlear nerve, 202 Infundibulum of hair, 221f, 222 Inhalational injury, 30–31 Injectables, 219 – medicolegal aspects of, 61 Injection injury, high-pressure, 258 Innate immunity, 58 Inner root sheath of hair, 222 Inosculation stage of skin graft healing, 11t Insurance cases, 61 Integra Dermal Regeneration Template, 27 Intense pulsed dye laser, 227t, 228t Interdomal suture, 196 Internal acoustic meatus, 69t, 70f Internal carotid artery, 202f Internal oblique

muscle/musculocutaneous flap, 16t Internal valve obstruction, 193 International Federation of Societies for Surgery of the Hand (IFSSH) Classification of Congenital Hand Anomalies, 237 Interorbital distance (IOD), 84 Interposition flap, 9 Intersection syndrome, 287–288 Intertragic incisure, 127f Intertragic notch, 127 Intradermal nevus, 48 Intramedullary free fibula flap, 320–321 Intravenous fluid (IVF) for burns, 29 Intravenous (IV) infiltration injury, 257 Intrinsic tightness due to rheumatoid arthritis, 311–312 Inverted V deformity after rhinoplasty,

198 IOD (interorbital distance), 84 Ischemia due to filler, 218 Ischemic forearm contracture, 288–289 Ischial sores, 42, 43t Island flap, 10 Isograft, 57 IVF (intravenous fluid) for burns, 29 IV (intravenous) infiltration injury, 257 J Jaw, bisphosphonate-related osteonecrosis of, 136, 137t Jersey finger, 268, 268t Jessner solution for chemical peel, 213 Jeune syndrome, 167 Job hiring, medicolegal aspects of, 61 Jones tests, 157

Jugular foramen, 69t, 70f Junctional nevus, 48 Juri flap for baldness, 225, 226f Juvenile breast hypertrophy, 171, 176 Juvenile melanoma, 48 Juvenile rheumatoid arthritis, 313 K Kanavel's four signs of flexor tenosynovitis, 299 Kaposi sarcoma, 295 Karapandzic repair of lower lip, 116f Kasabach–Merritt syndrome, 103 Keloids, 4–5 Kenalog steroid injections for alopecia areata, 224 Keratoacanthoma, 49, 294 Keratocystic odontogenic tumor, 134

Keratosis – actinic (solar), 49 – seborrheic, 50 Kernahan and Stark's Striped Y classification of cleft lip and palate, 75, 75f Ketamine for anesthesia, 162 Kienböck disease, 304 Kirner deformity, 246 Kleeblattschädel, 97t Klinefelter syndrome, gynecomastia in, 172 Klippel–Feil syndrome, 100–101 Klippel–Trenaunay syndrome, 104 Klumpke palsy, 281 Kojic acid – for chemical peel, 213 – as skin lightener, 216

KTP laser, 227t, 228t – for vascular anomalies, 232t Kuhnt–Szymanowski procedure, 154 Kutler bilateral V-Y advancement flap for fingertip amputation, 249t L Labial surface of tooth, 73 Labiaplasty, 182 Lacrimal bone, 67, 67f Lacrimal sac, 157f Lacrimal system – anatomy of, 156, 157f – reconstruction of, 157–158 Lactrodectus mactans bites, 55 Lagophthalmos, 155–156 Lambdoid suture, 96f Laryngectomy, 113

Laser(s), 227–233 – defined, 227 – for hair removal, 232–233 – mechanism of action of, 227–228 – for skin resurfacing, 228–230, 229t – for tattoo removal, 230–231, 231t – types of, 227–228, 227t, 228t – for vascular anomalies, 231, 232t Lateral arm flap, 19t, 20 Lateral aspect of nose, partial nasal reconstruction for, 146 Lateral brow elevation, 208 Lateral calcaneal artery flap, 18, 20f Lateral calcaneal fasciocutaneous flap, 319 Lateral canthal tendon, 202, 202f Lateral canthus defect, 151 Lateral crus graft, 197

Lateral femoral cutaneous nerve during abdominoplasty, 184 Lateral incisors, 71 Lateral plantar nerve, 317 Lateral pterygoid muscle, 71t Lateral rectus muscle, 68t Lateral retinaculum, 203 Latissimus dorsi muscle/musculocutaneous flap, 16t – for abdominal wall reconstruction, 34 – for breast reconstruction, 177 – for chest reconstruction, 36 Lawsuits, 61 Leddy classification of Jersey finger, 268, 268t Leeches for improved flap perfusion, 23 Le Fort fractures, 120–121, 120f Le Fort I osteotomy, 92

Lentigo, 51 Lentigo maligna melanoma, 46 Lesser occipital nerve, 128 Lesser palatine foramina, 70f Levator advancement, 153 Levator aponeurosis, 203 Levator function, grades of, 153 Levator labii superior alaeque nasi muscle, 203 Levator palpebral muscle, 203 Levator plication, 153 Levator veli palatini (LVP) muscle, 79, 80f Lidocaine, 161, 161t, 162t Lid retractors, 203 Limb development, 237 Limberg flap, 8, 8f Lingual nerve in head and neck

reconstruction, 113 Lingual surface of tooth, 71 Lip cancer, 113 Lipectomy, suction, 185–186 Lipoma, 87 Liposuction, 185–186, 185t – upper arm, 181 Lip reconstruction, 115, 115–117f, 115t Lisch nodules, 51 Littler flap for fingertip amputation, 250t LMs (lymphatic malformations), 103 “Lobster claw hand,” 242 Lobule of ear, 127 Lobule to nostril ratio, 195, 195f Local anesthesia, 161–162, 161t, 162t Local flaps for fingertip amputation, 249, 249–250t Local muscle transposition for facial

paralysis, 106 Local tissue rearrangement, 6–10 – advancement flap as, 6–7, 7f – bilobed flap as, 9, 9f – distant flap as, 10 – excisions as, 6 – interposition flap as, 9 – island flap as, 10 – random cutaneous flap as, 6 – rhomboid (Limberg) flap as, 8, 8f – rotation flap as, 6, 6f – transposition flap as, 7–9, 8f, 8t, 9f – V-Y flap as, 7, 7f – Z-plasty as, 8, 8t, 9f Lockwood ligament, 203 Lop ear, 130, 131f Love sign, 293 Lower back wound, 37

Lower body lift, 182 Lower extremity, 317–322 – congenital anomalies of, 321 – foot reconstruction of, 319 – lower third reconstruction of, 319 – middle third reconstruction of, 318–319 – nerves and nerve disorders of, 317–318 – preoperative workup for, 318 – proximal third reconstruction of, 318 – trauma reconstruction of, 319–321, 320f – ulcers of, 321 Lower eyelid – blepharoplasty of, 204–205 – – malposition after, 205 – defect of, 151

– lid retractors of, 203 – malposition of, 154–156, 157f – periorbital fat of, 203 Lower jugular region, 110t, 111f Lower leg, transverse cross-section anatomy of, 138f Lower lip – Karapandzic repair of, 116f – static reconstruction for asymmetry of, 107 Low median nerve palsy, 290 Low radial nerve palsy, 290 Low ulnar nerve palsy, 290–291 Loxosceles reclusa bites, 55 Luckett procedure, 211 Ludwig classification of female alopecia, 223, 223f Lumbrical(s), 283

Lumbrical plus after fingertip amputation, 251 Lunotriquetral interosseous ligament, 304 Lunula, 247, 247f LVP (levator veli palatini) muscle, 79, 80f Lyme disease, 301 Lymphangioma circumscriptum, 52, 103 Lymphatic drainage patterns of head and neck, 111 Lymphatic malformations (LMs), 103 Lymphedema, 41–42, 41t Lymph node biopsy, sentinel, 47 M Mackinnon classification of nerve injuries, 275, 275t

Macrodactyly, 243 Macrostomia, 76 Madelung deformity, 241, 242f Mafenide acetate (Sulfamylon) for burns, 30, 30t Maffucci syndrome, 104, 296 Major histocompatibility complex (MHC), 58 Malar support, 154 Male facelift, 190 Male pattern baldness, 222, 222f Male rhinoplasty, 197 Malignant hyperthermia, 163 Malignant melanoma. See Melanoma Malignant soft tissue hand tumors, 295–296 Malingering for anosmia, 62 Mallet injury, 267, 268t

Malocclusion, 88, 88t Mammary tissue, accessory, 167 Mammograms, Eklund displacement or compression, 169 Mandible – anatomy of, 69, 71t – computer simulation surgery in mandible reconstruction, 139–140 – defect classification, 134 – deformities of, 92 – fibula osteoseptocutaneous flap, 139–140 – fractures of, 124 – – pediatric, 125 – osteonecrosis of, 136, 137t – reconstruction of, 136–139, 137t, 138f – tumors of, 134–137 Mandibular ligaments, 188t

Mandibulectomy, 136 Mandibulofacial dysostosis, 100 Marcaine (bupivacaine) for anesthesia, 161t Marcus Gunn pupil, 123 Marfan syndrome, chest anomalies in, 36 Marginal mandibular nerve injury – due to facelift, 189 – due to neck dissection, 112 Marjolin ulcers, 43 Marlex (polypropylene) mesh for abdominal wall reconstruction, 35 Martin–Gruber connection, 274 Masseteric ligaments, 188, 188t Masseter muscle, 71t Massive localized lymphedema (MLL), 41t, 42 Massive weight loss

– body contouring complications with, 183 – gastric bypass procedures for, 182 – mastopexy and autoaugmentation of breasts after, 182 – nutrition with, 182–183 – pseudogynecomastia after, 183, 183t Mastectomy, 175 Mastication muscles, 69, 71t Mastoid foramen, 70f Mastopexy, 170, 170t – after massive weight loss, 182 Mathes–Nahai classification – of fasciocutaneous flaps, 19t, 20f – of free fibular flap, 138 – of muscle/musculocutaneous flaps, 14t Matrix cells of hair, 221f Maxilla, 67, 67f

– blood supply to, 92, 93f – hypoplasia of, 92 – vertical deficiency of, 92 – vertical excess of, 92 Maxilla-mandibular fixation (MMF), 124–125 Maxillary artery, 92, 93f Maxillectomy, midface reconstruction after, 113 Maxillofacial trauma, 120–126 – coding for, 61 – frontal sinus fractures as, 123–124 – general information on, 120 – indications to extract teeth in line of fracture with, 124–125 – Le Fort fractures as, 120–121, 120f – mandibular fractures as, 124 – nasal fractures as, 121–122

– nasoorbitoethmoid (NOE) fractures as, 123, 123t – orbital fractures as, 122–123 – pediatric, 125 – zygoma fractures as, 121 Maxillonasal dysplasia, 100 Mayfield progressive perilunate instability classification, 308 McCash procedure for Dupuytren disease, 260 McCune–Albright syndrome, 101 MCP joint. See Metacarpophalangeal joint Medial arm flap, 19t Medial brow elevation, 208 Medial canthal tendon, 202, 202f Medial canthus defect, 151 Medial plantar flap, 319

Medial plantar nerve, 317 Medial pterygoid muscle, 71t Medial rectus muscle, 68t Medial thigh lift, 181–182 Medial wall of orbit – anatomy of, 67 – fractures of, 122 Median forehead flap, 19t Median nerve, 273 Median nerve block, 162 Median nerve compression at forearm, 278 Median nerve palsy, 290 Medicinal leeches for improved flap perfusion, 23 Medicolegal aspects, 61–62 Medium peels, 213t, 214 Medpor (porous polyethylene) implants,

26 – mandibular angle, 92 Meissner corpuscles, 274 Melanocytic nevi, 48 – giant congenital, 40, 47–48 Melanoma, 45–47 – acral lentiginous, 46, 295 – diagnosis of, 45 – and giant congenital melanocytic nevi, 47 – of hand, 295 – juvenile, 48 – malignant, 295 – metastasis of, 46 – of nail bed (subungual), 47, 295 – nodal involvement in, 46 – sentinel lymph node biopsy for, 47 – staging of, 46

– surgical margins for, 46–47 – tumor depth of, 46 – types of, 46 Melasma, 52 Membranous bone formation, 12 Mental foramen, 69 Mental nerve, 94 Menton, 91f, 91t Merkel cell(s), 274 Merkel cell carcinoma, 52 Mesial surface of tooth, 73 Mesotherapy, 183 Metacarpal fractures, 264, 264f, 265–266 Metacarpophalangeal (MCP) joint – dorsal dislocation of, 272 – osteoarthritis of, 315 – radial collateral ligament injury of

index finger at, 272 Metachondromatosis, 296 Metal implants, 26 Metastasis – of melanoma, 46 – unknown primary presenting in neck as, 108 Methemoglobinemia from local anesthesia, 162 Metopic suture, 96f, 97 Meurmann classification of microtia, 128 MHC (major histocompatibility complex), 58 Micrografting for hair transplantation, 223 Microsomia, craniofacial (hemifacial), 88–89, 99

Microsurgery, 22–24 Microtia, 128–129 Middle third helical rim defect, 131 Midface reconstruction after total/subtotal maxillectomy, 113 Midjugular region, 110t, 111f Midline nasal lesions, congenital, 86–87 Midpalmar space infection, 301 Milroy disease, 41t Miniabdominoplasty, 184 Minoxidil (Rogaine) for androgenic alopecia, 224 Mitten hand, 241 Mixed dentition, 71 MLL (massive localized lymphedema), 41t, 42 MMF (maxilla-mandibular fixation), 124–125

Moberg flap for fingertip amputation, 250t Möbius syndrome – craniofacial anomalies in, 100 – hand anomalies in, 246 Mohs surgery, 50 Molars, 71 Molluscum contagiosum, 52 Mongolian spot, 48 Monsplasty, 182 Mucocele, 123 Mucoepidermoid carcinoma, 114t Mucous cyst, 297 Muenke syndrome, craniosynostosis in, 98t Müller muscle, 203 Munro classification of hypertelorbitism, 85, 85f

Muscle flaps, 14, 14–16t, 17f, 18f Muscle transposition, local, for facial paralysis, 106 Musculocutaneous flaps, 14, 14–16t, 17f, 18f, 19t, 20f Musculocutaneous nerve, 274 Mustarde sutures, 210–211 Mutton chop flap for abdominal wall reconstruction, 35 Myasthenia gravis, ptosis due to, 152 Mycobacterium marinum, hand infections due to, 300 Mycophenolate mofetil, common side effects of, 59t Myelomeningocele, 37 Myoglobinuria due to electric burns, 31

N Nagata technique for autologous ear reconstruction, 129, 129t Nager syndrome, 100 Nailbed – anatomy of, 247, 247f – hematoma of, 248 – injuries of, 248 – melanoma of, 47, 295 Nail fold infection, 299 Nail plate – anatomy of, 247, 247f – deformities of, 251 NAM (nasoalveolar molding) – for alveolar cleft, 81 – for cleft lip repair, 77 Nasal airway obstruction, 203–204 Nasal alar defects

– partial nasal reconstruction for, 146 – rhinoplasty for, 197 Nasal alar flaring, 197 Nasal alar retraction/collapse, 197 Nasal anatomy, 192–193, 192f Nasal dermoid cyst, 86 Nasal dorsum defect, partial nasal reconstruction for, 147 Nasal dorsum deformity, rhinoplasty for, 194–195, 194t Nasal fractures, 121–122 – pediatric, 125 Nasal hump deformity, rhinoplasty for, 194–195, 194t Nasal lesions, congenital midline, 86–87 Nasal lining reconstruction, 145–146 Nasal reconstruction, 142–149 – auricular composite graft for, 143

– bilobed flap for, 144 – dorsal nasal (Rieger) flap for, 145, 146f – forehead flap for, 144–145, 144f, 145f – full thickness skin graft for, 143 – of nasal lining, 145–146 – of nasal septum, 147 – partial, 146–147 – principles of, 142, 142f, 143t – for rhinophyma, 143 – for septal perforation, 142, 143t – total, 147–148, 148f Nasal septum – arterial supply of, 192 – defects of, 147 Nasal sidewall defect, partial nasal reconstruction for, 146 Nasal subunits, 142, 142f

Nasal surgery olfactory dysfunction, 198 Nasal tip defects – anatomic landmarks for, 195, 195f – angle of divergence for, 195, 196f – partial nasal reconstruction for, 146 – rhinoplasty for, 195–196, 195f, 196f NASHA (nonanimal stabilized hyaluronic acid) filler, 217 Nasion, 91f, 91t Nasoalveolar molding (NAM) – for alveolar cleft, 81 – for cleft lip repair, 77 Nasofrontal duct injury, 123 Nasolabial chin plane (NLCP), 191 Nasolabial flap, 19t Nasolacrimal duct, 157f Nasoorbitoethmoid (NOE) fractures, 123, 123t

Nasopalatine artery, 93f Nasopalatine nerve, 203 Natatory bands in Dupuytren disease, 259, 259t Nausea, postoperative, 163 NCM (neurocutaneous melanosis), 47–48 Nd:YAG (neodymium:yttrium-aluminumgarnet) laser, 227t, 228t – for tattoo removal, 231t Neck – anatomy of, 74, 74t – bilateral exploration of, 110 – layers of, 187t – regions of, 110, 110t, 111f – skin lymphatic drainage patterns of, 111 – of tooth, 72f

Neck dissection, 109–112 – complications of, 111–112 – principles of, 109–110 – radical, 110 – – modified, 110 – regions of neck for, 110, 110t, 111f – selective, 110 Neck reconstruction, 112–113 Neck rejuvenation, 190–191, 191t Neck tumors – classification and staging of, 108, 109t – neck dissection for, 109–112, 110t, 111f – pediatric, 118 – reconstruction for, 112–113 – unknown primary presenting as metastatic, 108 Necrotizing fasciitis, 56, 302

Necrotizing soft tissue infections, 56, 302 Neisseria gonorrhoeae, hand infections due to, 300 Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, 227t, 228t – for tattoo removal, 231t Nerve(s) – anatomy and physiology of, 273–274 – layers of, 274 Nerve compression, 277–280 – in carpal tunnel syndrome, 277–278 – in cubital tunnel syndrome, 278–279 – in Guyon canal syndrome, 279 – of median nerve at forearm, 278 – pathophysiology of, 277 – of radial nerve at forearm, 279 Nerve conduit, 276

Nerve fibers, 274 Nerve graft, 276 Nerve injury (ies) – of brachial plexus, 280–281 – classification of, 275, 275t, 290–291 – evaluation and timing of repair of, 275 – due to facelift, 189 – high, 290 – low, 290 – nerve regrowth after, 275 – nerve repair for, 276–277 – postoperative management of, 276 – principles of, 275–276 – and Wallerian degeneration, 275, 275t Nerve regrowth, 275 Nerve repair, 275–277 Nerve transfer, 276 Neurapraxia, 275t

Neurilemmoma, 294 Neurocutaneous melanosis (NCM), 47–48 Neurofibroma, 51, 294 Neurofibromatosis, 51 Neuroma – after fingertip amputation, 250 – after nerve injury or repair, 276–277 Neuroma-in-continuity, 275t Neurotmesis, 275t Nevus(i) – Becker, 51 – blue, 48 – blue rubber bleb, 103 – compound, 48 – halo, 48 – intradermal, 48 – of Ito, 48

– junctional, 48 – melanocytic, 48 – – giant congenital, 40, 47–48 – of Ota, 48 – sebaceous of Jadassohn, 50 – spilus, 48 – Spitz, 48 – Sutton, 48 Nifedipine for improved flap perfusion, 23 Nipple, average male, 166 Nipple sensitivity after breast augmentation, 169 NLCP (nasolabial chin plane), 191 Nodal involvement in melanoma, 46 Nodular melanoma, 46 Nodules due to filler, 218–219 NOE (nasoorbitoethmoid) fractures,

123, 123t Nonanimal stabilized hyaluronic acid (NASHA) filler, 217 Norwood-Hamilton classification of male pattern baldness, 222, 222f Nose. See also under Nasal – aesthetic subunits of, 142, 142f – anatomy of, 192–193, 192f Notta nodule, 240 Nutrition – for burn patients, 29–30 – with massive weight loss patient, 182–183 O Obstetrician's hand, 241 Obstructive sleep apnea, orthognathic surgery for, 89

Obturator nerve, 318 Oculoauriculovertebral dysplasia (OAVD) syndrome, 99–100 Odontogenic tumors, 134 OKT3 (anti-CD3), common side effects of, 59t Olfactory dysfunction, nasal surgery, 198 Ollier disease, 296 Omental muscle/musculocutaneous flap, 16t – for chest reconstruction, 36 Onabotulinumtoxin A (botulinum toxin, BOTOX), 219 – for brow lift, 208 Open book deformity after rhinoplasty, 198 Operating room (OR), minimal ambient temperature in, 163

Opponensplasty, 290 Optic canal, 67, 67f, 70f Optic foramen, 69t Optic neuropathy, traumatic, 122–123 Oral cancer, 108 Orbicularis oculi muscle, 201 Orbit – anatomy of, 67, 67f, 68t – pediatric tumors of, 118 Orbital apex syndrome, 123 Orbitale, 91f, 91t Orbital fractures, 122–123 – pediatric, 125 Orbital septum, 202 Organ transplantation immunosuppressants, impaired wound healing due to, 4 Orofacial clefts, rare, 83, 84f

Orthognathic surgery, 88–93 – and blood supply to maxilla, 92, 93f – for centric occlusion and relation, 90 – cephalometric analysis for, 90–92, 91f, 91t – for cleft lip and palate, 81, 88 – for craniosynostosis, 99 – distraction osteogenesis in, 92 – indications for, 88–89, 88t – for mandibular deformities, 92 – for maxillary hypoplasia, 92 – Medpor mandibular angle implants in, 92 – for overbite, 90, 90f – for overjet, 90, 90f – planning for, 89 – timing of, 89 – for vertical maxillary excess, 92

Orticochea flap for baldness, 225 Osler–Weber–Rendu syndrome, 103 Osmotic tissue expander, 40 Osseocutaneous flap, 21 Osseointegrated dental implant, 137 Osseous free flaps for mandible reconstruction, 136–137, 137t Osteoarthritis, 315 Osteochondroma, 296–297 Osteoconduction, 12 Osteogenesis, 12 Osteogenic sarcoma, 297 – of mandible, 136 Osteoid osteoma, 297 Osteoinduction, 12 Osteointegrated auricular prosthesis, 128 Osteomyelitis, 42–43

Osteonecrosis of mandible, 136, 137t Osteoplastic thumb reconstruction, 255 Osteoradionecrosis of mandible, 136 Osteosarcoma, 297 – of mandible, 134 Otitis externa after otoplasty, 211 Otoplasty, 210–212 – anatomical measurements for, 210 – complications of, 211–212 – techniques for, 210–211 – timing of, 212 Outer root sheath of hair, 222 Overbite, 90, 90f Overjet, 90, 90f Over-resuscitation with burns, 31 Oxycephaly, 97t P

Pachydermoperiostosis, 152 Palatal surface of tooth, 71 Palate – anatomy of, 79, 80f – primary vs. secondary, 80f Palatine bone, 67, 67f Palatine foramen, 80f Palatoglossus muscle, 79 Palatopharyngeus muscle, 79 Palatoplasty, 80, 81 Palm, distal injuries of, 255 Palmar fasciitis and polyarthritis syndrome (PFPAS), 315 Palmar space infections, 301 Parascapular flaps, 19t, 20–21, 21f Paraspinous musculofascial flaps for myelomeningocele, 37 Parkes Weber syndrome, 104

Parkland rule for fluid management, 29 Parona space infection, 301 Paronychia, 299 Parotidectomy, 113–114 Parotid ligaments, 188t Parotid tumors, 114t – pediatric, 118 Parry–Romberg syndrome, 100 Partial-thickness burns, 28, 28t Particulate bone, 12 Passavant ridge, 79 PE (pulmonary embolism), 163–164, 164t Pectoralis major muscle advancement flap for chest reconstruction, 36 Pectoralis major muscle/musculocutaneous flap, 16t Pectoralis major muscle turnover flap

for chest reconstruction, 36 Pectus excavatum due to Marfan syndrome, 36 Pediatric cranioplasty, 12 Pediatric facial fractures, 125 Pediatric growth plate fractures, 269, 270f, 270t Pediatric hand fractures, 269–270, 270f, 270t Pedicled flaps for breast reconstruction, 176–177 Peels. See Chemical peels Penile reconstruction, 24 Penile replantation, 24 Perialar crescentic advancement flaps, bilateral, 117f Periareolar mastopexy, 170 Perilunate instability, 308–309

Perineal reconstruction, 24 Perineurium, 274 Periocular defect, 151 Periodontal ligaments, 71, 72f Periorbital fat, 203 Periostitis after rhinoplasty, 198 Peripheral vascular disease ulcer, 321 Permacol for abdominal wall reconstruction, 35 Permanent teeth, 71, 72f Peroneal artery flap, 18, 19t Peroneal nerve, 138f Peroneal nerve palsy, 317 Peroneal vessels, 138f Peroneus brevis muscle, 138f Peroneus longus muscle, 138f Petrotympanic fissure, 70f Pfeiffer syndrome, craniosynostosis in,

98t PFPAS (palmar fasciitis and polyarthritis syndrome), 315 Phalangeal fractures and dislocations, 267 Pharyngoplasty, sphincter, 81 Phenol for chemical peel, 214–215 Photodynamic therapy prior to skin resurfacing, 230 Phyllodes tumor, 176 Pierre Robin sequence, 76–77 Pilomatricoma, 52 Pincer nail syndrome, 251 Pinna, 127 PIP joint. See Proximal interphalangeal joint Pitanguy line, 187, 207 Pit viper bites, 54

Plagiocephaly, 97t Plantar nerves, 317 Plasmatic imbibition stage of skin graft healing, 11t Plating, resorbable, 26 Pleomorphic adenoma, 114t PMMA (polymethyl methacrylate) implants, 26 Pneumonia due to burns, 31 Podagra, 314 Pogonion, 91f, 91t Poland syndrome – breast anomalies in, 167 – hand anomalies in, 241 Pollicization, 245–246 Polly beak deformity after rhinoplasty, 198 Polydactyly, 237–239, 238f, 238t

Polymethyl methacrylate (PMMA) implants, 26 Polypropylene (Marlex, Prolene) mesh for abdominal wall reconstruction, 35 Polytetrafluoroethylene (Gore-Tex) mesh for abdominal wall reconstruction, 35 PONV (postoperative nausea and vomiting), 163 Porion, 91f, 91t Porous polyethylene (Medpor) implants, 26 – mandibular angle, 92 Positional molding, 97t Posterior adductor space infection, 301 Posterior condylar canal, 70f Posterior fontanelle, 96, 96f Posterior interosseous flap, 18, 19t Posterior lamella of eyelid, 201

Posterior pharyngeal flap, 81 Posterior thigh flap, 24 Posterior tibial vessels and nerve, 138f Posterior triangle of neck, 110t, 111f Postoperative complications, 163–164, 164t Postoperative nausea and vomiting (PONV), 163 Postseptal fat pads, 203 PRC (proximal row carpectomy) for SLAC wrist, 305 Prednisolone, common side effects of, 59t Preiser disease, 305 Premaxilla, 79, 80f Preseptal incision, 204 Pressure sores, 42–43, 42t, 43t Pretendinous bands in Dupuytren

disease, 259, 259t Primary palate, 80f Procerus muscle, 203, 207t Progeria, facelift for, 190 Prognathia, 92 Prolabium, 79 Prolene (polypropylene) mesh for abdominal wall reconstruction, 35 Proliferative phase of wound healing, 3t Prominent eye blepharoplasty, 205 Pronator syndrome, 278 Propecia (finasteride) – for androgenic alopecia, 224 – for male pattern baldness, 222 Proptosis, 156 Prosthetic mesh for abdominal wall reconstruction, 35 Proximal interphalangeal (PIP) joint

– contracture of, 289 – fractures and dislocations of, 269 – – complications of, 270 – osteoarthritis of, 315 Proximal row carpectomy (PRC) for SLAC wrist, 305 Pseudoaneurysm of radial artery, 262 Pseudofolliculitis barbae, 51 Pseudogout, 302, 314 Pseudogynecomastia, 183, 183t Pseudohypertelorbitism, 86 Pseudomonas aeruginosa, hand infections due to, 300 Pseudoptosis, 152 Psoriatic arthritis, 314 Psychiatric aspects, 62 Pterygopalatine nerve, 203 Ptosis, 152–153

– assessment of, 152–153, 153t – brow, 207 – defined, 152 – etiology of, 152 – after mastopexy, 170, 170t – repair of, 153, 153t – senescent, 152 Ptyalism, 114–115 Pudendal flap, 19t, 24 Pulmonary embolism (PE), 163–164, 164t Pulp chamber, 72f Pulsed dye laser, 227t, 228t – for tattoo removal, 231t – for vascular anomalies, 232t Punch biopsy for melanoma, 45 Punch grafting for hair transplantation, 223

Punctal occlusion, 158 Punctum, 157f Pupillary defect, afferent, 123 Purpura fulminans, 32 Pyogenic granuloma, 52, 294 Q Q-switched alexandrite laser, 227t, 228t – for tattoo removal, 230–231, 231t Q-switched ruby laser, 227t, 228t – for tattoo removal, 230–231, 231t Quadrangular space, 21 Quadriga after fingertip amputation, 251 Quadriplegia, 291 R Radial artery – anatomical landmarks of, 22f

– pseudoaneurysm of, 262 Radial collateral ligament injury, index finger MCP, 272 Radial forearm flap, 19t – distally based pedicled, 22, 22f – fasciocutaneous free, 21, 319 Radial limb syndromes, 244, 245t Radial nerve – anatomy and physiology of, 273–274 – compression at forearm of, 279 Radial nerve palsy, 163, 290 Radial sensory nerve block, 162 Radiation therapy – and breast reconstruction, 178 – impaired wound healing due to, 4 – after mastectomy, 175 Radiesse, 217 Ramirez, Oscar, 35

Ramus lateralis nasi, 202f Ramus septi nasi, 202f Random cutaneous flap, 6 Raynaud disease, 261–262 Rectangular advancement flap, 7, 7f Rectus abdominis muscle/musculocutaneous flap, 16t – for chest reconstruction, 36 – vertical, 24 Rectus femoris muscle/musculocutaneous flap, 15t – innervation of, 16t – vascular supply to, 17f Rectus sheath, 34, 34f Reflex sympathetic dystrophy (RSD), 282 Regional anesthesia, 162–163 Regional flaps for fingertip amputation,

249 Reidel line, 94 Reiter arthritis, 314 Rejection of transplant, 58, 59t Remodeling phase of wound healing, 3t Replantation, 253–254 Resorbable plating, 26 Retaining ligaments of face, 188, 188t Retin-A (tretinoin) – for chemical peel, 213, 215 – prior to skin resurfacing, 230 Retrobulbar hematoma after blepharoplasty, 206 Retrognathia, 92 Retro-orbicularis oculi fat (ROOF), 203 Revascularization stage of skin graft healing, 11t Reverse cross finger flap for fingertip

amputation, 249t Reverse latissimus dorsi flap for lower back wound, 37 Reverse sural artery fasciocutaneous flap, 319 Rheumatoid arthritis, 310–313 – boutonniere deformity due to, 312 – caput ulnae syndrome due to, 313 – conservative early treatment of, 311 – demographics of, 310 – diagnostic criteria for, 310, 310t – differential diagnosis of, 313 – evaluation of, 310–311 – extensor digitorum communis (EDC) ulnar sublimation due to, 311 – extensor tendon rupture due to, 312–313 – flexor tendon adhesions due to, 312

– intrinsic tightness due to, 311–312 – juvenile, 313 – perioperative management of, 311 – surgical treatment for progression of, 311–313 – swan neck deformity due to, 311–312 – and trigger finger, 312 Rheumatologic disorders, 310–316 – gout as, 314 – HIV-related arthritis as, 314 – osteoarthritis as, 315 – pseudogout (chondrocalcinosis) as, 314 – psoriatic arthritis as, 314 – Reiter arthritis as, 314 – rheumatoid arthritis as, 310–313, 310f – scleroderma as, 314 – septic arthritis as, 314

– systemic lupus erythematosus as, 314–315 Rhinitis, seasonal allergic, 194 Rhinophyma, 143 Rhinoplasty, 192–200 – advancing age, 197 – Asian, 197 – cleft, 79 – complications of, 198 – male, 197 – for nasal airway obstruction, 193–194 – of nasal ala, 197 – nasal anatomy for, 192–193, 192f – of nasal dorsum, 194–195, 194t – of nasal tip, 195–196, 195f, 196f – secondary, 197 – thick skin, 197 Rhomboid flap, 8, 8f

Riedel procedure, 124 Rieger flap, 145, 146f Ring avulsion injury, 257 Roberts syndrome, 245t Rocker deformity, 195 Rogaine (minoxidil) for androgenic alopecia, 224 Rolando fracture, 267 ROOF (retro-orbicularis oculi fat), 203 Root of tooth, 71, 72f Rosebud hand, 241 Rotation flap, 6, 6f RSD (reflex sympathetic dystrophy), 282 Rule of nines, 28, 29f S Sacral ulcers, 42, 43t Saddle nose deformity after rhinoplasty,

198 Saethre-Chotzen syndrome, craniosynostosis in, 98t Sagittal suture, 96f Salabration for tattoo removal, 231t Salicylic acid for chemical peel, 213 Saline implant, 168 Salivary fistula from neck dissection, 112 Salivary gland secretion, excessive, 114–115 Salivary gland tumors, 113–115, 114t Salter Harris classification of pediatric growth plate fractures, 269, 270f, 270t Sarcoma – epithelioid, 295 – Kaposi, 295

– osteogenic, 297 – – of mandible, 136 – synovial, 296 Sartorius muscle/musculocutaneous flap, 16t Satyr ear, 130–131 Scalp anatomy, 68 Scalp expansion, 39 Scalp flaps, 19t – for baldness, 224–225, 224–226f Scalping flap for nasal reconstruction, 147, 148f Scalp loss, partial or total, 225 Scalp reconstruction, 118, 118t Scalp reduction for baldness, 224, 224f Scapha, 127 Scaphocephaly, 97t Scaphoid fossa, 127f

Scaphoid fracture, 307–308, 308f Scaphoid ring sign, 305 Scaphoid shift test, 305 Scapholunate advanced collapse (SLAC), 304–305 Scapholunate interosseous ligament, 304 Scapular flaps, 19t, 20–21 Scar(s), hypertrophic, 5 Scarpa fascia, 181 SCC. See Squamous cell carcinoma SCDs (sequential compression devices), 164 Schirmer test, 153 Schwannoma, 294 Scleral show, 205 Scleroderma, 262, 314 Sculptra, 217 Seasonal allergic rhinitis, 194

Seborrheic keratosis, 50 Secondary palate, 80f Second-degree burns, 28, 28t12 Second molars, 71 Seddon classification of nerve injuries, 275, 275t Selective photothermolysis, 228, 228t – for vascular anomalies, 231, 232t Sella, 91f, 91t Sella nasion pogonion (SNPg) angle, 91f, 91t, 92, 94 Semimembranous muscle/musculocutaneous flap, innervation of, 16t Semitendinous muscle/musculocutaneous flap, innervation of, 16t Senile lentigo, 51 Sensory receptors, 274

Sentinel lymph node biopsy (SLNB), 47 Septal fracture, 122 Septal hematoma, 122 Septal perforation, 142, 143t Septal pivot flap, 147 Septic arthritis, 314 Septocutaneous flap, 19t, 20, 20f Sequential compression devices (SCDs), 164 Seroma – from abdominoplasty, 184–185 – from body contouring, 183 – from breast reconstruction, 179 Serratus branch of thoracodorsal artery with breast reconstruction, 179 Serratus muscle/musculocutaneous flap, 16t Seymour fracture, 269–270

SGAP (superior gluteal artery perforator) flap for breast reconstruction, 177 Sharpey's fibers, 71, 72f SHFM (split hand/split foot malformation), 242 Shock, burn, 31 Shprintzen syndrome, 77 Sicca syndrome, 115 Sickle flap for nasal reconstruction, 147–148 SIEA (superficial inferior epigastric artery) flap, 19t – for breast reconstruction, 177 Silicone granuloma, 168 Silicone implants – complications of, 168–170 – generations of, 167t

– solid, 26 Silver nitrate for burns, 30 Silver sulfadiazine (Silvadene) for burns, 30, 30t SIMON acronym, 62 Simple lentigo, 51 Sinus anatomy, 68 Sjögren syndrome, 115 SJS (Stevens-Johnson syndrome), 32 Skier's thumb, 271–272, 271f Skin, Fitzpatrick classification of, 229, 229t Skin avulsion of ear, 130 Skin cancer, 45 – basal cell carcinoma as, 49–50 – classification of, 45 – melanoma as, 45–47 – Merkel cell carcinoma as, 52

– Mohs surgery for, 50 – prevention of, 45 – risk factors for, 45 – sentinel lymph node biopsy for, 47 – squamous cell carcinoma as, 48–49 Skin diseases, facelift for, 190 Skin grafts, 11–12, 11t Skin lesions, 45–52 – basal cell carcinoma as, 49–50 – melanocytic nevi as, 48 – – giant congenital, 40, 47–48 – melanoma as, 45–47 – miscellaneous, 50–52 – Mohs surgery for, 50 – sentinel lymph node biopsy for, 47 – squamous cell carcinoma as, 48–49 Skin lighteners, 215–216 Skin lymphatic drainage patterns of head

and neck, 111 Skin resurfacing, 228–230, 229t Skin slough after facelift, 189 Skull base anatomy, 69, 69t, 70f SLAC (scapholunate advanced collapse), 304–305 SLE (systemic lupus erythematosus), 314–315 Sleep apnea, obstructive, orthognathic surgery for, 89 SLNB (sentinel lymph node biopsy), 47 Small finger duplication, 238 Smoking, impaired wound healing due to, 4 SNA angle, 90, 91f, 91t Snake bites, 54, 54t Snap-back test, 154 SNB angle, 91, 91f, 91t

SNPg (sella nasion pogonion) angle, 91f, 91t, 92, 94 Soft palate, 80f Soft tissue infection(s), 54–56 – due to hydradenitis suppurativa, 55–56, 55t – necrotizing, 56, 302 – due to snake bites, 54, 54t – due to spider bites, 55 Soft tissue tumors, 50–52 – of hand – – benign, 293–294 – – malignant, 295–296 Solar keratosis, 49 Solar lentigo, 51 Soleus muscle/musculocutaneous flap, 15t, 318–319 Solid organ transplantation, 57

Solid silicone implants, 26 SOOF (suborbicularis oculi fat), 203 Spade hand, 241 Sphenoid bone, 67, 67f Sphincter pharyngoplasty, 81 Spider bites, 55 Spina bifida, 37 Spiral bands in Dupuytren disease, 259, 259t Spitz nevus, 48 Splay graft, 193 Split hand/split foot malformation (SHFM), 242 Split-thickness skin graft (STSG), 11–12 Spock ear, 130–131 Spoon hand, 241 Spreader grafts – for internal valve collapse, 193

– for nasal dorsum defects, 195 Squamous cell carcinoma (SCC), 48–49 – of hand, 295 – oral, 108 Staging – of breast cancer, 175t – of head and neck tumors, 108, 109t – of hydradenitis suppurativa, 55t – of melanoma, 46 Stahl ear, 130–131 Staphylococcus aureus, hand infections due to, 300 Stener lesion, 271, 271f Stenstrom technique, 211 Sterile matrix – anatomy of, 247, 247f – injury of, 248 Sternal cleft, 36

Sternal debridement, 36 Sternal wounds, 36, 36t Sternocleidomastoid muscle injury from neck dissection, 112 Sternocleidomastoid muscle/musculocutaneous flap, 15t Steroids – common side effects of, 59t – impaired wound healing due to, 4 Stevens-Johnson syndrome (SJS), 32 Stewart–Treves syndrome, 42 Stickler syndrome, 77 Strattice for abdominal wall reconstruction, 35 Streptococcus toxic shock syndrome, 56 Streptokinase for improved flap perfusion, 23 Striped Y classification of cleft lip and

palate, 75, 75f Stroke, 291 STSG (split-thickness skin graft), 11–12 Sturge–Weber syndrome, 104 Stylomastoid foramen, 70f Subciliary incision, 204 Subcondylar fractures, 124 Subglandular pocket, 168 Subglottic hemangioma, 102 Sublingual gland tumors, 114t Submandibular gland tumors, 114t Submandibular region, 110t, 111f Submental region, 110t, 111f Submucous cleft palate, 80 Suborbicularis oculi fat (SOOF), 203 Subpectoral pocket, 168 Subungual melanoma, 47, 295 Suction lipectomy, 185–186

Sulfamylon (mafenide acetate) for burns, 30, 30t Sunderland classification of nerve injuries, 275, 275t Sunscreen prior to skin resurfacing, 230 Superficial inferior epigastric artery (SIEA) flap, 19t – for breast reconstruction, 177 Superficial peels, 213, 213t Superficial peroneal nerve, 317 Superficial spreading melanoma, 46 Superficial temporal artery, 187 Superior crus, 127 Superior gluteal artery perforator (SGAP) flap for breast reconstruction, 177 Superior labial artery, 192, 192f Superior oblique muscle, 68t

Superior orbital fissure, 67, 67f, 69t, 70f Superior orbital fissure syndrome, 123 Superior pharyngeal constrictors, 79 Superior rectus muscle, 68t Supernumerary breast, 167 Supraomohyoid dissection, 110 Supraorbital nerve, 202, 207 Supratip deformity after rhinoplasty, 198 Supratrochlear artery, 202f Supratrochlear nerve, 202, 206–207 Sural artery flap, 19t Sural nerve, 317 Surgical margins for melanoma, 46–47 Surgisis, 27 – for abdominal wall reconstruction, 35 Sutton nevus, 48 Sutures for tip rhinoplasty, 196 Swan neck deformity, 267, 287,

311–312 Sweet syndrome, 302 Symmastia after breast augmentation, 169 Symphalangism, 246 Syndactyly, 239–240, 239f – bilateral, 241 Synovial sarcoma, 296 Syringoma, 51 Systemic lupus erythematosus (SLE), 314–315 T Tacrolimus (FK-506), common side effects of, 59t Talipes equinovarus, congenital, 321 TAM (total active range of motion), 283–284

Tar burns, 32t Tarsal conjunctival mullerectomy, 153 Tarsal tunnel syndrome, 317 Tarsoligamentous structures, 202–203, 202f Tarsus, 202 TAR (thrombocytopenia–absent radii) syndrome, 245t Tattoo(s) – dyes for, 231 – removal of, 230–231, 231t – types of, 230 TBSA (total body surface area) of burns, 28, 29f TCA (trichloroacetic acid) for chemical peel, 214 Tearing, excessive, 157 Teeth

– anatomy of, 71–73, 72f – in line of fracture, 124–125 Telephone ear deformity after otoplasty, 212 Telogen effluvium, 224 Temporalis muscle, 71t Temporomandibular joint disorders, 93–94 Temporomastoid flap for nasal reconstruction, 148 Temporoparietal fascia flap, 19t Temporoparieto-occipital flap for baldness, 225, 226f TEN (toxic epidermal necrolysis), 32 Tendonitis, 287–288 Tendon transfers, 289–290 Tensor fascia lata muscle/musculocutaneous flap, 15t

– for abdominal wall reconstruction, 34 – innervation of, 16t – vascular supply to, 17f Tensor veli palatini (TVP) muscle, 79, 80f Terry Thomas sign, 305 Tessier, Paul, 83 Tessier clefts, 83, 84f Tetrapod fracture, 121 Textured breast implants, 168 TFCC (triangular fibrocartilage complex), 304 Thelarche, benign premature, 167 Thenar flap for fingertip amputation, 250t Thenar space infection, 301 Thermal burns, 28–31, 28t, 29f, 30t Thick skin rhinoplasty, 197

Thigh nerves, 318 Third-degree burns, 28, 28t Thoracodorsal artery, serratus branch of, with breast reconstruction, 179 Thrombocytopenia–absent radii (TAR) syndrome, 245t Thromboembolism from liposuction, 186 Thrombosis, deep vein, 163–164, 164t Thumb – amputation and reconstruction of, 255, 256f, 256t – clasped, 240 – duplication of, 238, 238t – fractures of, 266–267 – gamekeeper's/skier's, 271–272, 271f – hypoplasia of, 244, 245t – trigger, 240

Thumb in palm deformity, 241–242 Thumb position, transfer of index finger to, 245–246 Tibial fractures, 319–321, 320t Tibialis anterior muscle, 138f Tibialis anterior muscle/musculocutaneous flap, 16t Tibialis posterior muscle, 138f Tibial nerve, 317 Tip graft, 196 Tip rhinoplasty, 195–196, 195f, 196f Tip rotation, cephalic, 196 Tip rotation suture, 196 Tissue expansion, 39–40, 39f – for baldness, 225 – for breast reconstruction, 176, 178 Tissue plasminogen activator (t-PA) for improved flap perfusion, 23

TON (traumatic optic neuropathy), 122–123 Tongue anatomy, 73, 73f Torticollis, 99 Total active range of motion (TAM), 283–284 Total body surface area (TBSA) of burns, 28, 29f Toxic epidermal necrolysis (TEN), 32 Toxic shock syndrome – after rhinoplasty, 198 – streptococcus, 56 t-PA (tissue plasminogen activator) for improved flap perfusion, 23 Traction alopecia, 224 Tragus, 127, 127f TRAM (transverse rectus abdominis muscle) flap for breast reconstruction,

176–177 Transconjunctival incision, 204 TransCyte, 27 Transdomal suture, 196 Transplantation, 57–59 – grafts for, 57 – history of, 57 – immunology of, 57–59, 58t, 59t – immunosuppressive agents for, 58, 58t – – common side effects of, 58, 59t – rejection of, 58, 59t – solid organ, 57 – types of, 57 Transposition flap, 7–9, 8f, 8t, 9f Transverse back flap, 19t Transverse facial artery, 187 Transverse nasalis muscle, 203 Transverse rectus abdominis muscle

(TRAM) flap for breast reconstruction, 176–177 Transverse upper gracilis (TUG) flap for breast reconstruction, 177–178 Trapeziometacarpal arthrodesis, 307 Trapezius muscle/musculocutaneous flap, 15t Traumatic optic neuropathy (TON), 122–123 Treacher Collins syndrome, 100 Tretinoin (Retin-A) – for chemical peel, 213, 215 – prior to skin resurfacing, 230 Triangular fibrocartilage complex (TFCC), 304 Triangular fossa, 127, 127f Triangular space, 20 Trichloroacetic acid (TCA) for chemical

peel, 214 Tricholemmoma, 51 Trichotillomania, 224 Trigger finger, 287 – rheumatoid arthritis and, 312 Trigger thumb, 240 Trigonocephaly, 97t Trisomy 21, 100 Trochanter sores, 42, 43t Trunk reconstruction, 34–37 – of abdominal wall, 34–35, 34f – of chest, 36, 36t – of lower back, 37 Tsuge classification of ischemic forearm contractures, 288 Tuberous breast deformity, 166–167 TUG (transverse upper gracilis) flap for breast reconstruction, 177–178

Tumescence techniques for liposuction, 185, 185t TVP (tensor veli palatini) muscle, 79, 80f 22 minus syndrome, 77 22q11.2 deletion syndrome, 77 Two-flap palatoplasty, 80 U Ulcer(s) – of below-the-knee amputation stump, 321 – diabetic, 321 – peripheral vascular disease, 321 – venous stasis, 321 ULC (upper lateral cartilage) fold-in flap, 193 Ulnar nerve

– anatomy and physiology of, 273 – compression at wrist of, 279 Ulnar nerve palsy, 290–291 Ultrasound-assisted liposuction, 185 Umbilical necrosis with breast reconstruction, 179 Unilambdoid synostosis, 97t Upper eyelid – blepharoplasty of, 204 – – malposition after, 205 – defect of, 150–151 – lid retractors of, 203 – malposition of, 152–153, 153t – paralysis of, 107 – periorbital fat of, 203 Upper jugular region, 110t, 111f Upper lateral cartilage (ULC) fold-in flap, 193

Upper third helical rim defect, 131 Urbaniak classification of ring avulsion injuries, 257 Urokinase for improved flap perfusion, 23 Uvula, 79, 80f V VACTERLS syndrome, hand anomalies in, 245t Vaginal reconstruction, 24 Van der Woude syndrome, 76 Vascular anomaly (ies), laser treatment for, 231, 232t Vascular anomaly syndromes, 103–104 Vascular disease of hand, 261–262 Vascular malformations, 102–103 Vastus lateralis

muscle/musculocutaneous flap, 15t – for abdominal wall reconstruction, 34 – innervation of, 16t – vascular supply to, 17f Vaughan–Jackson progression, 313 Veau classification of cleft lip and palate, 75, 75f, 75t Velocardiofacial syndrome, 77 Velopharyngeal insufficiency, 81 Venous congestion due to filler, 218 Venous flow through flap, 24 Venous malformations (VMs), 103 Venous stasis ulcer, 321 Verruca vulgaris, 294 Vertical buttresses of face, 120 Vertical mastopexy, 170 Vertical maxillary deficiency, 92 Vertical maxillary excess (VME), 92

Vertical rectus abdominis myocutaneous (VRAM) flap, 24 Vincula, 283 Virchow's law, 96 VISI (volar intercalated segment instability), 304, 306, 306f Visual loss – from blepharoplasty, 206 – due to filler, 218 VM(s) (venous malformations), 103 VME (vertical maxillary excess), 92 Volar beak ligament, 304 Volar intercalated segment instability (VISI), 304, 306, 306f Volar V-Y cup advancement flap for fingertip amputation, 249t Volkmann contracture, 289 Vomer flap, 80

Vomiting, postoperative, 163 von Hippel–Lindau disease, 52 von Recklinghausen disease, 51 VRAM (vertical rectus abdominis myocutaneous) flap, 24 Vulcan ear, 130–131 V-Y flap, 7, 7f V-Y hamstring flap, innervation of, 16t W Waardenburg syndrome, 77 Waiter's tip deformity, 281 Wallerian degeneration, 275, 275t Wartenberg sign, 278, 288 Wartenberg syndrome, 288 Warthin tumor, 114t Washio flap for nasal reconstruction, 148

Wassel thumb duplication classification, 238, 238t Watson shift test, 305 Webster technique, 211 Webster triangle, 195 Wedge resection for abdominoplasty, 184 Weight loss, massive. See Massive weight loss Werner syndrome, facelift for, 190 Wernicke encephalopathy, 164 White phosphorus burns, 32t Whitnall ligament, 203 Whitnall tubercle, 203 Wound care, 5 Wound closure coding, 60, 60t Wound dehiscence with body contouring, 183

Wound dressings for burns, 30, 30t Wound healing, 3–5 – for burns, 30 – collagen in, 3–4, 3t – excessive, 4–5 – impaired, 4 – phases of, 3, 3t – synthesis in, 4 – wound care and, 5 Wrist, 304–309 – anatomy of, 304 – basal joint arthritis of, 307 – DISI and VISI deformities of, 305–306, 306f – ligaments of, 304 – perilunate instability of, 308–309 – scaphoid fracture of, 307–308, 308f – scapholunate advanced collapse of,

304–305 – ulnar nerve compression at, 279 Wrong site surgery, 62 Wucheria bancrofti, lymphedema due to, 41t X Xanthelasma palpebrarum, 51 Xenograft, 57 Xeomin (incobotulinumtoxin A), 219 Xeroderma pigmentosum, 45 Z Zone of polarizing activity (ZPA), 237 Z-plasty, 8, 8t, 9f Zygoma fractures, 121 Zygomatic bone, 67, 67f Zygomatic ligaments, 188, 188t

Gregory Lakin - Plastic Surgery Review_ a Study Guide for the in-Service, Written Board, And Maintenance of Certification Exams (2014, Thieme) - PDFCOFFEE.COM (2025)

References