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Plast ic Surgery Case Review

Oral Board Study Guide

Alber t S. Woo
Section Ch ief, Pediatric Plast ic Surgery
Director, Cleft Palate-Cran iofacial In st itute
Divison of Plastic an d Recon structive Surgery
Depart m en t of Surger y
Wash in gton Un iversit y, St. Louis
Adjun ct Assistan t Professor, Orth odon t ics
Sain t Louis Un iversit y

Farooq Sh ah zad
Cran iofacial Surger y Fellow
Division of Plastic Surger y
Wash in gton Un iversit y Sch ool of Medicin e in St . Louis
St. Louis, Missouri

Alison K. Sn yd er-War w ick


Division of Plastic an d Recon structive Surger y
Wash in gton Un iversit y Sch ool of Medicin e in St . Louis
St. Louis, Missouri

Th iem e
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ISBN 978 1 60406 808 5 (ebook) referred to in th is book are in fact registered tradem arks or
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I. Woo, Albert S., editor of com pilation . II. Sh ah zad, Farooq,
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represen tat ion by th e publish er th at it is in th e public dom ain .
[DNLM: 1. Recon struct ive Surgical Proceduresm eth odsCase
Reports. 2. Orth opedic Proceduresm eth odsCase Reports. 3.
Woun ds an d InjuriessurgeryCase Reports. WO 600]
RD119
617.9 052 dc23 2013039499

Copyright # 2014 by Th iem e Medical Publish ers, In c. Th is book,


in cluding all parts th ereof, is legally protected by copyrigh t. Any
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Prin ted in Un ited States of Am erica


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This book is dedica ted to my w ife, Judy, the mother of my t wo children, w ithout whom no a ccomplishment is ever
worthwhile.
Preface
Th e eld of plastic surgery is as w ide as it is deep. It is a straigh tforw ard, focusin g upon th e crit ical elem en ts of
specialt y un ique in its abilit y to defy de n ition . Con t rar y to kn ow ledge an d decision m akin g. Th ey are n ot n ecessarily
th e paradigm of oth er surgical disciplin es, plast ic surger y in ten ded to presen t th e latest cuttin g edge procedures or
h as n o organ system to call its ow n . Th erefore, th ose in our to be exh austive, but rather to discuss safe an d proven
eld w ill regularly operate on pat ien ts from h ead to toe, m eth ods of patien t care.
ven t urin g from skin to bon e, som et im es delving even deeper
in to the vital organ s of the body. Possibly the best m eans of Th e book com prises 50 cases, each of w h ich explores a
description com es from the original Greek term pla stikos, fun dam en tal topic of st udy. Th e rst page of each case
derived in turn from pla ssein, m eaning to m old, shape, or in cludes a ph otograph of a represen tative patien t an d a
form . Indeed, plastic surgeons use specialized tech niques sh ort description , such as on e m igh t n d in a board exam i-
and principles to rem odel the body, replacing w h at h as been n at ion sett in g. Readers are en couraged to exam in e each
lost and poten tially creating that w h ich is m issing. This m ay scen ario an d th orough ly explore h ow th e patien t m igh t
h ave been expressed best by a founding father, Gaspare be approached clin ically. W h at crit ical elem en ts of th e
Tagliacozzi, w h o in 1597 stated, "We restore, repair, and patien ts h istory an d physical exam ination are n ecessar y?
m ake w hole those parts w hich fort une h as taken aw ay, Is any furth er w ork-up n eeded before a surgical plan of
n ot so m uch that th ey m ay delight the eye, but that th ey m ay act ion is determ in ed? W h at key com pon en ts of t reat m en t
buoy up th e spirit and h elp the m in d of the af icted." sh ould be iden t i ed an d discussed in a test environ m en t?
Sh ould com plication s occur, h ow w ill th ey be m an aged?
Given th e vastn ess of th e eld an d th e un usual dif cult y in W h at crit ical m istakes sh ould th e pract ition er be con scious
de n in g its boun daries, th e task th at academ ic plastic sur- to avoid? Each of th ese question s sh ould be asked an d
geon s face in teach ing th e specialt y to en suin g gen eration s an sw ered before th e subsequen t body of th e text is read.
becom es especially daun t in g. Despite th is en orm ous un der-
takin g, train in g program s h ave don e an excellen t job in Th e text w as in spired by th e m ock oral exam in ation th at is
w orkin g to de n e a curriculum an d provide a vast array regularly con ducted by th e Division of Plastic Surger y at
of surgical experien ces for residen ts an d fellow s. Because it Wash ington Un iversit y in St . Louis. Alth ough th e exam in a-
is n early im possible to h ave ever y t rain ee learn ever y sin gle tion is invariably a dif cult un dertakin g for th e residen ts,
operat ive procedure, th e specialt y h as been distilled in to train ees an d facult y alike h ave alw ays un iform ly agreed th at
n um erous crit ical areas of learn ingw ith a n um ber of th e testin g is a trem en dously w orth w h ile learn in g en deavor.
stan dard procedures an d foun dation al prin ciples th at all It is th e h ope of th e editors th at th is w ork m ay prove in som e
plast ic surgeon s are expected to h ave m astered. w ay useful to oth er plast ic surgeon s, at all levels of expe-
rien ce. St uden ts an d residen ts m igh t use th is w ork as a quick
Th e purpose of th is book is to ser ve as an addit ion al resource study resource, w h ich m ay h igh ligh t areas of fur th er study
for education am ong th ose pursuin g a career in plastic or poin t out details in decision m akin g th at are possibly n ot
surger y. In particular, it is especially geared tow ard in divid- readily obvious in didact ic texts. Older surgeon s m ay n d
uals preparin g for th eir oral board exam in ation s. Th e th e book useful as a review, rem in din g each of us of sm all
cases are th erefore design ed to be relatively sh ort an d details th at w e m ay h ave forgotten .

vi
Acknow ledgm ent
Th e auth ors w ould like to ackn ow ledge th e con tribution of
Dr. Susan E. Mackin n on , w h o in itially developed th e con cept
for th is book an d in spired its developm en t .

vii
Cont ent s
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Acknow ledgm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Cont ribut ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

Sect ion I. Facial Fract ures

1. Zygom a Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3


Farooq Shahzad & Albert S. Woo

2. Mandible Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7


Leahthan Domeshek & Albert S. Woo

3. Front al Sinus Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


Neil S. Sachanandani & Albert S. Woo

4. Le Fort Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15


Michael J. Franco & Albert S. Woo

5. Pediat ric Mandible Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19


Noopur Gangopadhyay & Albert S. Woo

Sect ion II. Face Cancer (Squam ous Cell Carcinom a, Basal Cell Carcinom a, Melanom a,
and Reconst ruct ion (including Mohs Defect s))

6. Lip (Cancer and Reconst ruct ion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25


Tracy S. Kadkhodayan & Terence M. Myckatyn

7. Nose (Cancer and Reconst ruct ion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29


Alison K. Snyder-Warwick & Marissa Tenenbaum

8. Eyelid (Cancer and Reconst ruct ion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33


Jason R. Dudas & Eva A. Hurst

9. Ear (Cancer and Reconst ruct ion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37


Tracy S. Kadkhodayan & Terence M. Myckatyn

10. Cheek (Cancer and Reconst ruct ion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41


Santosh Kale, Albert S. Woo, & Terence M. Myckatyn

Sect ion III. Face Congenit al

11. Unilat eral Cleft Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47


Albert S. Woo

viii
Cont ent s

12. Bilat eral Cleft Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51


Farooq Shahzad & Albert S. Woo

13. Cleft Palat e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55


Farooq Shahzad & Albert S. Woo

14. Microt ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Farooq Shahzad & Albert S. Woo

Sect ion IV. Face Cosm et ic

15. Aging Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65


Tracy S. Kadkhodayan & Marissa Tenenbaum

16. Aging Upper Face (Brow and Lids) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69


Neil S. Sachanandani & Marissa Tenenbaum

17. Low er Lid Ect ropion (Cicat rical) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73


Michael C. Nicoson & Terence M. Myckatyn

18. Low er Lid Ect ropion (Senile or Paralyt ic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77


Noopur Gangopadhyay & Albert S. Woo

19. Rhinoplast y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Amy M. Moore & Albert S. Woo

20. Facial Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85


Alison K. Snyder-Warwick & Thomas H. H. Tung

Sect ion V. Foot and Low er Ext rem it y Reconst ruct ion

21. Open Wound: Upper Third of Leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91


Leahthan Domeshek & Thomas H. H. Tung

22. Open Wound: Middle Third of Leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95


Louis H. Poppler & Terence M. Myckatyn

23. Open Wound: Low er Third of Leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99


Santosh Kale & Thomas H. H. Tung

24. Foot and Ankle Reconst ruct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103


Justin B. Cohen

Sect ion VI. Breast

25. Breast Cancer Reconst ruct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109


Jessica M. Belz, Albert S. Woo, & Thomas H. H. Tung

26. Tuberous Breast Deform it y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113


Jessica M. Belz & Terence M. Myckatyn

ix
Contents

27. Breast Augm ent at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115


Simone W. Glaus & Marissa Tenenbaum

28. Mast opexy/Augm ent at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119


Simone W. Glaus & Marissa Tenenbaum

29. Breast Reduct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123


Louis H. Poppler & Marissa Tenenbaum

30. Gynecom ast ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125


Gwendolyn Hoben & Marissa Tenenbaum

Sect ion VII. Trunk

31. Ischial Pressure Sores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129


Neil S. Sachananadani & Thomas H. H. Tung

32. Body Cont ouring aft er Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133


Simone W. Glaus & Marissa Tenenbaum

33. Major Liposuct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137


Justin B. Cohen & Terence M. Myckatyn

34. Abdom inal Wall Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139


Michael J. Franco & Ida K. Fox

35. Sternal Wound Infect ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143


Louis H. Poppler & Thomas H. H. Tung

36. Chest Wall Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147


Gwendolyn Hoben & Ida K. Fox

37. Perineal Reconst ruct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151


Noopur Gangopadhyay & Ida K. Fox

38. Abdom inoplast y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155


Elizabeth B. Odom & Terence M. Myckatyn

Sect ion VIII. Burn

39. Acut e Burn Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161


Amy M. Moore & Ida K. Fox

40. Hand Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165


David T. Tang & Ida K. Fox

41. Scalp Burn Reconst ruct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171


Gwendolyn Hoben & Albert S. Woo

42. Neck Burn Cont ract ure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175


Gwendolyn Hoben & Albert S. Woo

x
Cont ent s

Sect ion IX. Hand

43. Flexor Tendon Lacerat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179


Justin B. Cohen & Thomas H. H. Tung

44. Soft -Tissue Defect of t he Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183


David T. Tang

45. Radial Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185


John R. Barbour & Ida K. Fox

46. Dupuyt ren Cont ract ure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189


John R. Barbour, Albert S. Woo, & Ida K. Fox

47. Syndact yly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193


Michael C. Nicoson & Thomas H. H. Tung

48. Met acarpal and Phalangeal Fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197


Aaron Mull & Amy M. Moore

49. Carpal Tunnel Syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199


Minh-bao Le, David T. Tang, & Susan E. Mackinnon

50. Tendon Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201


John R. Barbour & Ida K. Fox

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

xi
Cont ribut ors
Joh n R. Barbou r, MD Gw en d olyn Hoben , MD, Ph D
Assistan t Professor Plastic Surgery Residen t
Plast ic an d Recon structive Surger y Division of Plastic an d Recon structive Surgery
Georgetow n Un iversit y School of Medicin e Wash ington Un iversit y School of Medicin e in St. Louis
Wash ington DC VA Medical Cen ter St. Louis, Missouri
Wash ington, DC
Eva A. Hu rst , MD
Jessica M. Belz, MD Assistan t Professor of Medicin e (Derm atology)
Aesth etic an d Reconst ruct ive Breast Surger y Fellow Director, Cen ter for Derm atologic an d Cosm etic Surgery
Partn ers in Plastic Surger y of West Michigan Wash ington Un iversit y School of Medicin e in St. Louis
Gran d Rapids, Mich igan St. Louis, Missouri

Ju st in B. Coh en , MD, MS Tracy S. Kad kh od ayan , MD


Residen t Physician Private Pract ice Plastic Surgeon
Division of Plastic an d Reconst ructive Surger y Min n eapolis, Min n esota
Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri San t osh Kale, MD
Physician
Leah t h an Dom esh ek, MD St. Louis, Missouri
Residen t Physician
Division of Plastic an d Reconst ructive Surger y Min h -Bao Le, MD
Wash ington Un iversit y School of Medicin e in St. Louis Residen t Physician
St. Louis, Missouri Depart m en t of Surger y
Division of Plastic an d Recon structive Surgery
Jason R. Du d as, MD Wash ington Un iversit y School of Medicin e in St. Louis
UCSF School of Medicin e St. Louis, Missouri
San Fran cisco, Californ ia
Su san E. Mackin n on , MD
Id a K. Fox, MD Ch ief, Division of Plastic an d Recon st ructive Surgery
Assistan t Professor Wash ington Un iversit y School of Medicin e in St. Louis
Division of Plastic an d Reconst ructive Surger y St. Louis, Missouri
Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri Am y M. Moore, MD
Assistan t Professor of Surgery
Mich ael J. Fran co, MD Division of Plastic an d Recon structive surgery
Plast ic Surger y Residen t Wash ington Un iversit y School of Medicin e in St. Louis
Wash ington Un iversit y School of Medicin e in St. Louis St. Louis, Missouri
Barn es-Jew ish Hospital
St. Louis, Missouri Aaron Mu ll, MD
Residen t
Noop u r Gan gop ad hyay, MD Division of Plastic an d Recon structive Surgery
Plast ic Surger y Residen t Wash ington Un iversit y School of Medicin e in St. Louis
Wash ington Un iversit y School of Medicin e in St. Louis St. Louis, Missouri
St. Louis, Missouri
Teren ce M. Myckat yn , MD
Sim on e W. Glau s, MD Associate Professor
Residen t Physician Director, Breast an d Aesth etic Surger y
Division of Plastic an d Reconst ructive Surger y Division of Plastic an d Recon structive Surgery
Wash ington Un iversit y School of Medicin e in St. Louis Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri St. Louis, Missouri

xii
Contribut ors

Mich ael C. Nicoson , MD David T. Tan g, MD, FRCSC


Division of Plastic an d Recon st ructive Surgery Assistan t Professor of Surgery
Wash ington Un iversit y School of Medicin e in St. Louis Director, Surgical Foun dation s Program
Barn es-Jew ish Hospital Division of Plastic an d Recon st ructive Surgery
St. Louis, Missouri Dalh ousie Un iversit y Facult y of Medicin e
Halifax, Nova Scot ia, Can ada
Elizabet h B. Od om , MD
Division of Plastic an d Recon st ructive Surgery Mar issa Ten en bau m , MD
Wash ington Un iversit y School of Medicin e in St. Louis Assistan t Professor an d Program Director
St. Louis, Missouri Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri
Lou is H. Pop p ler, MD
Division of Plastic an d Recon st ructive Surgery Th om as H. H. Tu n g, MD
Wash ington Un iversit y School of Medicin e in St. Louis Associate Professor
St. Louis, Missouri Director, Microsurgical Reconst ruction
Co-Director, Cen ter for Nerve Injury an d Paralysis
Neil S. Sach an an d an i, MD Division of Plastic an d Recon st ructive Surgery
Division of Plastic an d Recon st ructive Surgery Wash ington Un iversit y School of Medicin e
Wash ington Un iversit y School of Medicin e in St. Louis St. Louis, Missouri
St. Louis, Missouri
Alber t S. Woo, MD
Farooq Sh ah zad , MD Assistan t Professor of Surgery
Cran iofacial Surger y Fellow Ch ief, Pediatric Plastic Surger y
Division of Plastic an d Recon st ructive Surgery Director, Cleft Palate an d Cran iofacial In st it ute
Wash ington Un iversit y School of Medicin e in St. Louis Division of Plastic an d Recon st ructive Surgery
St. Louis, Missouri Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri
Alison K. Sn yd er-War w ick, MD
Assistan t Professor of Surger y
Director, Facial Ner ve In st itute
Division of Plastic an d Recon st ructive Surgery
Wash ington Un iversit y School of Medicin e in St. Louis
St. Louis, Missouri

xiii
Part 1

Sect ion I. Facial Fract ures


Zygom a Fractures

1 Zygom a Fract ures


Farooq Shahzad & Albert S. Woo

Fig. 1.1 (a-b) A 20-year-old man presents to the


em ergency departm ent with left cheek pain and
swelling after an assault to the face.

3
Zygom a Fract ures

1.1 Descript ion 1.2.3 Pert inent im aging or


Left m idfacial an d periorbital edem a w ith m alar depression diagnost ic st udies
an d left en oph th alm os. High -resolution m axillofacial CT scan
Com puted tom ography (CT) dem on st rates depressed left Evaluate th e five articulation s of th e zygom a for degree of
zygom aticom axillar y (ZM) com plex fracture w ith displacem en t an d com m in ution : (1) la tera l orbita l r im
com m in ution at th e ZM butt ress. (zygom aticofron tal [ZF]); (2) infer ior orbita l rim; (3) ZM
By defin it ion , th e left orbital floor is fractured in a displaced buttress; (4) zygoma tic a rch an d tem poral articulation ;
ZM com plex fracture. an d (5) la tera l orbita l wa ll (zygom aticosph en oid [ZS]).
Evaluate orbital floor defect. Corona l ima ges a re crit ica l to

this eva lua tion.


1.2 Work-up
1.2.1 Hist ory 1.2.4 Consult at ions
Mech an ism of injur y: Helpful in determ in in g an gle of force Traum a evaluation based on m ech an ism of injur y an d if oth er
an d severit y of injur y. injuries suspected.
Previous facial injuries or fract ures. Oph th alm ology con sultation in all orbital fractures to rule out
Ch an ge in vision , loss of vision , or double vision . oph th alm ologic injur y. Must be perform ed before opera t ive
Must rule out orbital injuries before con siderin g operative
inter vention because in traoperative m an ipulation m ay
in terven tion . exacerbate eye injury.
Num bn ess of th e ch eek or upper lip sign ifyin g in fraorbital
n er ve V2 injur y.
Ch an ge in occlusion .
1.3 Treat m ent
Alw ays start w ith th e ABCs (airw ay, breath ing, circulation ) of
1.2.2 Physical exam inat ion traum a. All em ergen t injuries m ust be m an aged first .
ATLS protocol: Iden tify any poten t ially life-th reaten in g Defin itive treatm en t of facial fractures m ay be delayed for

con dition s. up to 2 w eeks w ith out com prom ising results. Lon ger delay
Perform a detailed exam in at ion of th e face, in cluding in spec- in treatm en t in creases risk for in fection an d th e n eed for
tion for sw ellin g an d depression ; palpation for ten dern ess, osteotom ies as bon e h ealin g takes place.
crepit us, or step -o ; sen sor y an d m otor exam in at ion s; eye, Sim ple, n on displaced fractures do n ot n eed surgery an d m ay
n asal, an d in t raoral exam in ation s; an d exam in ation of ears be m an aged con servatively.
an d t ym pan ic m em bran e. Fractures th at are sign ifican tly displaced or com m in uted
Sign s of ZM com plex fractures are m alar depression (m asked at m ult iple articulation s require open reduction /in tern al
by soft-tissue sw ellin g early on ), subconjun ctival an d perior- fixation (ORIF). Plates sh ould be position ed at facial but tresses
bital ecchym oses, en oph th alm os an d/or hypoglobus (usually ( Fig. 1.2).
m asked by orbital sw ellin g result in g in ptosis), in ferior slan t Critical poin ts of fixation in clude th e follow in g: (1) ZF

of th e palpebral fissure, n um bn ess in th e in fraorbital n er ve region or lateral orbital rim , (2) in fraorbital rim , an d (3) ZM
dist ribut ion , an d upper buccal sulcus ecchym oses. buttress. At least th ree poin ts of fixation are n ecessar y to

Fig. 1.2 Buttresses of the face. Vertical but-


tresses include the zygom aticom axillary and
nasom axillary but tresses. The infraorbital rim ,
m axillary alveolus, and mandible contribute to
transverse buttresses of the face.

4
Zygom a Fractures

guaran tee th ree-dim en sion al stabilit y. W h en n ecessar y, pupillar y defect, ch ange in visual acuit y, an d ult im ately blin d-
th e zygom atic arch m ay be stabilized at a fourth poin t of n ess. Th is is a surgica l emergency an d requires an im m ediate
fixation . lateral can th otom y w ith in ferior can th olysis for drain age of
Th e operat ive approach is determ in ed by th e status of th e th e h em atom a. Man n itol, acetazolam ide, an d oph th alm ology
zygom atic arch . If th e arch is com m in uted or oth erw ise con sult are supplem en tar y m easures. Im m ediate return to
irreducible, a coron al in cision w ill be n eeded for reduction th e operatin g room is usually in dicated.
an d fixation of th e arch . Oth erw ise, th e zygom a can be In adequate reduction resultin g in m alposit ion .
reduced an d fixed w ith an an terior approach . Orbital floor un dercorrection or overcorrection result in g in
Th e st an d ard an t erior ap p roach con sists of th ree in cision s: en oph th alm os, proptosis, or vertical dystopia. Requires
Lateral part of upper bleph aroplast y in cision (or lateral im plan t reposit ion in g.
brow in cision ) for access to th e lateral orbital rim an d w all. An esth esia or paresth esia in in fraorbital n er ve distribut ion .
Note th at the best mea ns of confir ming three-dimensiona l Th is is m ost com m on ly due to n erve contusion an d gen erally
reduction of a ZM complex fra ct ure is a t the la tera l orbita l resolves w ith in 6 m on th s.
wa ll, which is a ccessed through this a pproa ch. Low er-lid ectropion (subciliar y in cision ) or en tropion
Low er-eyelid in cision (tran sconjun ctival, subciliar y, or sub- (tran sconjun ctival in cision ). Th is usually respon ds to
tarsal) for in ferior orbital rim an d orbital floor. eyelid m assage but m ay require surgical correction . Th e
Upper buccal sulcus in cision for access to m axillar y but- subciliar y in cision h as th e h igh est risk for ectropion in
tresses. com parison w ith th e tran sconjun ctival an d subtarsal
Isolated zygom at ic arch fract u r es: May be reduced via tem - approach es.
poral (Gillies) or in t raoral (Keen ) approach . In fect ion requires an t ibiot ics an d possible h ardw are
Orbit al floor evalu at ion : As a com pon en t of th e ZM com plex, rem oval.
th e orbital floor is (by defin ition ) fract ured w h en th e zygom a
is displaced an d m ust be evaluated at th e tim e of operation .
If th e pat ien t h as en oph th alm os or hypoglobus, or if a siz- 1.5 Crit ical Errors
able defect is present , th e floor sh ould be recon structed Failure to assess ABCs in acute traum a.
w ith an im plan t (e.g., porous polyethylen e or titan ium ) or Failure to evaluate for oth er facial injuries on exam in at ion or
bon e graft after th e ZM com plex fracture h as been reduced.
CT scan . Watch out for n aso-orbito-eth m oid (NOE) fractures,
w h ich m ay occur concom itan tly.
1.4 Com plicat ions Not kn ow in g th e various approach es for zygom atic fracture
exposure an d fixation .
Ret robu lbar h em atom a: Can occur at tim e of injur y or post- Not kn ow in g th e in dication s for orbital floor recon struct ion .
operatively. Sign s are severe eye pain , proptosis, a eren t In abilit y to recogn ize an d treat a retrobulbar h em atom a.

5
Mandible Fractures

2 Mandible Fract ures


Leahthan Domeshek & Albert S. Woo

Fig. 2.1 (a-c) A 50-year-old man presents to the em ergency departm ent following an assault to the face.

7
Mandible Fractures

2.1 Descript ion 2.3.2 Definit ive t reat m ent


Malocclusion w ith left-sided an terior open bite. Can be delayed for up to 2 w eeks w ith out com prom isin g
Displaced oblique righ t subcon dylar fracture exten din g results. Lon ger delay in treatm en t in creases risk for
th rough sigm oid n otch . in fection an d n eed for osteotom ies as bon e h ealin g
Displaced, com m in uted fracture of left posterior body of takes place.
m an dible, w ith possible involvem en t of m an dibular th ird
m olar (tooth No. 17). 2.3.3 Nondisplaced fract ures
If sta ble: Con ser vative m an agem en t w ith a soft, n on -ch ew
2.2 Work-up diet for rough ly 4 w eeks. Subsequen t in stabilit y or
displacem en t n ecessitates operative treatm en t .
2.2.1 Hist ory and physical exam inat ion Mild insta bilit y: Treat w ith m axillom an dibular
ABCs (airw ay, breath in g, circulation ): Atten tion to stabilit y fixation (MMF).
of th e airw ay, given m ult iple m an dible fractures. Rarely, Tw o t ypes of MMF are reason able: Arch bars an d

in t ubation m ay be n ecessar y if th e patien t can n ot protect in term axillar y fixation (IMF) screw s.
th e air w ay. MMF is e ective in patien ts on ly w h en appropriate

Con com itan t injuries: Man age any poten tially life-th reaten in g den tition is present.
injuries first . Th e repair of m an dibular fract ures is n ot em er- Rule of th um b

gen t an d can be perform ed on an elective basis (gen erally Subcondyla r: 2 w eeks w ith early return of m otion usin g
w ith in 14 days of injur y). guidin g elastics.
Palpate/m an ipulate th e m an dible for step -o s an d in stabilit y. Body/a ngle: 4 w eeks.
Assess mobilit y (abilit y to open an d close m outh , deviation of (Pa ra )symphysea l: 6 w eeks.
m an dible on m ovem en t) an d occlusion (m ay evaluate based
on w ear facets of teeth ).
State of den tition : Pat ien ts w ith eden tulous m an dibles w ill
2.3.4 Displaced fract ures
require m ore aggressive procedures to rigidly fix bon e seg- Open reduction /in tern al fixation (ORIF)
m en ts because of decreased bon e stock. W ide exposure of fractures.

Neurologic exam in at ion : Th e menta l/inferior a lveola r ner ve Establish occlusion (MMF m ay h elp w ith th is).

provides sen sation to th e low er lip an d frequen tly sustain s Plate fract ures.

n eurapraxic injur y w ith blun t traum a. Th e ma rgina l ma ndibu- Release MMF an d con firm n orm al occlusion w h en con dyles

la r bra nch of th e facial n erve in n ervates th e depressors of th e are seated in th e tem porom an dibular join t (TMJ).
low er lip an d is rarely injured. Reestablish MMF if in dicated.

Assess for con com itan t m idfacial fractures (m ay Gen erally, tran sfacial approach es are preferred for th e ORIF of
alter occlusion ). comminuted fractures: In creased visualization , access to all
m an dibular surfaces. Also use in eden tulous patien ts for
2.2.2 Pert inent im aging or im proved reduction .
Platin g tech n ique
diagnost ic st udies Stron ger plates (i.e., fracture or recon struction ) n ecessar y

High -resolution m axillofacial com puted tom ography (CT): to establish rigid fixation of th e in ferior border of
Th is is th e gold stan dard for im aging. Th ree-dim en sion al th e m an dible.
recon struction s m ay assist in furth er evaluatin g injur y. A tension ba nd m ay be placed superiorly to avoid splayin g

W h en CT is un available, oth er st udies m ay be useful. of th e fracture lin e. Th is m ay be accom plish ed w ith eith er
Pan orex: Allow s visualization of th e en tire m an dible an d a m in iplate just below th e tooth roots or an arch bar
den t ition . Lim ited evaluation at sym physis an d con dyles. an ch ored to th e den t ition .
Addition al Tow n e view im proves visualization of Subcon dylar/ram us fract ures ( Fig. 2.2)
subcon dylar region s. Mildly displaced: Preferen tially treat w ith closed m eth ods

Man dible series (an teroposterior, lateral, oblique, (MMF w ith early release an d elastic guidan ce). Muscular
open -m outh reverse Tow n e view ). forces an d proprioception com pen sate for arch itect ural
deform ities in th ese region s, perm itt in g n orm al fun ct ion al
occlusion in th e settin g of m ild displacem en t th at w ould be
2.3 Treat m ent in tolerable elsew h ere.
ORIF n ecessary if deform it y precludes proper m an dibular
2.3.1 Init ial m anagem ent (in t he m ovem en t or occlusion (i.e., con dylar h ead displacem en t
em ergency depart m ent ) in to m iddle cran ial fossa; foreign body lodged in TMJ;
Oral ch lorh exidin e rin se: Decreases oral flora/bacterial count . bilateral subcon dylar fractures th at w ill result in an an terior
Bridle w ire (option al): Stain less steel w ire t ypically placed open bite).
Preferred approaches: Extraoral via retroma ndibula r
t w o teeth aw ay on eith er side of a fracture lin e to h elp w ith
tem porar y stabilit y. May be useful to in crease patien t com fort in cision (good exposure of fracture, ease of plating) or
in th e sett in g of un stable fractures. subm an dibular (Risdon).

8
Mandible Fractures

(Para)sym p h yseal fract u res: In h eren tly un stable an d


require ORIF.
In traoral approach for m ost fractures: Excellen t exposure,

perm its con tin uous visual assessm en t of occlusion , n o


extern al scars.
Extraoral (subm en tal) approach m ay be useful for com m i-

n uted fractures.
Before com pletion of th e case, th e patien t m ust be exam -

in ed w ith MMF released.


Th e con dyles m ust be firm ly seated in th e TMJ fossa, an d

n orm al occlusion m ust be confirm ed. If th is does n ot result


in n orm al occlusion , th e plates m ust be released an d th e
fract ure re-redu ced.
On ce occlusion h as been con firm ed, MMF m ay be reestab-

lish ed as n ecessary.
Ed en t u lou s m an d ibles: Pron e to m alun ion due to lim ited
bon e stock.
Require m ore aggressive treatm en t , gen erally w ith an

extern al approach an d fixation w ith large recon struction


plates th at provide lon g-term stabilit y.
In lim ited circum stan ces, on e m ay consider use of a Gun -

n in g splin t or w irin g in th e pat ien ts curren t den tures. Th is


Fig. 2.2 Zones of the m andible.
provides less stabilit y th an an open approach .

2.4 Com plicat ions


Malocclusion : Adequate occlusion m ust be con firm ed before
An gle fract u res: Require ORIF. If th e th ird m olar is involved, it
com pletion of th e procedure.
m ust be rem oved if it in terferes w ith reduction .
Malun ion /n on un ion : May require dbridem en t an d bon e
In t raoral approach w ith percutan eous access for plating
graftin g.
alon g th e in ferior border appropriate for easily reduced
In fect ion : Avoid th e urge to rem ove plates un til fract ure h eal-
n on com m in uted fract ures.
in g h as been ach ieved. Early rem oval of h ardw are w ill oth er-
Cha mpy technique is also acceptable in straigh tforw ard,
w ise result in m alocclusion .
n on com m in uted fract ures of th e an gle. Th is en tails place-
Dam age to in ferior alveolar n er ve: Avoid injur y by keepin g
m en t of a ten sion ban d plate at th e extern al oblique ridge
h ardw are aw ay from th e m idportion of th e m an dible w h ere
w ith out use of an in ferior border plate.
n er ve courses.
Risdon approach for com m inuted fractures.

Bod y fract u res: Require ORIF.


In t raoral (vestibular) approach preferred for m ost fractures:

Excellen t visualization of an d access to m an dibular body, n o


2.5 Crit ical Errors
extern al scars, lit tle risk to vital st ruct ures (i.e., m argin al Failure to obtain accurate occlusion an d reduct ion before
m an dibular n er ve). platin g fractures.
Risdon approach for com m inuted fractures an d Failure to con firm n orm al occlusion upon com pletion
th ose requirin g exposure/m an ipulat ion of in ferior of surgery.
border of m an dible. Useful for w ide access to posterior Failure to rem ove plates an d re-reduce th e m an dible if th e
body fract ures. patien t does n ot h ave n orm al occlusion after MMF is released.

9
Frontal Sinus Fractures

3 Front al Sinus Fract ures


Neil S. Sachanandani & Albert S. Woo

Fig. 3.1 (a-c) A 37-year-old man presents following an assault to the forehead with a baseball bat.

11
Front al Sinus Fractures

3.1 Descript ion 3.3.1 Isolat ed, displaced ant erior


Large, oblique foreh ead laceration exten din g dow n to bon e. t able fract ure
Displaced left fron tal sin us fract ure w ith involvem en t of th e Open reduction /in tern al fixation (ORIF) is perform ed
an terior an d posterior tables. th rough a preexist in g laceration or coron al in cision . Th e
sin us is preserved.
An terior table fracture w ith a ssocia ted na sofronta l duct injur y
3.2 Work-up Man dates fron t al sin u s oblit erat ion an d perm an en t block-

age of th e n asofron tal ducts.


3.2.1 Hist ory Th e fron tal sin us m ucosa is com pletely rem oved w ith a

Mech an ism of injur y: Helpful in determ in in g severit y an d h igh speed drill an d diam on d burr. Th e fron tal sin us is
t ype of injur y. obliterated w ith a pericran ial flap, fat , fascia, bon e ch ips,
Ch an ge in vision , loss of vision , or double vision . or spon tan eous osteogen esis (n o m aterial used). Th ere
Must rule out orbital injuries before con siderin g operative is n o sign ifican t advan tage to any on e of th ese particular
in terven tion . tech n iques over th e oth er.
Num bn ess of foreh ead sign ifyin g injur y to cran ial n er ve Required for isolation of th e fron tal sin us from th e
V1 dist ribution . sin on asal tract to preven t contam in ation an d
Rh in orrh ea: Con cern in g for dural injur y an d cerebrospin al m ucosal regrow th from th e eth m oids in to th e
fluid (CSF) leak. fron tal sin us.
Th e an terior table is replaced, reduced, an d plated

as n eeded.
3.2.2 Physical exam inat ion Perform ed on ly if th ere is m in im al or n o posterior table

Iden tify any poten t ially life-th reaten in g condit ion s. displacem en t an d n o CSF leak.
Iden tify laceration s over th e foreh ead, glabella, or supra-
orbital ridge; m ay be used for direct access for repair in
selected cases. 3.3.2 Com bined ant erior/post erior
Evaluate for palpable step -o s an d/or depression s in th e fron -

t able fract ures
tal area.
Evaluate for sen sibilit y ch anges in supraorbital/supratroch lear Involvem en t of th e posterior table is con cern in g for dura l
n er ve distribution . injur y an d m u st be addressed by a n eurosurgeon before repair
Exam in e for CSF rh in orrh ea. of th e fracture.
Ring test at th e bedside. Injuries w ith displacem en t of th e posterior table of less

May test for -t ra nsfer r in in n asal disch arge, sign ifyin g CSF. th an on e table w idth are frequen tly obser ved w h en th ere is
Test fun ction of fron talis an d corrugator m uscles. n o clear eviden ce of dural tear.
W h en th e posterior table is m in im ally involved but th e
n asofron tal ducts are injured, fron t al sin u s oblit erat ion
3.2.3 Pert inent im aging or is in dicated.
diagnost ic st udies W h en th e posterior table is sign ifican tly displaced or com m i-
n uted, cran ializat ion of th e fron tal sin us w ith obliteration of
High -resolution m axillofacial com puted tom ograph ic scan :
th e fron ton asal outflow tract (duct) sh ould be perform ed.
Assessed in both axial an d coron al plan es.
Cran ialization steps are iden tical to th ose of fron tal sin us
Evaluate for involvem en t of an terior/posterior tables an d
obliteration , w ith th e addit ion of com plete rem oval of th e
determ in e degree of com m in ution /displacem en t.
posterior table.
Evaluate na sofronta l outflow t ra ct for abilit y to drain th e
A per icra nia l fla p is placed alon g th e floor of th e
fron tal sin us.
an terior cran ial fossa to separate th e n asal an d
Iden tify in t racran ial injuries (pn eum oceph alus, etc.) an d
in tracran ial cavities.
oth er facial fract ures.

3.2.4 Consult at ions 3.4 Com plicat ions


Neurosurgical con sultat ion is n ecessary if in tracran ial injury Fron tal sin usit is, m en in gitis/en ceph alitis, brain /epidural
is suspected (sign ifican t displacem en t of posterior table, abscess: Must obliterate th e n asofron tal outflow tract to
pn eum oceph alus, CSF rh in orrh ea). preven t bacterial contam in ation of in tracran ial conten ts.
Mucocele/m ucopyocele: May present m any years after

3.3 Treat m ent traum a as a consequen ce of in adequate rem oval of


sin us m ucosa.
Man agem en t is guided by th e injur y pat tern ( Fig. 3.2). Cavern ous sin us th rom bosis.
Non displaced fractures of th e fron tal sin us m ay n ot n eed Posttraum atic deform it y from in adequate an terior
operative repair. table recon struction .

12
Frontal Sinus Fractures

Fig. 3.2 Algorithm for the m anagem ent of frontal sinus fractures. (Reproduced with perm ission from Yavuzer R, Sari A, Kelly C, et al. Managem ent of
frontal sinus fractures. Plast Reconstr Surg 2005;115:79e93e.)

3.5 Crit ical Errors


Failure to rem ove all of th e m ucosa durin g sin us obliteration .
Failure to separate th e n asal cavit y from th e an terior cran ial
Failure to evaluate for cerebrospin al fluid leak. fossa durin g cran ialization .
Failure of th orough irrigation an d dbridem en t on in itial Failure to obtain n eurosurgical con sultation w h en th ere is
en coun ter. involvem en t of th e posterior table or eviden ce of brain injur y.

13
Le Fort Fractures

4 Le Fort Fract ures


Michael J. Franco & Albert S. Woo

Fig. 4.1 An 18-year-old m an presents with m al-


occlusion and upper jaw pain following a m otor
vehicle collision.

15
Le Fort Fractures

4.1 Descript ion


An terior open bite. Eviden ce of repaired righ t brow
laceration .
Tran sverse fracture across th e m axilla involving th e zygom a-
ticom axillar y (ZM) an d n asom axillar y (NM) butt resses on
both sides, consisten t w ith a Le Fort I fracture. (Coron al
im ages are n eeded to evaluate th e pterygoid plates to con firm
th e diagnosis.)
Fract ure exten ding from th e righ t NM buttress to th e
in fraorbital rim w ith out displacem en t at th e n asofron tal (NF)
jun ction , con sisten t w ith a t ype IA n aso-orbito-eth m oid
(NOE) fracture.

4.2 Work-up
4.2.1 Hist ory
Mech an ism of injur y: Helpful for determ in in g severit y of
im pact an d trajectory of force.
Ch an ges in vision , occlusion , breath ing, or h earin g.
Previous facial t raum a.

Fig. 4.2 Le Fort fractures patterns. Le Fort I: transverse fracture


4.2.2 Physical exam inat ion through the zygom aticom axillary (ZM) and nasom axillary but tresses.
Le Fort II: pyram idal fracture through the ZM but tresses, infraorbital
Iden tify any poten t ially life-th reaten in g condition s. Always rim s, medial orbit, and nasofrontal (NF) junction. Le Fort III: com plete
take spin al precaut ion s an d rule out cervical injur y. craniofacial dysjunction with separation of the cranium from the face
Perform a detailed exam in at ion of th e face, in cluding in spec- at the zygom aticofrontal sutures and the orbital and NF junction.
tion for sw ellin g an d depression ; palpation for ten dern ess,
crepit us, or step -o ; sen sor y an d m otor exam in at ion s; eye,
n asal, an d in t raoral exam in ation s; an d exam in ation of ears
an d t ym pan ic m em bran e.
4.2.4 Consult at ions
State of den tition : Fractured, m issing, or rotten (carious) Oph th alm ology con sultation in all orbital fractures to rule out
teeth an d occlusal pat tern . oph th alm ologic injur y. Must be perform ed before operative
Assessm en t for m idface in stabilit y: Stabilize th e face at in terven tion because in traoperative m an ipu lation m ay exac-
th e n asal root (left h an d) an d grasp th e upper an terior erbate eye injur y.
alveolar arch (righ t h an d) an d pull forw ard/dow n . If th e
m idface is m obile w ith stabilit y at th e n asal root, it is in dica-
tive of a Le Fort I fract ure. If th ere is also m obilit y at th e 4.3 Treat m ent
NF sutu re, it is a Le Fort II fract ure. If th ere is also m obilit y ATLS (a dvan ced trau m a life support) protocol: Airw ay,
at th e zygom aticofron tal sut ure, it is a Le Fort III
breath ing, circulation , disabilit y, exposure. All em ergen t inju-
fract ure ( Fig. 4.2).
ries m u st be m an aged first.
Defin itive treatm en t of facial fractures m ay be delayed for

up to 2 w eeks w ith out com prom ising results. Lon ger delay
4.2.3 Pert inent im aging or in treatm en t in creases risk for in fection an d n eed for
osteotom ies as bon e h ealin g takes place.
diagnost ic st udies
High -resolution m axillofacial com puted tom ograph ic scan

Fracture of th e pter ygoid plates is th e sin e qua n on of Le


4.3.1 Nondisplaced, st able fract ures
Fort fractures. Non operative m an agem en t is an option w ith a soft, n on -ch ew
Le Fort I is a tran sverse fract ure of th e m axilla involving th e diet for 4 to 6 w eeks.
ZM an d NM but t resses. Close follow -up to en sure th at th e patien t m ain tain s
Le Fort II is a pyram idal fracture involving th e ZM buttress, good occlusion .
in ferior orbital rim , in ferior an d m edial orbital w all, an d
NF region .
Le Fort III causes cran iofacial dysjun ction an d involves
4.3.2 Displaced, unst able fract ures
th e zygom atic arch , lateral orbital rim , lateral orbital Require open reduction /in tern al fixation (ORIF).
w all, orbital floor, m edial orbital w all, an d Th e establish m en t of nor ma l occlusion is critical because th is
NF region . is m ost n oticeable to th e pat ien t.

16
Le Fort Fractures

Maxillom an dibular fixat ion (MMF) can be perform ed by Le Fort II: ZM butt resses an d in fraorbital rim s. Un com m on ly,
usin g den tal w ear facets as guides. Th is m ay be accom - platin g of th e NF jun ction is n ecessar y if th is region is
plish ed w ith Erich arch bars or in term axillar y fixation sign ifican tly displaced.
(IMF) screw s. Le Fort III: ZF (lateral orbital rim ) region s an d NF jun ction .

Bon e gaps at but tresses: Especially th ose > 5 m m w ill n ot h eal MMF is th en released an d occlusion is ch ecked w ith m an dib -
an d require bon e graftin g. ular con dyles seated in th e glen oid fossa.
In easily reducible, m in im ally displaced fractures of th e
m axilla an d/or m an dible, patien ts m ay be treated w ith 4 to 4.4 Com plicat ions
6 w eeks of MMF.
Malocclusion : May be secon dar y to in com plete in itial reduc-
tion of th e fractures or lack of stabilization w ith MMF.
Non un ion , m alun ion , or fibrous un ion : Requires dbridem en t
4.3.3 Surgical t echnique

of th e fracture site, possible bon e graft in g, an d refixation .


Nasal in t ubation . In fect ion : Be ver y cautious about rem oving h ardw are w h en
A bilateral gin givolabial in cision is m ade 5 to 10 m m from th e th e bon es h ave n ot h ealed com pletely because th is can result
apex of th e sulcus, an d th e an terior w all of th e m axilla is in loss of reduction . If possible, tr y to keep h ardw are in place.
exposed subperiosteally.

Occlusion is establish ed w ith MMF.


Reduct ion of th e fract ure: Im pacted fractures or di cult
4.5 Crit ical Errors
reduct ion s due to early fibrous un ion m ay require th e use of Missed injuries an d failure to perform a traum a w ork-up.
Row e disim pact ion forceps. Failure to diagn ose an d treat con com itan t facial fractures.
Fracture stabilizat ion Watch out for NOE fractures (as in th is case), w h ich require
Le Fort I: Platin g is perform ed at th e ZM buttress an d th e addition al reduct ion an d stabilization .
NM butt resses. Failure to ensure centric occlusion at the tim e of fracture repair.

17
Pediat ric Mandible Fractures

5 Pediat ric Mandible Fract ures


Noopur Gangopadhyay & Albert S. Woo

Fig. 5.1 (a-d) A 7-year-old boy presents to the em ergency departm ent after an ATV (all-terrain vehicle) crash with pain in his jaw and occlusal
abnormalities.

19
Pediat ric Mandible Fract ures

5.1 Descript ion 5.3 Treat m ent


Com m in uted an d sign ifican tly m edially displaced bilateral Goals of treatm en t: Restoration of occlusion , fun ction , an d
subcon dylar fract ures. facial balan ce.
Com m in uted righ t m an dibu lar body fracture. Facial grow th : Vertical grow th of th e m an dible occurs
Green st ick fracture of th e in n er (lin gual) table of th e prim arily in th e subcon dylar region an d m ay be disrupted in
m an dibular sym physis. severe injuries to th is area. Coun selin g regardin g th is risk is
Mult iple injured teeth . im portan t.
Pediatric bon e h as th e abilit y to rem odel. Th us m in im ally
displaced fractures w ith n ear n orm al occlusion can be t reated
5.2 Work-up con servatively.

5.2.1 Hist ory and physical exam inat ion


Com plete t raum a evaluation , in cludin g ABCs (airw ay,
5.3.1 Acrylic dent al splint s
breath ing, circulation ). (Gunning splint s)
Must evaluate risk for airw ay com prom ise.
If th e patien t is youn ger th an age 2, th e decidu ous teeth h ave
Rarely, in t ubat ion m ay be n ecessary to protect
n ot com pletely erupted an d can n ot tolerate arch bars. Open
th e air w ay.
reduction /in tern al fixation (ORIF) w ith plates also risks injur y
Evaluate for associated injuries, in cludin g cervical
to tooth roots.
spin e injuries.
An acr ylic splin t m ay be fixed in place to both occlusive
Di cult to assess h istory in ch ildren . Th ey m ay describe jaw
surfaces w ith circum -m an dibular, circum -piriform , an d oth er
pain w ith m ovem en t an d n oticeable ch anges in occlusion .
t ypes of fixation w ires ( Fig. 5.2).
In spect face for asym m etr y an d areas of ten dern ess, sw ellin g,
or ecchym osis.
Ecchym osis of preauricular areas can in dicate un derlyin g

fract ures.
Ch in lacerat ion m ay in dicate superiorly directed force con -

sisten t w ith condylar fract ures.


Deviation of jaw open in g or lim ited m obilit y.

In t raoral exam in at ion m ay reveal laceration s or h em ato-

m as; evaluate for den tal injuries, in cluding presen ce of


perm an en t den t it ion .
Body/angle fract ures m ay a ect th e in ferior alveolar n er ve,

causin g n um bn ess of th e low er lip an d teeth .


State of den tition
Ch ildren ages 6 to 12 w ill presen t in various states of m ixed

den t ition . Youn ger ch ildren w ill h ave perm an en t tooth


roots deep to th eir prim ar y den t ition . These fa ctors w ill
cr it ica lly influence a surgeons options for reconstr uction
of injur ies.
Assess for den tal fract ure, stabilit y, tooth root exposure,

an d caries.

5.2.2 Pert inent im aging or


diagnost ic st udies
High -resolution m axillofacial com puted tom ography: Gold
stan dard for evaluation of facial t raum a. Th ree-dim en sion al
recon struction s m ay assist in evaluatin g injur y. Maxim um -
in ten sit y project ion view (w h en available) can reveal
den t ition for evaluation of tooth roots.
Pan orex: Requires pat ien t cooperation , an d patien t m ust be
uprigh t for th e stu dy. Allow s visualization of th e en tire m an -
dible an d den tition . Tow n e view adds im proved evaluation
of condyles.
Fig. 5.2 Options for wiring techniques, including circum -m andibular,
Plain radiography (m an dible series w ith an teroposterior,
circum -piriform , circum -orbital, and circum-zygom atic wires. At least
lateral, oblique, an d open -m outh Tow n e view ): Th ese studies three points of fixation should be used to optim ize stabilit y of the
are of lim ited ben efit in youn ger pat ien ts, w h ose skeleton s fixation.
are less calcified th an th ose of adults.

20
Pediat ric Mandible Fractures

5.3.2 Erich arch bars for Th e presen ce of developin g tooth roots is critical in operative
plan n in g.
m axillary fixat ion In bilateral su bcon d ylar fract u res, th e vertical h eigh t of th e
If adult m olars are presen t or th e deciduous m olars are m an dible is lost.
Min iplates w ith m on ocortical screw s are placed at in ferior
reasonably solid, they m ay be used to stabilize arch bars. (Ch il-
dren ages 2 to 5 years have reasonably solid deciduous m olars, m an dibular border to m in im ize injur y to developin g tooth
w hereas ch ildren ages 6 to 12 years have m ixed den tition .) roots.
Circum -m an dibular w ires m ay be used to addition ally At least on e of th e fractures m u st be repaired to reestablish

stabilize a low er arch bar. th e h eigh t of th e m an dible an d preven t even tual collapse
A m axillar y arch bar m ay be fixed an teriorly to th e piriform resultin g in a perm an en t open bite.
aperture or an terior n asal spin e. Surgical access (see Case 2)
In traoral approach th rough a gin givolabial sulcus in cision
In older ch ildren w ith adult den t ition , in term axillar y fixation
(IMF) m ay be establish ed w ith arch bars or IMF screw s in for sym physeal an d body fractures.
In t raoral approach w ith percutan eous screw placem en t
stan dard fash ion .
Crow n s of decidu ous teeth an d partially erupted perm an en t versus Risdon (extern al) approach for an gle fractures.
teeth m ake in terden tal w irin g di cult an d poten tially t rau-
m atic to fut ure den tition .
5.4 Com plicat ions
5.3.3 Tim ing of im m obilizat ion Abn orm alities of occlusion or den t ition : Suggestive of
in adequate in it ial reduction or stabilization .
Fractures in ch ildren h eal m ore quickly th an th ose in adults, An kylosis of th e TMJ: Especially n otable w h en th e con dyle is
an d th e abilit y of th e con dyle to rem od el follow in g injur y to fractured an d th e patien t is treated w ith lon g-term
th is area is also excellen t . im m obilization .
Con d ylar fract u res: Treated con servatively w ith soft diet an d Grow th disturban ce: May be un avoidable because of severit y
physical th erapy. of injur y, especially in th e subcon dylar region .
(Su b)con d ylar fract u res: Wh en fractures to th e con dyle
are present , im m obilization sh ould be m in im ized
(rough ly 2 w eeks) to decrease th e risk for an kylosis of 5.5 Crit ical Errors
th e tem porom an dibular join t (TMJ).
Failure to address subcon dylar fractures an d m an dibular
Bod y an d an gle fr act u res: 3 to 4 w eeks.
h eigh t, resultin g in perm an en t open bite an d m alocclusion .
Parasym p h yseal fract u res: 4 w eeks.
Platin g th e m an dible fractures w ith out regard to perm an en t
tooth roots.
5.3.4 Open reduct ion and Failure to discuss w ith fam ily grow th disturban ce related to
subcon dylar fract ures.
int ernal fixat ion Failure to release m axillom an dibular fixation an d confirm th e
ORIF is perform ed if n orm al occlusion can n ot e obtain ed w ith presen ce of n orm al occlusion w ith condyles seated appropri-
closed reduction or if m ore th an on e fracture is present. ately in th e glen oid fossa upon com pletion of th e case.

21
Part 2

Sect ion II. Face Cancer


(Squam ous Cell Carcinom a,
Basal Cell Carcinom a,
Melanom a, and Reconst ruct ion
(including Mohs Defect s))
Lip (Cancer and Reconstruction)

6 Lip (Cancer and Reconst ruct ion)


Tracy S. Kadkhodayan & Terence M. Myckatyn

Fig. 6.1 A 42-year-old wom an presents with a


defect on her upper lip after Mohs surgery for
basal cell carcinom a resection.

25
Lip (Cancer and Reconstruction)

6.1 Descript ion Squ am ou s cell carcin om a: Most com m on t ype in lip, > 90%
occur on low er lip.
A 2.3 2.5-cm partial-th ickn ess defect of cent ral upper lip 4 m m m argin s for low risk lesion s: Well/m oderately di er-

involving m ucosa, verm ilion , an d cutan eous lip. en t iated, w ell defin ed borders, trun k/extrem it y
Involves m ultiple crit ical st ructures: Cupids bow, ph iltral lesion s > 2 cm .
dim ple, an d ph iltral colum n s bilaterally. 6 m m m argin s for h igh risk lesion s: Poorly di eren t iated,

Orbicularis oris m uscle in tact . poorly defin ed borders, perin eural/vascular involvem en t,
Clark level IV or V, recurren t , h igh risk location s (m ask area
of face, h an ds/feet, gen italia)
6.2 Work-up En larged lym ph n odes sh ould be evaluated for m etastases

w ith FNA or core n eedle biopsy.


6.2.1 Hist ory Radiation th erapy can be used for n on -surgical can did ates

History of sun exposure. Melan om a: Margin s determ in ed by Breslow t h ickn ess.


In situ: 5 m m .
Person al an d fam ily h istory of skin can cer.
< 1 m m : 1-2 cm
Gen etic condit ion s: Xeroderm a pigm en tosum , Gorlin (n evoid
1 to 2 cm .
basal cell) syn drom e, albin ism .
2.1 to 4 m m : 2 cm .
History of radiation th erapy
> 2 cm : 2 cm .
Organ tran splan tat ion : Squam ous cell carcin om a is th e m ost
Stage Ib (0.76-1 m m th ick w ith ulceration or m itotic rate > =
com m on can cer in solid organ tran splan t recipien ts
1 per m m 2) or stage II m elan om a (> 1 m m th ick) m ay
require sen tin el lym ph n ode biopsy (ENT or surgical on col-
6.2.2 Physical exam inat ion ogy con sultation ). If lym ph n odes are posit ive, n eck dissec-
Full-body exam in at ion of in tegum en t. tion is perform ed.
Stage III m elan om a (positive lym ph n odes) m ay require
Lym ph n ode exam in ation to rule out m etastatic disease.
in terferon (m edical on cology consultation ).

6.2.3 Diagnost ic st udies


6.3.2 Reconst ruct ion
If patien t presen ts in it ially w ith out resect ion , a biopsy
sh ould be perform ed at th e tim e of evaluation to esta blish Goals: Restoration of fun ction (oral com peten ce, speech ) an d
a dia gnosis. cosm esis.
Full-th ickn ess incisiona l versus excisiona l biopsies m ay be
Recon struct ion sh ould be delayed un til nega tive ma rgins a re
perform ed. Avoid sh ave biopsies. confir med on fin al path ology.
Local w oun d care or tem porizin g skin graft in in terim .

Fresh frozen path ologic evaluation can n ot en sure n egative

6.3 Treat m ent m argin s.


Surgical pearls
Con sider Moh s surgery, if available. Mark or tattoo lan dm arks (e.g. w h ite roll, red lin e) before
Allow s exam in ation of ~ 100% of surgical m argin s; h igh est
in filtratin g local an esth etic.
cure rates. Prim ar y closure: Upper lip 1/4 defect, low er lip 1/
Board exam in er m ay require th at you excise th is yourself.
3 defect.
Mu cosal/ver m ilion d efect s: Replace like w ith like.
6.3.1 Excision ( Table 6.1) Mucosa l a dva ncement: Wh en defect is partial th ickn ess.

Ver milion a dva ncement: Musculoverm ilion flaps for sm all,


Basal cell carcin om a: full-th ickn ess defects.
Stan dard m argin is 2-5 m m
Ver milion lip sw itch
Larger m argin for h igh risk t ypes (poorly defin ed borders,
For larger defects, prim arily of th e upper lip.
recurren t, perin eural invasion , aggressive grow th pat tern ) Requires second stage (2 w eeks) for division of flaps.
Radiation th erapy can be used for n on -surgical can did ates
Ton gue flap

An teriorly based, from th e ven tral surface.


Table 6.1 Standard m argin recom m endations for di erent t ypes of Requires second stage for division (~10 days).
skin cancer Up p er lip fu ll-t h ickn ess d efect s: Focus on restoration of
Basal Cell Cancer Squam ous Cell Melanom a (Breslow lan dm arks.
Cancer thickness) Prim ar y closure if defect 1/4 of lip.

Standard m argin: < 2 cm , well differen- In situ: 5 m m Full-thickness skin gra ft: Wh en m uscle layer is n ot involved.
25 m m tiated: 4 m m Con sider replacem en t of full aesth etic subun it.
Margin for aggressive > 2 cm , invasive to < 1 m m : 1 cm Abbe fla p ( Fig. 6.2)
subt ypes: 7 m m fat, high-risk location: Lip sw itch from low er to upper lip, design ed as h alf th e
6 mm defect w idth .
1 to 2 cm Can correct defects involvin g 1/3 to 1/2 of th e lip.
> 2 m m : 2 cm Secon d stage for division at 2 to 3 w eeks.

26
Lip (Cancer and Reconstruction)

Fig. 6.2 Abbe flap. (a) The Abbe flap is elevated from the central lower lip. For central upper defects, it is elevated to the labiomental fold. For lateral
defects, it continues through the central chin pad. (b) It is inset onto the columella, above the colum ellar base, with the extensions to the nasal sill.
(c) The flap is divided and inset at 2 weeks.

Karapan dzic flap ( Fig. 6.3)


Myocutan eous rotation al flap prim arily for low er lip
defect involvin g 1/3 to 2/3 of lip; m ay be used for upper
lip as w ell.
Restores oral com peten ce (preser ves neurova scula r
pedicle) but m ay result in m icrostom ia.
Low er lip full-th ickn ess defects
Prim ar y closure if defect 1/3 of lip.

Reverse Abbe fla p: Upper to low er lip sw itch .

Schucha rdt For defects 1/3 to 2/3 of th e lip.

Perform ed w ith lip advan cem en t w ith in cision s in


labiom en tal crease.
Typically com bin ed w ith lip sw itch to preven t
m icrostom ia.
Ka ra pa ndzic: As n oted above.

Bern ard-Burrow -Webster procedure: For defects > = 2/3 of lip.


Bilateral ch eek advan cem en t flaps w ith Burrow s trian gles

excised at th e n asolabial an d labiom en tal crease.


Com m issure defects
Estlan der flap ( Fig. 6.4): Lip sw itch involving

th e com m issure.
Useful for full-th ickn ess defects, 1/2 to 2/3 of th e lip.
Total lip recon struction
Free ra dia l forea rm fla p w ith palm aris lon gus slin g

for support.
Bern ard-Burrow -Webster procedure: As n oted above.

6.4 Com plicat ions


Recurren t can cer: Re-excision is n ecessar y.
Woun d deh iscen ce, part ial flap n ecrosis: Treat w ith local
w oun d care.
Microstom ia: May be preven table w ith postoperative
splin tin g.
Abbe flap (sin gle or bilateral) m ay be useful adjun ct to

prim ar y flap procedure.


Oral in com peten ce: Orbicu laris recon struct ion is im portan t
for preven tion . Fig. 6.3 Karapandzic flap.

27
Lip (Cancer and Reconstruction)

6.5 Crit ical Errors


Failure to perform appropriate biopsy w h en concern
for m elan om a.
In adequate resect ion .
Recon struct ion before en surin g n egative m argin s.
Failure to repair orbicularis oris m usculature.
Failure to address all th ree layers of m issing t issue (m ucosa,
m uscle, skin ) or ign orin g critical structures (ph iltrum , Cupid s
bow, w h ite roll).

Fig. 6.4 Estlander flap.

28
Nose (Cancer and Reconstruction)

7 Nose (Cancer and Reconst ruct ion)


Alison K. Snyder-Warwick & Marissa Tenenbaum

Fig. 7.1 A 59-year-old wom an presents to the


clinic with a lesion on her nasal tip that she
noticed 3 m onths ago.

29
Nose (Cancer and Reconstruction)

7.1 Descript ion


Full-thickness defect of the sebaceous skin covering the nasal tip.
Th e st ructural fram ew ork an d n asal lin in g are n ot violated.
Th e defect m easures < 1.5 cm in size, w h ich is appropriate for
local tissue tran sposition .
Involves on e n asal subun it , th e tip, but does n ot violate th e
rem ain in g aesth etic subun its.

7.2 Work-up
7.2.1 Hist ory
History of sun exposure.
Person al or fam ily h istory of skin can cer.
In h erited predisposin g con dition s
Xeroderm a pigm en tosum , Muir-Torre syn drom e, Gorlin

syn drom e, albin ism , basal cell n evus syn drom e, oth ers.

7.2.2 Diagnost ic st udies Fig. 7.2 Aesthetic subunits of the nose.

Full-body in tegum en t exam in at ion .


If patien t presen ts in it ially w ith out previous t reatm en t, a
biopsy sh ould be perform ed at th e tim e of evaluation to
esta blish a dia gnosis.
Full-th ickn ess incisiona l versus excisiona l biopsies m ay be

perform ed. Avoid sh ave biopsies. Nasal subun its ( Fig. 7.2)
Nin e n asal subun its

7.3 Treat m ent Th ree m idlin e subun its (dorsum , tip, colum ella).
Th ree paired lateral subun its (sidew alls, alae,
Con sider Moh s surgery con sultat ion , if available. soft trian gles).
Allow s exam in ation of ~ 100% of surgical m argin s; h igh est Scars best placed at borders of subun its for optim al

cure rates. aesth et ics.


Board exam in er m ay require th at you excise th is yourself. Su bu n it p r in cip le: If a defect com prises > 50% of th e t ip or

alar subun it, th e residual n orm al skin sh ould be discarded


7.3.1 Excision (see Table 6.1) an d th e en tire subun it resurfaced. Th is prin ciple is som e-
w h at debated.
Basal cell carcin om a: 2- to 5-m m m argin . Larger m argin for
aggressive subt ypes.
Squam ous cell carcin om a
4 m m if lesion < 2 cm , w ell-di eren tiated, n ot invasive. 7.3.3 Reconst ruct ive opt ions
6 m m if lesion > 2 cm , poorly di eren tiated, invasive in to fat,

or in h igh -risk location (cen tral face, ears, scalp, h an ds,


Healin g via secon dar y in ten tion
Sm all, superficial defects on conca ve or pla na r surfaces
feet, gen italia).
Melan om a: Excision m argins determ ined by Breslow thickness. aw ay from m obile lan dm arks (e.g., m edial can th al area,
In sit u: 5-m m m argin .
sidew alls, alar groove).
Cover w ith m oist dressin g (e.g., petroleum jelly).
< 1 m m : 1-cm m argin .

1 to 2 m m : 1- to 2-cm m argin .
Prim ar y closure
Defects < 0.5 cm in upper 2/3 of th e n ose.
> 2 m m : 2 cm m argin .

Stage II mela noma (depth > 2 m m or > 1 m m w ith ulceration )


Full-th ickn ess skin graft
Sm all (< 1.5 cm ) an d su p er ficial d efect s in u p p er 2/3
m ay require sen t in el lym ph n ode biopsy (surgica l oncology
consulta t ion). of n ose.
Skin from above th e clavicles provides best color m atch
Stage III mela noma (positive lym ph n odes) m ay require

in terferon (medica l oncology consulta tion). (e.g., foreh ead, preauricular, postauricular, supraclavicular).
Com posite ch on drocutan eous graft
Sm all (< 1 cm ), full-th ickn ess alar rim an d colum ella defects.
7.3.2 Reconst ruct ion From auricular h elix, rim , or ear lobe.

Do n ot recon struct un t il t um or-free m argin s are con firm ed. Local flaps: Sm all (< 1.5 cm ) superficial defects.
Fresh frozen path ologic evaluation can n ot en sure n egative Tra nsposit ion (ba nner) fla p: Upper 2/3 of n ose.

m argin s. Bilobed fla p ( Fig. 7.3): Low er 1/3 of n ose.

Excision an d dressing versus tem porary skin graft are rea- Dorsa l na sa l (miter) fla p ( Fig. 7.4): Dorsum an d t ip

son able first steps. defects (< 2 cm ).

30
Nose (Cancer and Reconstruction)

Fig. 7.3 Bilobed flap.

Region al flaps
Na sola bia l fla p

Based on perforators from facial an d an gular arteries.


Sin gle-stage, superiorly based flap: Superficial sidew all
an d alar defects.
Tw o-stage flap: Deep alar defect requirin g placem en t of
cartilage graft .
Foreh ead flap

Based on supratroch lear artery.


Tw o or th ree stages, depen din g on severit y of defect.
Workh orse for large (> 1.5 cm ) or deep defects (involving
fram ew ork replacem en t).
Full-th ickn ess defects: Require replacem en t of outer skin,
fra mework, a nd lining.
Fram ew ork don or sites: Nasal septal, con ch al, an d costal

cartilage; cran ial bon e graft .


Nasal lin ing recon struct ive option s: Turn over h in ge flap of Fig. 7.4 Dorsal nasal flap.
adjacen t skin , skin graft, rotat ion advan cem en t flaps from
residual n asal lin in g, septal m ucoperich on drial flaps,
folded foreh ead flap, facial artery m usculom ucosal (FAMM)
flap, free flap (radial forearm , an terolateral th igh [ALT], 7.5 Crit ical Errors
dorsalis pedis).
Failure to biopsy suspicious skin lesion .
In adequate resect ion .
7.4 Com plicat ions


Recon struct ion before en surin g n egative m argin s.
Failure to describe th e defect (n asal subun its).
Recurren t can cer: Re-excise. Failure to recon struct all n ecessary layers of th e n ose
Woun d deh iscen ce, part ial flap n ecrosis: Local w oun d care. (m ucosa, cartilage fram ew ork, skin ).

31
Eyelid (Cancer and Reconstruction)

8 Eyelid (Cancer and Reconst ruct ion)


Jason R. Dudas and Eva A. Hurst

Fig. 8.1 An 87-year-old wom an presents with


basal cell carcinoma of the lower eyelid and
resultant defect following excision.

33
Eyelid (Cancer and Reconstruction)

8.1 Descript ion Con firm n egative path ologic m argin s follow in g
in itial resect ion before attem pting sign ifican t
Basal cell carcin om a of low er eyelid w ith poorly defined recon struction .
ma rgins (e.g., good can didate for Moh s m icrograph ic surgery). Magn etic reson an ce im agin g: Useful adjun ct in determ in in g
Full-th ickn ess defect of low er eyelid exten t of tum or an d lym ph n ode status in cases of
~ 50%, in cluding lid m argin an d en tire h eigh t of tarsus. aggressive tum or h istology (e.g., perin eural invasion or
Con t iguous skin an d m uscle defect exten din g to ch eek deeply invasive t um ors).
lid jun ction .
Medial an d lateral can th al ten don s in tact w ith n o eviden ce
of lacrim al system involvem en t . 8.2.4 Consult at ions
Ophtha lmology: For visual acuit y an d field testin g,
8.2 Work-up Sch irm er test .

8.2.1 Hist ory


History of oph th alm ologic con dition s, in cluding dr y eye an d 8.3 Treat m ent ( Fig. 8.3)
excessive tearin g.
Person al or fam ily h istory of skin m align an cy or sign ifican t
8.3.1 Key point s
sun exposure. Need to recon struct all m issin g layers.
History of previous periorbital surgery or traum a. Anter ior la mella : Skin an d orbicularis m u scle

(outer coverin g).


Middle la mella : Tarsus an d septum (structural support).
8.2.2 Physical exam inat ion Poster ior la mella : Conjun ctiva (in n er lin in g).

Divide th e periocular region in to zon es ( Fig. 8.2). If full th ickn ess (i.e., all th ree lam ellae), m ust recon struct at
Determ in e layers th at h ave been lost. least on e of th ese layers w ith a flap.
Full or part ial th ickn ess. Can n ot recon struct full-th ickn ess defects w ith grafts

Skin , m uscle, tarsus, conjun ct iva. sim ultan eously. A flap is n ecessar y to provide vascularit y
Evaluate can th al suppor t an d suspected involvem en t of to th e graft.
lacrim al system .
Iden tify viable elem en ts available for recon struction (i.e., skin ,
m uscle, tarsus, conjun ctiva). 8.3.2 Zone I (upper lid)
Evaluate eyelid fun ct ion .
Partial th ickn ess
< 50% of eyelid w idth : Prim ary closure w ith local t issue

8.2.3 Diagnost ic st udies advan cem en t.


> 50% of eyelid w idth : Full-th ickn ess skin graft (FTSG) from
Esta blish the dia gnosis: If it w as n ot don e earlier, an
con tralateral upper eyelid.
in cision al biopsy sh ould be perform ed at in itial visit
Full th ickn ess
to con firm th e path ology.
< 25%: Prim ar y closure w ith possible can th otom y an d/or

can th olysis.
25 to 50%: Ten zel sem icircular rotation al flap

50 to 75%: Recon struct ive option s

Cutler Beard flap (w ith cartilage graft): Full th ickn ess


low er lid pedicled flap. Division perform ed at 6 to
8 w eeks.
Com posite graft (i.e., tarsoconjun ctival graft from
con tralateral upper lid or n asal septal cartilagem ucosa)
an d local m yocutan eous flap
> 75%

Low er lid tran sposition (Mustard lid sw itch ) flap.


May n eed ch eek advan cem en t to recon struct don or site.
Foreh ead flap w ith m ucosal graft

8.3.3 Zone II (low er lid)


Partial th ickn ess
< 50%: Prim ar y closure w ith local tissue advan cem en t .

> 50%: Recon structive option s

Fig. 8.2 Zones of the eyelid. FTSG from contralateral upper eyelid.
Upper lid tran sposition (Fricke, Tripier) flap.

34
Eyelid (Cancer and Reconstruction)

Fig. 8.3 A sum m ary of guidelines for reconstruction of the periocular region. FT, full t hickness; FTSG, full-thickness skin graft; PT, partial
thickness. (Reproduced with perm ission from Spinelli H, Jelks GW. Periocular reconstruction: a system atic approach. Plast Reconstr Surg
1993;91(6):10171024.)

Full th ickn ess 8.3.5 Zone IV (lat eral cant hus)


< 25%: Prim ar y closure w ith can th otom y an d/or

can th olysis. Ch eek advan cem en t flap or FTSG.


25 to 50%: Ten zel sem icircular rotation al flap Lateral can th al supportin g procedure: Can t h op exy
50 to 75%: Tarsoconjun ct ival (Hugh es) flap or can t h op last y.
w ith FTSG.
> 75%: Ch eek advan cem en t flap w ith a graft (palatal
8.3.6 Zone V (periorbit al) or
m ucosa, septal cartilage-m ucosa).
m ult iple -zone defect
Corn eal protection is priorit y.
8.3.4 Zone III (m edial cant hus) Im m ediate coverage w ith myocuta neous fla p or FTSG.
In t ubate th e lacrim al system . Defin itive recon struct ion m ay n eed to be staged.
Local flaps from upper eyelid or glabella.
Healin g by secon dary in ten tion is acceptable (in areas
of concavit y).
8.4 Com plicat ions
If detach ed, m edial can th us sh ould be recon structed posterior Ectropion
an d superior to its origin al location . Avoid ten sion on closure.

35
Eyelid (Cancer and Reconstruction)

All flaps sh ould be design ed w ith ten sion orien ted


h orizon tally. Vert ical ten sion w ill pull th e eyelid dow n ,
8.5 Crit ical Errors
in creasin g th e risk for ect ropion . Failure to iden tify exten t of defect (i.e., an terior an d/or
Perform la tera l ca ntha l support procedure. posterior lam ella).
Corn eal abrasion Failure to con firm n egative m argin s before recon struction .
Avoid con tact of sut ure m aterial w ith corn ea: Resorbable Failure to recon struct all lam ellae appropriately
sut ures on ly w it h buried kn ots. Exam ple: Usin g graft on graft (FTSG + ch on drom ucosal
Avoid con tact of kera tinized epithelium w ith corn ea. com posite graft).
Suboptim al aesth et ic outcom e Failure to recogn ize con com itan t injur y, such as lacrim al
Avoid vert ical in cision s: Can lead to n otch in g. system or can th al involvem en t .
Accurate reapproxim ation of eyelid layers.

Preserve m edial cont in uit y of lash lin e if possible.

36
Ear (Cancer and Reconstruction)

9 Ear (Cancer and Reconst ruct ion)


Tracy S. Kadkhodayan & Terence M. Myckatyn

Fig. 9.1 A 50-year-old m an presents with a right


ear defect following Mohs resection of basal cell
carcinom a.

37
Ear (Cancer and Reconstruction)

9.1 Descript ion 9.3.3 Treat m ent by size


Full-th ickn ess skin defect exten din g dow n to cart ilage Sm all defects (< 1/4 of ear)
Prim ar y closure Tan zer excision pattern s.
over an tih elix.
Wedge resection (defect < 1.5 cm ).
Exposed cart ilage w ith part ial loss of perich on drium .
Healin g by seconda r y intention or skin gra ft (if in tact

cartilage an d perich on drium ).


9.2 Work-up Medium defects (1/4 to 1/2 of ear)
Local flaps an d grafts.
9.2.1 Hist ory Con t ralateral ch on drocutan eous com posite graft .

History of sun exposure. Large defects (> 1/2 of ear)


Person al or fam ily h istory of skin can cer. Total ear recon struct ion (see Case 14: Microt ia).

Gen etic condit ion s: Xeroderm a pigm en tosum , Gorlin (n evoid Complete a vulsion: Replan tation if superficial tem poral

basal cell) syn drom e, albin ism . artery or posterior auricular artery available.

9.2.2 Physical exam inat ion 9.3.4 Treat m ent by locat ion
Upper 1/3
Full-body in tegum en t exam in at ion .
Skin graft: Preferably con tralateral postauricular full-
Lym ph n ode exam in ation .
th ickn ess skin graft; poor results for h elical rim defects.
For h elical rim defects < 2 cm

9.2.3 Diagnost ic st udies An t ia-Bu ch ( Fig. 9.2): Ch on drocutan eou s h elical rim
advan cem en t flaps based on posterior blood supply.
If patien t presen ts in it ially w ith out resect ion , a biopsy
For large h elical rim defects (> 2 cm )
sh ould be perform ed at th e tim e of evaluation to est ablish
Tw o-stage procedure: (1) in itial coverage of ear w ith
a d iagn osis.
postauricular skin ; (2) subsequen t release an d skin
Full-th ickn ess incisiona l versus excisiona l biopsies m ay be
graftin g of residual defect.
perform ed. Avoid sh ave biopsies.
Tubed pedicle flap from postauricular skin : Tw o stages.
Converse tun n el tech n ique or tubed pedicle flaps.
9.3 Treat m ent Ban n er flap : Skin flap based on an terosuperior

auriculoceph alic sulcus


If resect ion h as n ot yet been don e, con sider Moh s surger y, Com bin e w ith con tralateral auricular cartilage graft for
if available larger defects (> 2 cm ).
Allow s exam in ation of ~ 100% of surgical m argin s. High est Ch on drocutan eous tran sposition flaps: Often require
cure rates. graftin g of don or site
Board exam in er m ay re qu ire t h at you excise t h is
Orticoch ea procedure: Based laterally on h elix.
you rself. Davis flap: Based an teriorly on crus h elicis, from
con ch al bow l.
9.3.1 Excision (see Table 6.1) Costal cartilagin ous fram ew ork an d tem poroparietal fascial

flap for large defects.


Middle 1/3
9.3.2 Reconst ruct ion

Helical rim defect: Ch on drocutan eous advan cem en t flaps.


Sh ould be delayed un t il n egative m argin s are confirm ed on Mastoid (postau ricular attach m en t) flap: Skin flap on ly.

fin al path ology. Often requires secon d stage (3 to 4 w eeks) for division
Local w oun d care or tem porizin g skin graft in in terim . an d/or split-th ickn ess skin graft to don or site.
Fresh frozen path ologic evaluation can n ot en sure n egative May com bin e w ith con tralateral auricular cartilage graft
m argin s. (i.e., Die en bach flap).

Fig. 9.2 (a-c) Antia-Buch helical rim advancement

38
Ear (Cancer and Reconstruction)

Converse flap: Con t ralateral auricular cartilage graft Hem atom a: Prom pt in cision , drain age, an d bolster
tun n eled un der skin flap from m astoid, requires second application .
stage (3 w eeks) for division an d in set. Scar con tracture leadin g to blockage of extern al
Low er 1/3 auditor y can al.
Lobule recon struct ion di cult because of lack of structural Cartilagin ous deform it ies.
support.
Superiorly based flaps w ith cart ilage graft.

Con t ralateral com posite lobule grafts.

Postauricular ch on drocutan eous flaps.


9.5 Crit ical Errors
Extern al auditory can al Failure to perform appropriate biopsy w h en concern
Main ten an ce of paten cy m ore im portan t th an coverage. for m elan om a.
Requires use of sten t or splin t for 6 m on th s. In adequate resect ion .
Recon struct ion before en surin g n egative
9.4 Com plicat ions
m argin s.
In adequate in fect ion prophylaxis: Topical m afen ide
Recurren t can cer: Re-excise. (Sulfam ylon ; Mylan Ph arm aceuticals, Can on sburg, PA;
Woun d deh iscen ce, part ial flap n ecrosis: Local w oun d care. topical) an d fluoroquin olon es (system ic) h ave excellen t
In fect ion /ch on drit is cartilagin ous pen etration .
An tibiotics: Topical m afen ide an d oral fluorquin olon es h ave In adequate dressin g: Bolster, suction drain to preven t
excellen t cart ilage pen etration . h em atom a.
Dbridem en t if appropriate. Failure to sten t th e extern al auditor y can al.

39
Cheek (Cancer and Reconstruction)

10 Cheek (Cancer and Reconst ruct ion)


Santosh Kale, Albert S. Woo & Terence M. Myckatyn

Fig. 10.1 (a,b) A 56-year-old m an presents after


Mohs resection of squam ous cell carcinom a of
the right cheek.

41
Cheek (Cancer and Reconstruct ion)

10.1 Descript ion 10.2.3 Diagnost ic st udies


Ulcerated lesion over th e righ t ch eek m alar em in en ce Full-th ickn ess incisiona l versus excisiona l biopsy m ay be
abut tin g th e low er eyelidch eek jun ct ion . perform ed. Avoid sh ave biopsies.
Follow in g resect ion , full-th ickn ess defect of th e in ferior Biopsy any oth er suspicious skin lesion s (if previously n ot
lidch eek jun ction th at involves perform ed)
Lower eyelid: Preseptal orbicularis m uscle and orbital septum .

Suborbital ch eek: Skin , fat , SMAS (superficial m usculo-

apon eurotic system ).


10.3 Treat m ent
Moderate skin laxit y on exam in at ion . Recon struct ion sh ould be delayed un til nega tive ma rgins a re
confir med on fin al path ology.
10.2 Work-up Local w oun d care or tem porizin g skin graft in in terim .

Fresh frozen path ologic evaluation can n ot en sure

10.2.1 Hist ory n egative m argin s.


Malign an cy: Tim elin e of presen tation .
History of sun an d environ m en tal exposure. 10.3.1 Excision (see Table 6.1)
Person al an d fam ily h istory of skin can cer.
Gen etic condit ion s: Xeroderm a pigm en tosum , Gorlin (n evoid
basal cell) syn drom e, albin ism . 10.3.2 Reconst ruct ion
Com plicat in g com orbidities Must consider eyelid support w h en operatin g alon g th e
Cardiopulm on ar y/periph eral vascular disease, diabetes,
eyelidch eek jun ction
obesit y, tobacco use, prior irradiation , previous surger y, Con sider can th oplast y/can th opexy for addition al support of
an t icoagulation . lax eyelid.
Pr im ar y closu re: Wh en adequate skin laxit y is present .
10.2.2 Physical exam inat ion Sk in graft s: Less ideal color m atch
W h en patien t is a poor flap can did ate because of
Full-body in tegum en t exam in at ion .
com orbidities.
Lym ph n ode exam in ation to rule out con cern for m etastatic
High risk for recurren ce or tem porar y coverage before
disease.
defin itive recon struction .
Wound characteristics (hair-bearing areas, adjacent skin laxity).
Tran sposition flaps (ban n er, rh om boid): Useful for sm aller
Subun it involvem en t ( Fig. 10.2)
defects of th e face.
Recon struct ion based on correction of facial subun its.
Mustard ch eek rotation flap ( Fig. 10.3)
Ch eek m ay be con sidered on e large subun it or it m ay be
divided in to zon es.

Fig. 10.3 Mustard cheek rotation flap for reconstruction of defects


Fig. 10.2 Facial subunits m ay be utilized to guide reconstruction. involving the lower eyelid.

42
Cheek (Cancer and Reconstruction)

Fig. 10.4 Design for cervicofacial flap.


(a) Anteriorly based. (b) Posteriorly based

Wide-based ch eek rotation flap useful for defects of th e Flap sh ould be an ch ored to zygom a or in ferolateral orbital
low er eyelid or in fraorbital region . rim periosteum to preven t ectropion .
Allow s t issue to be advan ced superiorly to m in im ize Cer vicopectoral flap ( Fig. 10.5)
retraction of th e low er eyelid. Design sim ilar to th at of cer vicofacial flap but dissect ion

Exten ds alon g lid m argin t ran sversely to th e preauricular exten ds postauricularly an d dow n in fron t of h airlin e across
region . n eck to allow addition al m ovem en t.
Burow t rian gle rem oved in th e lateral cervical region . Cer vicofacial flap m ay be exten ded to cervicopectoral flap if

May be elevated in subcutan eous plan e or deep to SMAS (to in adequate release of th e t issues is ach ieved w ith in itial
in crease blood supply). procedure.
Flap sh ould be an ch ored to zygom a or in ferolateral orbital Dissected deep to platysm a, can in corporate pectoral an d

rim periosteum to preven t ectropion . deltoid fascia.


Cer vicofacial advan cem en t flap ( Fig. 10.4) Region al flaps
An teriorly or posteriorly based flap th at advan ces/rotates Useful for large defects.

facial skin to fill defect. Deltopectoral, cer vicoh um eral, pectoralis m ajor, t rap ezius,

Sim ilar in con cept to Mustard flap, but w ith out latissim us flaps.
involvem en t of low er eyelid. Less ideal skin an d color m atch th an local flaps usin g like

Design ed below eyelid tran sversely to ear, exten ds in feriorly skin .


aroun d earlobe Tissue expansion
Dissected above SMAS, releases zygom atic retain ing May be perform ed w h en few recon struct ive option s exist

ligam en ts. an d recon struction can be delayed.

Fig. 10.5 Design for cervicopectoral flap.


(a) Anteriorly based. (b) Posteriorly based

43
Cheek (Cancer and Reconstruct ion)

Microvascular recon struct ion Hem atom a: Large flaps sh ould h ave drain s placed at in it ial
May be perform ed w h en locoregion al option s are absen t or procedure.
in adequate for recon struction .
Helpful for recon struct ion of large oral m ucosa defects or

w h en com posite t issue recon struct ion (m ucosa, bon e, skin ) 10.5 Crit ical Errors
is n ecessary. Failure to obtain n egative m argin s on path ology before
Disadvan tage: poor color an d texture m atch .
recon struction .
Poor flap design th at is in adequate to recon struct a sizable
10.4 Com plicat ions
facial defect.
Failure to con sider th e im portan ce of th e low er eyelid,
Ectropion : Frequen tly results from excessive dow nw ard pull resultin g in ectropion
of low er eyelid. In adequate support of th e eyelid (can th oplast y/

Partial flap loss: Frequen tly m ay be m an aged w ith local can th opexy).
w oun d care. Failure to suspen d flap to periosteum of zygom a or

Con tour abn orm alit ies an d un sigh tly in cision s/color m atch . in ferolateral orbital rim periosteum .
Alteration of h air-bearin g region w ith advan cem en t of Poor design of flap w ith dow nw ard vector alon g low er

h air-bearin g areas in to previously h airless areas. eyelid, leadin g to h igh risk for ectropion .

44
Part 3

Sect ion III. Face Congenit al


Unilateral Cleft Lip

11 Unilat eral Cleft Lip


Albert S. Woo

Fig. 11.1 Full-term newborn m ale presents to the


clinic with the displayed congenital anom aly.

47
Unilat eral Cleft Lip

11.1 Descript ion Feeding: critical aspect of cleft care.


Specialized nipples/bottles: Haberm an feeder (w ith a squeez-

Com plete un ilateral cleft lip deform it y able tip), or Pigeon nipple (w ith cross-cut opening for faster
Cleft n asal deform it y: Nostril is w iden ed an d slum ped (alar flow ), or Dr. Brow ns Level 2 nipple w ith Pigeon valve.
cartilage is in feriorly, posteriorly, an d laterally displaced), Molding: Narrows cleft and aligns alveolar arch to optim ize repair.
but n ot hypoplast ic. Th e n asal tip is bulbous an d sh ifted Not em ployin g any m oldin g tech n ique is also a reason able

tow ard th e cleft. option .


Septal deform it y: Th e sept um is sh ifted a wa y from th e cleft. Lip taping: With Steri-Strips or com m ercially available devices

Alveolar cleft . (e.g., DynaCleft; Canica Design, Alm onte, Ontario, Canada).
Com plete un ilateral cleft palate. Nasoalveolar m old in g (NAM)

Passive m oldin g applian ce rap idly becom in g th e gold


11.2 Work-up stan dard for optim izin g n asal sh ape.
Alveolar m oldin g alon e takes place un t il alveolar ridges
11.2.1 Hist ory are 5 m m apart , th en n asal prongs are attach ed to
im prove th e sh ape of th e n ose.
Fam ily h istor y of orofacial cleftin g. Lath am applian ce
Feeding di cult ies, appropriate w eigh t gain . Active m oldin g applian ce expands palate an d
Addition al m edical problem s an d associated syn drom es. retracts prem axilla.
Less com m on ly used because of con cern s regarding
11.2.2 Physical exam inat ion m axillar y grow th .
Evaluate involved st ructures (lip, alveolus, palate, un ilateral, Lip adh esion (n ot m an dator y)
Perform ed surgically, in place of m oldin g tech n iques.
bilateral).
Prelim in ar y repair of skin m uscle betw een 6 w eeks an d
Evaluate for associated bir th an om alies consisten t w ith a
syn drom ic presentation . 3 m on th s of age.
Goal: Min im ize ten sion durin g th e defin itive cleft repair

11.2.3 Diagnost ic st udies perform ed aroun d 3 to 6 m on th s of age.


Cleft lip repair: At approxim ately 3 m on th s of age
On ly if con cern for oth er system ic illn ess or syn drom e Rule of 10s: 10 lb of w eigh t, 10 g of h em oglobin ,

10 w eeks of age.
11.2.4 Consult at ions May be delayed secon dar y to m oldin g (NAM) or earlier lip

Best m an aged by a m u lt id iscip lin ar y t eam : Plastic surgery, adh esion .


pediatric otolaryn gology, speech path ology, ch ild psych ology, Cleft palate repair: At approxim ately 1 year of age
Earlier repairs favor speech but poten tially com prom ise
audiology, gen etics, pediatric den t istr y, orth odon tics,
m axillofacial surgery, social w ork, an d n ursin g. m axillar y grow th an d vice versa.
Gen etic evaluation if any concern exists. Alveolar bon e graftin g
Perform ed durin g period of m ixed den tition (rough ly 7 to

10 years of age) after appropriate orth odon tics.


11.3 Treat m ent Cleft n asal/septal recon struct ion
Man agem en t via a m ult idisciplin ar y team . Optim ally perform ed on ce th e patien t h as reach ed skeletal

m aturit y. Can be com bin ed w ith touch -up procedures to


11.3.1 Schedule of t reat m ent optim ize appearan ce.
Septoplast y is frequen tly deferred un t il th is tim e.
Mult iple procedures an t icipated (see Table 11.1 for cleft
m an agem en t t im elin e).
11.3.2 Cleft lip repair t echnique
Table 11.1 Timeline for the m anagem ent of a child with cleft lip and
Millard rotation advan cem en t repair
palate deform it y
Most com m on ly recogn ized repair tech n ique ( Fig. 11.2).
Age Treatm ent
Th e sh ort m edial lip elem en t is rota ted, an d th e lateral lip is
Newborn Feeding assessment, initial clinical a dva nced in to th e defect .
evaluation, possible genetics referral
Regardless of th e tech n ique you are m ost fam iliar w ith , you
03 mo Molding therapy, possible cleft lip adhesion sh ould plan to discuss th e Millard tech n ique un less you
3 m o (or after m olding) Definitive cleft lip repair are prepared for exten sive quest ion ing on a procedure th at
1y Cleft palate repair th e exam in er m ay n ot be fam iliar w ith or m ay be unw illin g
34 y Assessment of velopharyngeal com petence to accept.
Oth er valid tech n iques in clude th e Moh ler m odification ,
710 y Alveolar bone grafting following presurgical
orthodontics (during period of m ixed Noordh o tech n ique. Older procedures, such as th e
dentition) Ran dall-Ten n ison Z-plast y, are n o lon ger w idely accepted.
Skeletal m aturity Septorhinoplast y, final revisions as Prim ar y cleft n asal recon struct ion : Perform ed at th e tim e
necessary; orthognathic surgery if evidence of prim ar y lip repair, n ow w idely accepted but n ot
of midfacial growth disturbance m an datorily perform ed.

48
Unilateral Cleft Lip

Fig. 11.3 Definitive markings on patient case study. Standard m arkings


for Millard rotationadvancem ent.

Advan cem en t flap: From point 4, skirting along lateral cleft


m argin to nostril, then extending laterally to base of ala.
C flap : Used to recon struct base of colum ella on cleft side.
L flap : Can be used to recon struct n ostril floor or advan ce
lateral n asal w all.
M flap : Can add m ore m ucosa for in traoral lin in g.

11.4 Com plicat ions


Cleft lip deh iscen ce.
In fect ion .
Fig. 11.2 (a,b) Millard rotationadvancem ent flap for correction of
unilateral cleft lip deformit y.
11.5 Crit ical Errors
Surgical m arkin gs In abilit y to draw a cleft lip repair an d to iden t ify w h ere each
Essen tial com pon en t of exam in ation . You MUST kn ow h ow
poin t goes w ith closure.
to m ark a cleft lip. Un fam iliarit y w ith tim in g of repair.
Critical poin ts ( Fig. 11.3)
Discussing tech n iques oth er th an Millard rotat ion
1. Cen ter of Cupids bow.
advan cem en t repair w ith out appropriate kn ow ledge
2. Pea k of Cupids bow on n on cleft side.
an d fam iliarit y.
3. Measure from poin t 1 to poin t 2 an d m ark poin t on Advocatin g con troversial procedures, such as gin givoperios-
opposite side.
teoplasty, prim ar y septal recon struction , or oth er n on -
4. Edge of white roll on lateral lip elem en t .
stan dard procedures, m ay n egatively im pact exam in ation .
Critical flaps
Discussing option al th erapies w ith out appropriate kn ow ledge
Rot at ion flap : From poin t 3 in an arc up to base of (i.e., Lath am applian ce). If you m en tion it, be prepared to
colum ella an d poten t ial back-cut past m idlin e to get elaborate upon it.
appropriate rotation .

49
Bilat eral Cleft Lip

12 Bilat eral Cleft Lip


Farooq Shahzad & Albert S. Woo

Fig. 12.1 (a,b) You are asked to see a 7-day-old


infant boy born with a cleft lip.

51
Bilateral Cleft Lip

12.1 Descript ion Presurgical m oldin g: Narrow s cleft an d im proves sym m etr y
Lip tapin g: Started soon after birth .

Com plete bilateral cleft lip deform it y Nasoalveolar m old in g (NAM): Facilitates lip repair by

Notable projection of th e prem axilla w ith good sym m etr y. brin gin g lip elem en ts togeth er an d im provin g posit ion of
Cleft n asal deform it y: W iden ed n ostrils bilaterally w ith low er lateral n asal cartilages. It also align s th e alveolar
sh or t colum ella. segm en ts. Th is is rapidly becom ing th e gold stan dard for
Bilateral alveolar cleft deform it y w ith pron oun ced gap preoperative m oldin g before surgical in terven tion .
bet w een segm en ts. Lat h am ap p lian ce (act ive m oldin g applian ce): Expan ds

Likely com plete bilateral cleft palate (n ot com pletely palate, retracts prem axilla. Less com m on ly used because
visualized). of concern s regarding m axillar y grow th .
Su rgical lip ad h esion : Can be used in w ide clefts by

12.2 Work-up suturin g th e skin an d m ucosa m uscle of th e lip elem en ts.


Perform ed at 6 w eeks to 3 m on th s of age. Goal: Decrease
ten sion at subsequen t defin it ive lip repair.
12.2.1 Hist ory Surger y
Fam ily h istor y of orofacial cleftin g. Tim in g: Lip repair is typically perform ed aroun d 3 m on th s
Feeding di cult ies, appropriate w eigh t gain . of age.
Addition al m edical problem s an d associated syn drom es. May be delayed because of h ealth con cern s or addition al
tim e n eeded for m oldin g.
12.2.2 Physical exam inat ion
Th e exam in ation sh ould focus on four features: Nose, lip,
alveolus, an d palate.
12.3.2 Cleft lip repair t echnique
Cleft lip an d palate classification Various tech n iques h ave been described: McCom b, Trott ,
Un ilateral versus bilateral. Cuttin g, Millard, Fish er, an d Mulliken m eth ods ( Fig. 12.2).
Com plete (involvem en t of n asal floor) versus in com plete. Because of on ly m in or variation s betw een procedures, any
Isolated cleft lip (prim ar y palate) versus cleft lip an d reason able tech n ique m ay be used as lon g as key prin ciples
palate (prim ar y an d secon dary palate). are follow ed.
Addition al facial dysm orph ic features. Orbicularis recon struction ( Fig. 12.3): Curren t m eth ods

Com plete physical exam in at ion to look for any oth er brin g in m uscle from th e lateral lip to th e m idlin e to
an atom ical abn orm alit y recon struct th e orbicularis slin g.
Con sider possibilit y of syn drom ic presentation . Ph iltral preservation : Th e prolabial skin is preserved to

create th e ph ilt rum . How ever, th e prolabial verm illion


12.2.3 Pert inent im aging or (cen tral red lip) is discarded, an d verm ilion from th e lateral
lip is brough t to th e m idlin e.
diagnost ic st udies
Guided by physical fin din gs (e.g., echocardiogram , ren al
ult rasoun d, skeletal X-rays).

12.2.4 Consult at ions


Ch ildren w ith clefts are ideally cared for by a m u lt id iscip li-
n ar y t eam : Plast ic surgery, otolar yngology, speech path ology,
audiology, ch ild/developm en tal psych ology, n ursin g, pediatric
den t ist r y, orth odon t ics, an d oral an d m axillofacial surgery.

12.3 Treat m ent


Man agem en t via a m ult idisciplin ar y team .

12.3.1 Schedule of t reat m ent (see


Table 11.1 for cleft
m anagem ent t im eline)
Feeding: critical aspect of cleft care
Specialized n ipples/bottles: Haberm an feeder (w ith a

squeezable tip) or Pigeon n ipple (w ith cross-cut open in g


for faster flow )
Mon itor w eigh t: After th e first 2 w eeks of life, th e ch ild
Fig. 12.2 Standard m arkings for bilateral lip repair
sh ould gain h alf a poun d ever y w eek.

52
Bilat eral Cleft Lip

Fig. 12.3 Bilateral cleft lip repair advocated by


Mulliken. (a) Orbicularis m uscle and verm ilion
from lateral lip elem ents are brought to the
m idline. The skin of the prolabium is preserved to
create the philtrum. (b) Result following repair of
the cleft lip. Note that Mulliken advocates
external rim incisions for prim ary cleft nasal
repair.

Fig. 12.4 Authors suggested m arkings (modeled


after the Cut ting technique).

Markin gs ( Fig. 12.4) 12.4 Com plicat ions


Philt ra l fla p: Th e bottom of th e ph iltral flaps (poin ts 1, 2,
Bleedin g.
an d 3) are m arked 2 to 2.5 m m apart. Th e flap n arrow s
In fect ion .
sligh tly as it exten ds up to th e colum ella, w ith its len gth
Deh iscen ce.
t ypically 6 to 8 m m .
White roll a nd vermilion: Th e w h ite roll is m arked (poin ts 4
Prolabial isch em ia: Rem ove n asal sten t or any oth er
com pressive struct ures, if placed.
an d 5) on th e lateral lip elem en t w h ere it begin s to dim in ish
m edially. An oth er poin t (6 an d 7) is m arked lateral to each
of th ese poin ts at a distan ce equal to th e distan ce from poin t
1 to poin t 2 (~ 2 to 2.5 m m w ide). Mark th e verm ilion
12.5 Crit ical Errors
perpen dicular to poin ts 4 an d 5. Draw a lin e from poin ts Failure to m on itor feedin g/w eigh t gain .
6 an d 7, above th e w h ite roll, up to th e n asal sill an d th en In abilit y to draw a cleft lip repair an d to iden t ify w h ere each
tran sversely un der th e ala. poin t goes w ith closure.
Nasal recon struction : This is a n optiona l procedure a nd is Un fam iliarit y of tim in g of repair.
NOT performed by a ll cleft surgeons. Exposure is obtain ed via Failure to evaluate for oth er congen ital an om alies.
a separate rim in cision (Mulliken m eth od), exten sion of Advocatin g con troversial procedures, such as gin givoperios-
ph ilt ral flaps to rim in cision s (Trott m eth od), or exten sion teoplasty, prim ar y septal recon struction , or oth er n on -
of ph iltral flaps to in cision s in th e m em bran ous septum stan dard procedures, m ay n egatively im pact exam in ation .
(Cut t in g m eth od). Th e low er lateral n asal cartilages are Discussing option al th erapies w ith out appropriate kn ow ledge
dissected in th e supraperich on drial plan e, an d in terdom al (i.e., Lath am applian ce). If you m en tion it, be prepared to
sut ures are placed to approxim ate th e n asal tip. elaborate upon it.

53
Cleft Palate

13 Cleft Palat e
Farooq Shahzad & Albert S. Woo

Fig. 13.1 You are asked to evaluate this newborn


girl with a cleft of the palate.

55
Cleft Palat e

13.1 Descript ion Th e in fan t n eeds to be closely follow ed for sleep a pnea w ith
con tin uous pulse oxim etr y an d evaluation of desa tura tion
In com plete cleft of th e seconda r y palate exten ding to th e h ard dur ing feeding. Lar yn goscopy an d bron ch oscopy m ay be
an d soft palate jun ction . n eeded for air w ay evaluation if obstruct ion is severe an d
Th e pr ima r y palate is n ot a ected (an terior to th e in cisive surgical in terven tion is con sidered.
foram en ). Gen etics evaluation , particularly if associated an om alies
are present.

13.2 Work-up
13.2.1 Hist ory
13.3 Treat m ent
Man agem en t via m ultidisciplin ar y team .
Airw ay con cern s (especially w ith sm all jaw - Pierre Robin
Feeding: In fan ts w ith cleft palate are at h igh er risk of bein g
sequen ce).
un derw eigh t .
Feeding con cern s, appropriate w eigh t gain
In abilit y to create an e ective suction force because of
In fan ts w ith cleft palate are n ot able to breastfeed because
palatal cleft. As a result , th e in fan t tires before feedin g
of th eir in abilit y to create appropriate suction .
un til satiated.
Exposures durin g pregn an cy (alcoh ol, an ticonvulsan ts,
Elevate h ead an d cradle in fan t at 45 degrees.
corticosteroids).
Specialized n ipples/bottles: Haberm an feeder (w ith a
Fam ily h istor y of orofacial cleftin g or cran iofacial syn drom es.
squeezable tip), Pigeon n ipple (w ith cross-cut open in g for
Addition al m edical problem s
faster flow ), or Dr. Brow ns level 2 n ipple w ith Pigeon valve.
Ch ildren w ith isolated cleft palate h ave a 40% in ciden ce of
Mon itor w eigh t closely.
syndromic presentation .
Pierre Robin sequen ce: In fan ts require close airw ay m on itor-
in g (n eon atal in ten sive care un it, con tin uous pulse oxim etr y).
13.2.2 Physical exam inat ion Most babies respon d to side or p ron e p osit ion in g. Oth er
strategies are n asoph ar yn geal airw ay, n asal con tin uous
Evaluate for facial dysm orph ic features.
posit ive airw ay pressure, tongue lip adh esion , m an dibular
Classify th e exten t of cleft an d involved structures.
distraction , an d trach eostom y.
Prim ar y an d/or secon dary palate (dividing poin t is in cisive
Surgical repair: Typically at aroun d 1 year of age (see
foram en ).
Table 11.1). Earlier repair puts ch ild at in creased risk for
Com plete or in com plete.
m axillar y grow th abn orm alities; later repair delays lan guage
Un ilateral or bilateral (vom er visible on on e or both
developm en t .
sides): May n ot alw ays be classified if h ard palate is Hard palate repair
n ot a ected.
Tw o-flap p alatop last y (Bard ach ): Most com m on ly used
Evaluate for Pier re Robin sequ en ce (m icrogn ath ia or
tech n ique, in w h ich m ucoperiosteal flaps are elevated
retrogn ath ia, glossoptosis, an d airw ay di cult ies).
based on greater palatin e vessels ( Fig. 13.2).
Head-to-toe exam in ation for any oth er an atom ical
Von Lan gen beck p alatop last y: Lateral relaxin g in cision s,
abn orm alit y or eviden ce of syn drom ic presentation
usually w h en prim ary (an terior) palate n ot involved.
Van d er Wou d e syn drom e (autosom al dom in an t): cleft lip
V-Y p u sh back p alatop last y (Veau -Ward ill-Kiln er)
an d/or palate w ith low er lip pits. Soft palate repair
Isolated cleft palate m ore likely to h ave associated
In t r avelar velop last y: Most com m on ly used tech n ique, in
an om alies th an cleft lip an d palate.
w h ich levator veli palatin i m uscles are dissected out an d
reapproxim ated in a tran sverse orien tation .
Dou ble-op p osin g Z-p last y (Fu rlow ): Musculom ucosal
13.2.3 Pert inent im aging or
flaps are elevated w ith opposin g Z-plasties from th e oral
diagnost ic st udies an d n asal m ucosa layers ( Fig. 13.3).
All patien ts require postoperative airw ay m on itorin g w ith
Evaluate oth er organ system s (e.g., echocardiography, ren al
ult rasoun d, X-rays of th e spin e) if suspicion for oth er con tin uous pulse oxim etr y.
congen ital an om alies or a syn drom e. Myrin gtom y tubes: In fan ts w ith cleft palate are at h igh er
Gen etic test in g if a syn drom e is suspected. Ch rom osom al risk of ear in fection s/e usion s an d frequen tly un dergo
m icroarray an alysis is frequen tly used. placem en t of ear tubes at tim e of cleft palate repair.

13.2.4 Consult at ions 13.4 Com plicat ions


Mu lt id iscip lin ar y t eam : Plast ic surgery, pediatric Airw ay obstruction : Th is can be due to bleedin g, edem a, or
otolar yngology, speech path ology, ch ild psych ology, tongue sw ellin g. Suction oroph ar yn x. May place n aso-
audiology, gen etics, pediatric den t istr y, orth odon tics, ph ar yn geal airw ay. If ton gue stitch is in place, use to pull
oralm axillofacial surger y, social w ork, an d n ursin g. tongue forw ard to open th e posterior airw ay. If tongue is
If Pierre Robin sequen ce, a pediatric otolar yngologist obstructin g, pron e position in g m ay h elp. If n o respon se to
sh ould be involved for airw ay m an agem en t. above m easures, en dotrach eal in t ubation m ay be n eeded.

56
Cleft Palate

Fig. 13.2 Bardach t wo-flap palatoplast y. A. Hard


palate m ucoperiosteal flaps are elevated based
on the greater palatine vessels. B. Soft palate is
incised and muscle is separated from the nasal
and oral m ucosa. C. Nasal lining is repaired and
the levator m usculature is dissected out and
approxim ated at the m idline to establish the
intravelar veloplast y. D. Appearance of the palate
after repair is com plete.

Fig. 13.3 Furlow double opposing Z plasty. A. Z


plasties are m arked over the soft palate oral
mucosa. B. A right-sided (relative to the patient)
posteriorly based m usculom ucosal flap and left-
sided anteriorly based mucosal flap is elevated.
C. An opposing Z plast y is m arked on the nasal
side. A right-sided anteriorly based m ucosal flap
and left-sided posteriorly based m usculom ucosal
flap is elevated. D. Both the Z plasties are
transposed and sutured together.

57
Cleft Palat e

Bleedin g: Usually m in or an d self-lim ited; requires airw ay


m on itorin g. If severe, return to operatin g room for control.
13.5 Crit ical Errors
Palatal fist ula: Usually m an ifests several w eeks after surger y. Failure to assess an d m on itor adequacy of airw ay.
Th is is n ot an em ergen cy an d m ay be m an aged electively. Failure to address feedin g an d/or failure to m on itor
If asym ptom atic, can in itially treat n on operatively an d w eigh t gain .
repair in conjun ct ion w ith any fut ure surger y. Failure to con sider th e cleft as a part of a syn drom e or failure
If sym ptom at ic (n asal regurgitation /hypern asal speech ), to assess for oth er congen ital an om alies.
sh ould be repaired. Re-repair is t ypically perform ed w ith In abilit y to draw cleft palate repair; un fam iliarit y w ith t im in g
local palatal tissue AlloDerm (LifeCell, Bridgew ater, NJ). of repair.
Oth er option s (e.g., tongue flap, facial artery m usculom u- Failure to m on itor th e airw ay in th e postoperative period.
cosal [FAMM] flap, an d free flap) are reserved for m ore Failure to m an age patien t in m ult idisciplin ar y
com plex, in t ractable cases. team sett in g.

58
Microtia

14 Microt ia
Farooq Shahzad & Albert S. Woo

Fig. 14.1 The parents of this 5-year-old boy would like to have the
childs ear reconstructed.

59
Microtia

14.1 Descript ion cases of un ilateral m icrotia, con duct ive h earin g aids m ay be a
ben eficial option .
Righ t ear m icrotia (lobu lar t ype) W h en h earin g is present in on ly on e ear, th e un a ected

Absen ce of an atom ical lan dm arks of th e righ t auricle except ear m ust be closely m on itored an d aggressively trea ted if
for abn orm ally orien ted lobule. problem s occur to optim ize pat ien ts h earin g.
Superior auricle con sists of residual hypoplast ic,

disorgan ized cart ilage.


Absen ce of extern al auditory m eatus. 14.3 Treat m ent
Several option s exist for recon struction of th e m icrotic ear.

14.2 Work-up Care sh ould be taken w ith surgical decision -m akin g because
few option s exist for revision or redo if th e patien t h as a poor
14.2.1 Hist ory in itial result.

Hearin g loss an d previous h earin g aid placem en t.


Fam ily h istory of ear abn orm alit ies, facial clefts, or syn - 14.3.1 Aut ogenous
drom es.
Asym m etric facial m ovem en ts.
Recon struct ion requires rib h ar vest, w h ich is used to create a
Visual im pairm en t . costal cartilagin ous fram ew ork.
Cardiac or ren al dysfun ction .
Bren t t ech n iqu e ( Fig. 14.2): four stages classically
described
Begun as early as 6 years of age.

14.2.2 Physical exam inat ion Stage I: Fram ew ork construct ion an d placem en t

Har vest of con tralateral sixth th rough eigh th ribs.


Classify an om aly: Un ilateral or bilateral; severit y of auricular In set in pocket posterior to ear vestige.
hypoplasia (lobular t ype, conch al t ype, an otia); presence of Stage II: Earlobe t ran sposition .
extern al can al. Stage III: Ear elevation an d split-th ickn ess skin graft .
Evaluate qualit y of periauricular skin , position of h airlin e. Stage IV: t ragus const ruction , con ch al excavation .
Com plete physical exam in at ion : Assess for facial sym m etr y Repair of th e atretic m iddle ear: High er com plication rate,
(h em ifacial m icrosom ia), epibulbar derm oids (Gold en h ar n ot n ecessary if h earin g aids provide adequate h earin g.
syn d rom e), occlusal abn orm alities, m an dibular hypoplasia, If pursued, m iddle ear recon struct ion sh ould be don e after
facial n er ve fun ction , orofacial clefts, Treach er Collin s extern al ear recon struction to m in im ize scar tissue at th e
syn d rom e (bilateral m icrotia; hypoplasia of m axilla, tim e of m icrotia recon struct ion .
zygom a, an d m an dible; dow nw ard-slan tin g palpebral Nagata tech n ique ( Fig. 14.3): t w o stages
fissures; colobom as). Not perform ed before 10 years of age because of n eed for

abun dan t car t ilage.


Stage I: fram ew ork con struction , lobule tran sposition
14.2.3 Pert inent im aging or Har vest of ipsilateral sixth th rough n in th ribs.
diagnost ic st udies Con struct h as a secon d, stacked layer of cartilage to
im prove projection of th e an tih elix; also con tain s a
Com plete audiom etric test in g
tragal com pon en t .
Evaluate conductive or sen sorin eural h earin g loss.
Stage II: ear elevation w ith ban ked cartilage graft,
Th e coch lea (in n er ear) is usually in tact. Th e patien t m ay
coverage w ith tem poroparietal fascial flap an d split-
th erefore ben efit from a con duct ive h earin g aid or extern al
th ickn ess skin graft.
can al/m iddle ear recon struction to restore h earin g to th e
a ected ear.
Assess patien t for use of a bon e-an ch ored h earin g aid 14.3.2 Alloplast ic ( Fig. 14.4)
(BAHA) an d discuss th e possibilit y of surgical recon struct ion Classically, a sin gle-stage recon struction w ith a porous poly-
to aid h earin g. ethylen e (Medpor; Stryker, Kalam azoo, MI) auricular im plan t.
Tem poral bon e com puted tom ography to evaluate m iddle ear A large (~ 12 cm ) tem poroparietal fascia flap is h ar vested to
an d in n er ear an atom y. com pletely cover th e Medpor con struct an d m in im ize th e
ch an ce of extrusion .
Obviates ch est w all don or site m orbidit y. Im plan t in fect ion
14.2.4 Consult at ions extrusion an d fracture rem ain risks.
Audiologist: For h earin g evaluation . Most patien ts w ith
m icrotia h ave middle ea r a tresia w ith resultan t conduct ive
hea r ing loss. How ever, th e in n er ear is usually in tact w ith a
14.3.3 Prost het ic
viable sen sorin eural apparat us. A prosth etic ear can be created to m irror th e opposite,
Otolaryn gologist: Evaluation for BAHA. With bilateral n orm al ear.
m icrotia an d h earin g loss, h earin g aids sh ould be placed Th e prosth esis m ay be attach ed by a dhesive (t im e-
w ith in w eeks of birth to allow speech developm en t. Even in con sum ing an d som etim es un stable) or h eld in place by an

60
Microtia

Fig. 14.2 The Brent technique: fabrication of ear


fram ework from rib cartilage. The Brent fram e-
work consists of t wo pieces. The base is obtained
from the synchondrosis of t wo rib cartilages, and
the helical rim is obtained from a floating rib
cartilage. The details are carved into the base
with a gouge. The helical rim piece is thinned and
at tached to the base with nylon sutures.

Fig. 14.3 The Nagata technique. Stage 1: fabrication of the costal cartilage fram ework. (1) The helix and crus helicis unit constructed from the ninth
costal cartilage. (2) The antihelix and superior and inferior crus unit constructed from the rem aining portions of the seventh and eight costal
cartilages. The incisura intertragica and tragus unit constructed from the remaining portions of the seventh and eighth costal cartilages. (3) The base
fram e constructed from the seventh and eighth costal cartilages. (4) The fabricated fram e. AH, antihelix; CH, crus helicis; H, helix; II, incisura
intertragica; T, tragus.

61
Microtia

If pursued, m iddle ear recon struct ion sh ould be don e after


extern al ear recon struction to m in im ize scar tissue at th e
tim e of m icrotia recon struct ion .

14.4 Com plicat ions


Skin n ecrosis resultin g in cartilage exposure: early in ter ven -
tion is m an dator y to save th e cartilage fram ew ork.
< 1 cm : Local w oun d care w ith an tibiotic oin tm en t protects

cartilage from desiccation an d m ay allow h ealin g.


> 1 cm : Local skin an d fascial flaps are n ecessar y

for coverage.
In fection : Im m ediate in cision an d dbridem en t w ith
an tibiotic irrigation in com bin ation w ith system ic an t ibiotics.
If Medpor im plan t used, im m ediate debridem en t of exposed
portion s an d coverage w ith flap m ust occur to preven t
seedin g of bacteria in graft m aterial.
Hem atom a: Requires im m ediate evacuation .
Pn eum oth orax: If it occurs durin g rib h ar vest, evacuate
air an d repair pleural defect. Tube th oracostom y is rarely
n ecessary.
Ch est w all con tour deform ities: Preven t by preservin g
perich on drium an d replacin g un used cartilage.
Cart ilage resorption .

Fig. 14.4 Medpor porous polyethylene implant. The two-piece im plant


consists of a helical rim and ear base.
14.5 Crit ical Errors
osseointegra ted fram e placed in th e m astoid bon e. An Failure to assess for oth er features of cran iofacial
osseoin tegrated fram ew ork violates th e skin of th e ear an d m icrosom ia.
elim in ates th e possibilit y of later autogen ous or alloplast ic Failure to refer to audiologist for h earin g evaluation
recon struction . an d h earin g aids.
Typically in dicated for failed prim ar y recon struct ion , poor Failure to m on itor un a ected ear to protect patien ts h earin g
local t issue qualit y, an d pat ien ts w ith poor an esth etic risk. status.
Requires m eticulous hygien e an d lifelon g follow -up for m ain - Failure to prom ptly an d aggressively m an age h em atom a, car-
ten an ce of th e prosth esis. tilage exposure, or in fection .
Repair of th e atretic m iddle ear: High er com plication rate, Perform in g m iddle ear recon struction before extern al ear
n ot n ecessary if h earin g aids provide adequate h earin g. recon struction .

62
Part 4

Sect ion IV. Face Cosm et ic


Aging Face and Neck

15 Aging Face and Neck


Tracy S. Kadkhodayan & Marissa Tenenbaum

Fig. 15.1 A 60-year-old woman requests a consultation for facial rejuvenation because she looks old and tired.

65
Aging Face and Neck

15.1 Descript ion Table 15.1 Fit zpatrick scale for skin t ype
Type Color Tanning
Middle-aged w om an .
I White, very fair; often has Always burns, never tans
Skin : Min im al act in ic dam age an d glabellar rhytids, crow s
freckles
feet an d perioral rhyt ids.
II White, fair Usually burns, rarely tans
Eyelids: Hoodin g of th e upper lids an d fat h ern iation of th e
III Beige com plexion, most Usually tans, occasionally burns
low er lids.
com mon
Midface: Prom in en ce of th e n asojugal groove, n asolabial
IV Beige, Mediterranean Rarely burns, tans easily
folds, an d labiom en tal folds; m idface descen t an d m oderate
com plexion
jow ling.
V Dark brown com plexion Rarely burns
Neck: Moderate skin laxit y an d plat ysm al ban din g.
VI Black Never burns, deeply pigm ented

15.2 Work-up
15.2.1 Hist ory 15.3 Treat m ent
W h at does th e patien t specifically w an t im proved? Wh at are
h er prim ar y con cern s?
15.3.1 Facelift
Previous facial procedures an d surgeries. Stan dard in cision ( Fig. 15.2): Tem poral (w ith in or in fron t of
History of hyper ten sion , blood th in n ers/platelet in h ibitors, h airlin e); preauricular (an terior border of h elix, pretragal or
smoking (m ust quit at least 4 w eeks before surgery). post tragal, below an d aroun d earlobe); postauricular (retro-
auricular sulcus, exten ding h orizon tally to th e h airlin e).
Short sca r technique: Preauricular in cision w ith in cision
15.2.2 Physical exam inat ion aroun d earlobe but n ot exten din g in to h airlin e. Lim ited to
Facial an alysis younger patien ts w ith m in im al skin excess.
Upper th ird: Evaluate brow posit ion , upper an d low er eyelid Surgical tech n iques: Multiple option s are reason able,
laxit y, lateral can th al posit ion , presen ce of n asojugal alth ough SMAS (superficial m usculo-apon eurotic system )
grooves, foreh ead an d periorbital creases (w ith an d w ith out an d SMASectom y procedures are m ost com m on .
an im ation ). Subcutan eous facelift

Middle th ird: Assess m alar descen t; presen ce of n asolabial Un derm in in g on ly in subcutan eous plan e w ith skin flap
folds, jow ls, m arion ette lin es; upper an d low er lip fulln ess redraped in superoposterior direction .
an d w rin klin g; an gle of m outh (e.g., depressed oral com - High er recurren ce rate because of absen ce of deeper sus-
m issure); project ion of ch in ; n asal an alysis (see Case 19). pen sion .
Low er th ird (n eck): Evaluate skin laxit y, degree of sub- SMAS facelift ( Fig. 15.3)

cutan eous an d subplat ysm al fat , eviden ce of plat ysm al Th e SMAS is in cised t ran sversely below (tradit ion al SMAS
ban din g, m easurem en t of cervicom en tal an gle. dissect ion ) or above (exten ded SMAS dissection ) th e
Fit zpatrick scale for skin t ype ( Table 15.1) zygom atic arch , an d th en preauricularly dow n to th e an te-
Classifies respon se of skin to ult raviolet ligh t. rior border of th e stern ocleidom astoid.
Useful for determ in in g respon se of skin to aging an d Th e SMAS flap is un derm in ed, trim m ed, redraped, an d
surgical in terven tion . plicated in a superoposterior direction .

Fig. 15.2 Standard facelift incision. Typically


extends from within the temporal hairline,
anterior to the ear and behind the tragus, around
the lobule and into hairline of the posterior scalp.

66
Aging Face and Neck

Fig. 15.3 Standard SMAS (superficial m usculo-aponeurotic system ) Fig. 15.4 SMASectomy procedure. SMAS (superficial m usculo-
dissection with plication. aponeurotic system ) resection takes place along the m alar em inence
and lateral edge of the orbicularis m uscle, over the parotid gland, and
inferiorly into the neck to the posterior portion of the plat ysm a m uscle.

Facial n erve bran ches run in th e sub-SMAS layer an d can 15.3.3 Adjunct t reat m ent s
be injured w ith overly aggressive dissection .
SMASectom y procedure ( Fig. 15.4) Fat graftin g.
Sim ilar to th e SMAS procedure, but rath er th an exten sive Fillers
Hyaluron ic acid, calcium hydroxyapatite, polylactic acid.
dissect ion un der th e SMAS layer, an ellipse of SMAS is
excised from th e m alar em in en ce to th e posterior n eck. Cutan eous resurfacing
Derm abrasion .
Th e SMAS edges are th en sut ured togeth er to t igh ten
Laser resurfacing: Carbon dioxide, erbium :YAG (yt trium
th is layer.
Decreases risk for facial n er ve injur y because of decreased alum in um garn et).
Ch em ical peels
dissect ion in th is layer.
Com posite facelift: Skin an d SMAS dissected as a sin gle flap. Superficial: Jessn er solution , salicylic acid, -hydroxy
MACS (m in im al access cran ial suspen sion ) lift: Purse-strin g acids (glycolic acid).
sut ures placed in SMAS an d suspen ded to deep tem poral Deep: Trich loroacetic acid, ph en ol (requires cardiac
fascia. m on itorin g).
Subperiosteal facelift: Midface elevated in subperiosteal Botulin um toxin
Glabellar region , t ran sverse an d vertical foreh ead rhyt ids,
plan e an d redraped.
crow s feet, perioral rhytids.

15.3.2 Neck rejuvenat ion ( Fig. 15.5)


Plat ysm aplast y platysm al m yotom y
15.4 Com plicat ions
Subm en tal in cision . Hem atom a: Correlated w ith h igh blood pressure. Take back to
Plat ysm a dissected, tigh ten ed, an d reapproxim ated operatin g room im m ediately an d evacuate.
in m idlin e. Skin n ecrosis: Local w oun d care, scar revision w h en h ealed.
Plat ysm a can be divided at least 6 cm in ferior/posterior to Avoid th e com pulsion to revise th is early because th e t issues
low er m an dibular border to im prove n eck defin it ion . h ave already been stretch ed an d are n ot likely to h eal after
Subm en tal liposuction . addit ion al tigh tenin g.

67
Aging Face and Neck

Fig. 15.5 Plast ysm aplast y involving subm ental


incision and plication of the plat ysm a at the
m idline. The plat ysm a m ay be divided posteriorly
to im prove neck definition, as necessary.

Nerve dam age: More com m on w ith sub-SMAS dissection


because of addit ion al dissect ion . Many are tran sien t
15.5 Crit ical Errors
n eurapraxias due to tract ion or cautery injur y. Failure to recogn ize preoperative risk factors an d con trol
Great auricular n er ve injury: Most com m on ly n oticed postoperat ive hyperten sion .
n er ve injur y. Failure to take a patien t back to th e OR im m ediately for
Buccal bran ch of facial n er ve: Most com m on ly injured h em atom a. Even a sm all collection can cause flap n ecrosis.
n er ve. Injury n ot usually n oticed because of n er ve Man agem en t of skin n ecrosis: avoid th e desire to take a
in tercon n ect ion s w ith oth er facial n er ve bran ch es. patien t to th e operatin g room for flap n ecrosis because
Dissatisfied patien t surger y m ay lead to m ore problem s.
A dissat isfied patien t does n ot n ecessarily m ean th at th e Failure to in stitute prophylaxis for h erpes in all patien ts
surgeon h as m ade an error. un dergoing skin resurfacing.
Have a plan for h ow you w ill m an age patien ts w h o are In abilit y to recogn ize or discuss th e risk for em bolic
un h appy w ith th eir results. (I w an t m y m on ey back. com plication s from periorbital injectable agen ts (e.g.,
You didnt fix th e saggy skin on m y n eck.) blin dn ess).

68
Aging Upper Face (Brow and Lids)

16 Aging Upper Face (Brow and Lids)


Neil S. Sachanandani & Marissa Tenenbaum

Fig. 16.1 A 56-year-old wom an com es to your


office seeking a m ore refreshed facial appearance.

69
Aging Upper Face (Brow and Lids)

16.1 Descript ion Supratarsal fold posit ion : m easu re m argin -crease distan ce.
Norm al 7 to 11 m m . High position in dicates levator
Glabellar frow n lin es an d periorbital rhytids deh iscen ce.
Asym m etric brow position . Levator fun ction : m easure eyelid excursion from m axim al

Excess upper lid skin . dow n gaze to extrem e up gaze w h ile stabilizing th e
Tear trough deform it y brow.
Midface decen t w ith prom in en t n asolabial folds Cover test: to un m ask sub-clin ical ptosis if th ere is

asym m etric lid posit ion .


Low er lid
16.2 Work-up Excess skin , fat h ern iation , tear trough

Lid position : low er lid sh ould n ot be below in ferior lim bus

16.2.1 Hist ory Lid laxit y: lid dist raction m ore th an 6 m m requires can th al

procedures.
Iden tify m edical con dition s th at m ay in crease th e risk for Sn ap back test: after distraction low er lid sh ould
com plication s. im m ediately sn ap back to its position
Bleph aroch alasis, Graves disease, ben ign essen t ial
Posit ion of eye in relat ion to orbital rim : posit ive vs n egative
bleph arospasm . vector.
Rosacea, pem phigus, sarcoidosis.
Lateral can th al position :
Previous periorbital an d facial procedures.
Lateral can th us is position ed sligh tly superior to m edial
Assess for a h istory of dr y eyes. can th us (positive can th al tilt) by an average of 4 degrees.
Bleph aroplast y m ay w orsen a previous h istory of dr y eyes.
Negative can th al tilt m ay require can th opexy.
Con tact len ses: If patien t is able to use con tact len ses

com fortably, th ere is n o h istory of dr y eyes an d tear


product ion is n orm al. Assess for dry eyes
Recen t LASIK surgery: Sh ould n ot un dergo bleph aroplast y
Sch irm er test (see Case 18).
for at least 6 m on th s follow in g procedure. Bells ph en om en on (see Case 18).
Post m en opausal h orm on e replacem en t th erapy (HRT)

70% h igh er risk for dr y eye.


Addition al 15% in crease in risk for dr y eye ever y 3 years Ocular exam inat ion
durin g HRT.
Visual acuit y.
Visual fields.

16.2.2 Physical exam inat ion


Forehead analysis 16.3 Treat m ent
Position of an terior h airlin e 16.3.1 Brow lift
Sh ape an d slope of foreh ead
Mult iple tech n iques available
Tran sverse foreh ead an d glabellar rhytids
Open coron al

In cision is m ade w ith in th e h airlin e (usually w ith sm all


Brow analysis zigzag in cision s).
Pow erful tech n ique for brow elevation .
Eyebrow sh ape: Sh ould be a gen tle curve w ith th e m edial an d Scar m ay be m ore visible w ith th is tech n ique.
cen tral port ion s w ider th an th e lateral aspects. En doscopic
Eyebrow peak: Sh ould be located at or just lateral to th e Com m on ly used tech n ique for brow elevation .
lateral lim bus. Access in cision s are m ade in scalp, an d brow is fixed after
Eyebrow location : Brow peak sh ould be 1 cm above en doscopic release of retain ing structures (see below for
supraorbital rim in w om en an d at supraorbital rim in m en . tech n ique).
Brow ptosis: Direct approach
m ay be com pen sated by hyperact ivit y of fron talis m uscle.
In cision im m ediately above brow w ith resection of
Im m obilize fron talis an d ask patien t to open eye an d assess redun dan t tissue.
brow posit ion . Obvious scar on foreh ead.
Lateral exten sion of upper lid h oodin g on to periorbital
Tran spalpebral: Access is obtain ed th rough an upper
region is a m arker of foreh ead ptosis (Con n ell sign ). bleph aroplast y approach .
Tem poral brow lift: Lateral brow elevated via in cision s in

tem poral scalp.


Eyelid analysis In cision s for en doscopic brow lift
Upper lid: Mark m idlin e.
Excess skin , fat h ern iation , lacrim al glan d prolapse Iden t ify sen t in el vein .
Lid position : sh ould n ot be low er th an 2 m m from Usually 1.5 cm above an d lateral to th e lateral can th us.
superior lim bus. Seen m ore easily in th e depen den t position .

70
Aging Upper Face (Brow and Lids)

Fron tal bran ch of th e facial n er ve Lim ited skin excision m ay be perform ed th rough separate
Low est bran ch, usually 1 cm above th e sen tin el vein . subciliary in cision .
Tem poral crest: Cur ved lin e m arked just in fron t of th e Tran scutan eous approach es

con tractin g tem poralis m uscle. Skin on ly.


Vectors: Th ere are several option s for vectors of lift an d Skin m uscle flap.
fixation . Th ese direction al elem en ts are part of th e in it ial Markin gs for low er lid bleph aroplast y
m arks th at guide th e direction of th e brow lift an d are A sin gle poin t is ch osen at th e level of th e lateral can th us

draw n on th e foreh ead. alon g th e low er lid. Th is poin t is exten ded 6 to 10 m m


Vector from th e alar base to th e lateral can th us projected laterally alon g on e of th e crow s feet, bein g sure to h ave
on to th e foreh ead. at least a 1-cm bridge betw een th is an d an upper
Vector from th e oral com m issure to th e lateral can th us. bleph aroplast y in cision .
An oblique lin e alon g th e scalp start in g at th e apex of th e Th e m ark is exten ded cen trally from th e in itial poin t in a

brow. cur ve parallelin g th e lid m argin 1 to 2 m m below th e lash


In cision s: Five in cision s are used. All of th e in cision s are lin e an d th en taperin g to a poin t 4 m m below th e pun ctum
t ypically 1 to 2 cm in len gth . m edially.
On e m idlin e: Placed lon gitudin ally 0.5 to 1 cm beh in d th e W h ile perform in g a skin m uscle flap tech n ique, at least 4

h airlin e. to 5 m m of th e preseptal orbicularis m ust be preser ved to


Tw o vector in cision s: 1.5 to 2 cm beh in d th e h airlin e. keep spon tan eous blin kin g in tact.
Align ed w ith th e foreh ead vector m arkin gs an d w ill
determ in e th e placem en t of th e fixation device. Usually
6.5 to 7 cm lateral to th e m idlin e m arkin g. 16.4 Com plicat ions
Tw o lateral in cision s: 1.5 to 2 cm beh in d th e h airlin e, 3 cm
Vision loss
lateral to th e vector m arkin gs in th e tem poral region .
Usually caused by retrobulbar h em orrh age.

Evacuation m ust be perform ed in th e operatin g room

im m ediately or a lateral can th otom y m ust perform ed at th e


16.3.2 Upper lid blepharoplast y bedside to preven t perm an en t vision loss.
Mult iple tech n iques available Hem atom a.
Tran sconjun ct ival fat rem oval from th e m edial pocket. Dr y eye syn drom e: Patien ts m ust un dergo adequate w ork-up
Skin excision on ly for dr y eyes before surgery.
Fat rem oval. A-fram e deform it y
Skin an d m uscle excision Deep upper lid sulcus w ith reduced am oun t of m edial

Fat rem oval. orbital fat caused by excessive resect ion (peaked arch
Ptosis repair m ay be perform ed at sam e t im e. deform it y of th e supratarsal crease).
Markin gs for upper lid bleph aroplast y Deh iscen ce of th e levator attach m en ts m ay create ptosis after
Th e in ferior excision lin e is draw n first by startin g w ith a bleph aroplast y.
m ark at th e upper eyelid crease May require ptosis repair.

10 m m above th e lash m argin in w om en , 7 m m above th e Lagoph th alm os an d corn eal exposure


lash m argin in m en . Develop from an terior lam ellar sh ortage or excessive

Th ere sh ould be a gradual dow nw ard cur ve tow ard th e orbicularis rem oval.
m edial an d lateral can th i. Treated acutely by tapin g th e eye closed at n igh t w ith

Each corn er sh ould be 6 m m above each can th us. application of oph th alm ic oin tm en t .
Th e m edial m ark sh ould n ot be m edial to th e carun cle. In fect ion .
Th e lateral m ark sh ould n ot exten d lateral to th e lateral Ectropion
orbital rim . Caused by th e com bin ation of low er eyelid laxit y an d

Th e superior m ark sh ould be at th e level of th e scarrin g of th e capsulopalp ebral fasciasept um in terface.


lateral lim bus.
At least 1 cm of eyelid skin bet w een th is m ark an d th e
th icker brow skin . 16.5 Crit ical Errors
Th e superior m ark sh ould be tapered m edially an d laterally
Failure to take patien t to th e operatin g room im m ediately
in a cur ve parallelin g th e in ferior m arks, m akin g sure th e
w h en sign s of retrobulbar h em atom a are eviden t .
h eigh t of th e excision does n ot exceed 5 m m m edially.
If un able to go to th e operatin g room , m ust perform a

lateral can th otom y at th e bedside.


Failure to address th e brow ptosis at th e tim e of upper lid
16.3.3 Low er lid m anagem ent ptosis bleph aroplast y.
Mult iple option s available Excessive fat rem oval.
Fillers. Overzealous resection of th e upper lid skin an d/or m uscle
Pin ch bleph aroplast y: Excise on ly redun dan t skin th at can durin g upper lid bleph aroplast y.
be h eld w ith a pin ch . Tran section of in ferior oblique m uscle durin g low er lid
Tran sconjun ct ival fat rem oval/redistribution tran sconjun ctival approach es.

71
Lower Lid Ectropion (Cicat ricial)

17 Low er Lid Ect ropion (Cicat ricial)


Michael C. Nicoson & Terence M. Myckatyn

Fig. 17.1 (a,b) A 50-year-old m an presents with lower eyelid exposure and excessive tearing following previous lower eyelid blepharoplast y.

73
Lower Lid Ectropion (Cicatricial)

17.1 Descript ion im m ediately. Delay or in abilit y to do so (w ith out blin kin g)
in dicates sign ifican t ectropion .
Low er lid ectropion : Eversion of th e low er eyelid m argin , Pinch test: Sign ifican t lid laxit y is presen t if th e low er eyelid
resultin g in scleral sh ow an d exposure of th e conjun ctiva. can be pulled m ore th an 6 m m aw ay from th e globe.
Subciliar y scar of th e low er eyelid from previous operative Facial n er ve fun ct ion : Con firm fun ction of orbicularis oculi to
procedure cicatricial ectropion . close eyes.
Bells ph en om en on

17.2 Background
17.3.3 Diagnost ic st udies
Ectropion is th e m ost frequen t lid m alposit ion seen clin ically.
Ch aracterized by eversion (out w ard turn in g) of th e lid
No defin itive radiograph ic studies are n eeded. How ever, in
m argin w ith exposure of th e conjun ctiva. th e settin g of traum a, m axillofacial com puted tom ography
Classified according to t im e of on set an d path ophysiology provides furth er detail about fracture pattern s.
(cicatricial, sen ile, paralyt ic, congen ital).
Sch irm er t est : Objective m easure of tear production /
Cicatricial ectropion results from sh orten in g of th e an terior secretor y capacit y
Alw ays assess patien t for dr y eye symptoms because th ese
lam ella of th e eyelid.
Secon dary to t raum a, burn injuries, com plication s of
can w orsen postoperatively if n o preven tative m easures are
bleph aroplast y, involut ion al pat tern s, an d m edication s. taken (i.e., can th opexy/plast y).
Place a strip of filter paper on th e low er lid lateral sclera for

a 5-m in ute period.


17.3 Work-up Measure th e am oun t of w ett in g: < 10 m m of w ettin g is

abn orm al.


17.3.1 Hist ory
Sym ptom s: Epiph ora (excessive tearin g), ocular irritation ,
xeroph th alm ia (dr y eyes), poor cosm esis.
17.4 Treat m ent
Any prior eyelid-related surgeries or traum a. Histor y of dura-

17.4.1 General principles
tion an d progression of sym ptom s.
Ask about pat ien t m edication s an d if any n ew m edication s Release any scar tissue or teth erin g.
h ave been started. Recon struct a ected layers appropriately.
An terior lam ella: Skin an d orbicularis m uscle.

Middle lam ella: Orbital septum .


17.3.2 Physical exam inat ion Posterior lam ella: Conjun ctiva.

In spect th e eye an d lid m argin . Evaluate location of th e


pun ctum .
Th e n orm al pun ctum posit ion is inverted tow ard
17.4.2 Surgical opt ions
th e lacrim al lake. An terior lam ella: Eyelid skin an d orbicularis m uscle layer
Evaluate for scleral sh ow an d roun din g of th e lateral can th us. Full-thickness skin graft (FTSG)
Epiph ora: Excessive tearin g due to pun ctum eversion . Com m on don or sites of FTSG: Upper lid, retro- an d
Assess condit ion of th e low er lid skin an d support of th e preauricular region s, supraclavicular region .
low er eyelid. Con t ralateral (upper) eyelid tissue provides th e best
Evaluate for in com plete eyelid closure an d corn eal abrasion s aesth etic outcom e; closest color an d th ickn ess m atch .
Sna p-ba ck test: Pull low er lid dow n an d aw ay from th e globe Con sider bolster dressin g to preven t serom a form ation .
for several seconds an d w ait . Th e eyelid sh ould sn ap back Tr ip ier flap ( Fig. 17.2)

Fig. 17.2 (a-c) Tripier flap (bipedicled).

74
Lower Lid Ectropion (Cicat ricial)

A bipedicled m usculocutan eous flap from th e superior lid. Does NOT involve lateral can th us disin sert ion .
A sin gle pedicle (usually laterally based), m ay also be Allow s m ild lid t igh ten ing an d m ild can th al elevation .
perform ed. Can th opla st y
Used for part ial-th ickn ess coverage of th e low er lid. Involves detach m en t of th e lateral can th al ten don from
In cont rast to FTSG, provides addition al m uscle layer th e orbit an d subsequen t reposition in g for correct ion of
for coverage. h orizon tal lid laxit y.
Middle lam ella: Support layer of low er eyelid con sistin g of
orbital septum
Repair prim arily if possible. Grafts n eed to be reason ably 17.5 Com plicat ions
sti for struct ural suppor t. Skin graft loss.
Palatal m ucosal graft: Replaces both m iddle an d posterior
Localized in fect ion .
lam ellar layers. Globe injury/corn eal abrasion : Lubricat in g th e corn ea an d
Cartilage graft: Harvested from septum or ear.
usin g a corn eal protector in t raoperatively reduces th e risk.
Allograft (e.g., acellular derm al m atrix)
Bleedin g an d retrobulbar h em atom a
No don or defect an d available o th e sh elf. How ever, th is Main tain m eticulous operative h em ostasis an d con trol
tech n ique is less accepted as a stan dard for recon struction
blood pressure.
of th is layer. If th ere is eviden ce of proptosis an d concern for h em atom a,
Posterior lam ella
return to th e operatin g room im m ediately or evacuate at
Hu gh es t arsocon ju n ct ival flap : Tw o-stage procedure
bedside.
( Fig. 17.3)
Tran sfers conjun ctiva an d a sm all portion of superior
tarsus for a subtotal or total low er lid recon struct ion . 17.6 Crit ical Errors
Divided at secon d stage.
Middle an d posterior lam ellae are recon structed w ith In adequately recon structin g each of th e critical layers of th e
th is procedure. eyelid.
Skin coverage via FTSG or flap. Failure to con sider a h orizon tal lid-t igh ten in g procedure
Adjun ct m easures for low er lid support w h en excessive laxit y is presen t.
Can th opexy
Usin g a split-th ickn ess rath er th an a full-th ickn ess skin graft
Involves tigh ten ing th e lateral can th us to th e periosteum . (to preven t con tracture).

Fig. 17.3 (a-c) Hughes tarsoconjunctival flap.

75
Lower Lid Ectropion (Cicatricial)

Placing a skin graft on a n onviable/n onvascularized w oun d severe scar con tracture due to h ealin g by secondar y
bed (e.g., oth er graft m aterial). in ten tion .
Har vestin g a deficien tly sized skin graft an d failure to bolster Failure to recogn ize an d prom ptly treat retrobulbar
th e skin graft after placem en t. h em otom a.
Failure to replace m issing soft tissue after th e Injur y to extraocular m uscles, especially th e in ferior oblique
cicatricial ectropion h as been released, resultin g in m uscle, durin g dissect ion alon g th e orbital floor.

76
Lower Lid Ectropion (Senile or Paralyt ic)

18 Low er Lid Ect ropion (Senile or Paralyt ic)


Noopur Gangopadhyay & Albert S. Woo

Fig. 18.1 A 65-year-old m an presents to the


clinic with excessive watering and constant
irritation of his left eye.

77
Lower Lid Ectropion (Senile or Paralytic)

18.1 Descript ion


Low er lid ectropion : Out w ard turn in g of eyelid m argin ;
involut ion al or sen ile caused by h orizon tal lid laxit y an d
age-related w eakn ess of th e can th al ligam en ts an d pretarsal
orbicularis oculi.
Addition al fin din gs in clude upper eyelid laxit y, brow ptosis
(righ t m ore th an left), an d m ild tear trough deform it y of th e
righ t low er lid.

18.2 Work-up
18.2.1 Hist ory
Sym ptom s: Epiph ora (excessive tearin g), ocular irritation ,
xeroph th alm ia (dr y eyes), poor cosm esis.
Classification : Pun ctal ectropion (lacrim al pun ctum everted
on ly), m edial ect ropion , gen eralized ectropion , lagoph th al-
m os (in abilit y to com pletely close eyes), secon dary exposure
keratopathy, sen ile ectropion , paralytic ectropion , or
cicatricial ectropion .

Fig. 18.2 Lateral canthal strip procedure. The lower lim b of the lateral
18.2.2 Physical exam inat ion canthus is divided as in a lateral canthoplast y. A. The tarsal plate is
Sn ap -back t est : Pull low er lid dow n an d aw ay from th e globe additionally de-epithelialized before the lateral lid is resuspended along
the lateral orbit rim . B. Sutures anchored in the orbit are fixated to the
for several seconds an d w ait . Th e eyelid sh ould sn ap back
lateral canthal strip.
im m ediately. Delay or in abilit y to do so (w ith out blin kin g)
in dicates sign ifican t ectropion .
Pin ch t est : Lid laxit y is presen t if th e low er eyelid can be
pulled m ore th an 6 m m aw ay from th e globe. La tera l ca nthopla st y ( Fig. 18.3): Divide com m issure w ith
Medial can th al laxit y test: Pull low er lid laterally aw ay from
reposition in g/tigh ten ing of th e low er can th al ten don in to th e
th e m edial can th us an d m easure displacem en t of m edial
site of origin (Wh itn all tubercle).
pun ct um ; th e greater th e distan ce m easured, th e greater th e La tera l ca ntha l str ip ( Fig. 18.2): Addition al t igh ten ing (in
laxit y. Norm al displacem en t is 0 to 1 m m .
m ore severe cases) m ay be obtain ed by de-epith elializing
Lateral can th al laxit y test: Pull th e low er lid m edially aw ay
th e skin over th e lateral can th al ten don to sh orten it furth er
from lateral can th us an d m easure displacem en t of th e lateral
before in sertion in to th e lateral orbit.
can th al corn er; th e greater th e distan ce m easured, th e greater La tera l ca nthopexy/retina cula r suspension ( Fig. 18.4): Tigh t-
th e laxit y. Norm al displacem en t is 0 to 2 m m .
en in g of lateral can th us or lateral retin aculum to periosteum
Bells p h en om en on : Th e pat ien t attem pts to close th e eyes
w ith perm an en t sutures placed in to th e in n er aspect of th e
w h ile th e exam in er h olds th e eyelids open . If th e eyes rotate
orbit. Can be used in less severe cases, an d n o disin sert ion of
superiorly Bells ph en om en on is presen t an d in dicates th at
lateral can th us is perform ed. Access is ach ieved th rough
th is protect ive m ech an ism is in place.
lateral low er lid bleph aroplast y approach .

18.2.3 Diagnost ic st udies


Sch irm ers t est : Filter paper is applied to th e forn ix. Th e 18.4 Com plicat ions
am oun t of m oisture on th e st rip is m easured after 5 m in utes. Corn eal an d conjun ctival exposure: Conjun ctival
Norm al: > 10 m m . keratin ization , corn eal breakdow n , epiph ora, an d pain .
Corn eal exam in at ion w it h flourescein to an alyze corn eal Keep corn ea an d conjun ctiva w ell lubricated to preven t
ch anges or lacerat ion s. exposure an d dr yin g.
Slit lam p exam in at ion : Evaluate for corn eal abrasion Surgical com plication s: Bleedin g, h em atom a, in fection ,
or dr yn ess. w oun d deh iscen ce, pain , poor position ing of th e tarsal st rip
Ret r obu lbar h em atom a: This is a surgica l emergency.

Alth ough adjun ctive m easures m ay be used (i.e., adm in is-


18.3 Treat m ent tration of carbon ic an hydrase in h ibitors or osm otic agen ts),
th e key t reat m en t is surgical in terven tion . Th is m ay be
18.3.1 Correct ion of horizont al lid laxit y perform ed by im m ediate return to th e operatin g room
Ta rsa l shortening: pen tagon al w edge excision lateral to lateral for exploration an d evacuation of h em atom a or em ergen t
lim bus to avoid n otch ing (rarely used). la tera l ca nthotomy w ith ca ntholysis at th e bedside.

78
Lower Lid Ectropion (Senile or Paralyt ic)

Fig. 18.3 Lateral canthoplast y procedure. The lower lim b of the lateral Fig. 18.4 Lateral canthopexy. The lower eyelid is supported without
canthal tendon is divided and repositioned along the internal rim of the shortening of the lid.
lateral orbit after additional tightening of the lower eyelid is achieved.

18.5 Crit ical Errors Failure to appropriately diagn ose etiology of ectropion (sen ile,
Failure to return im m ediately to th e operatin g room w h en paralytic, cicat ricial, congen ital) an d establish an appropriate
sign s of retrobulbar h em atom a are presen t. If th e operatin g m ean s of treatm en t .
room is n ot available, a lateral can th otom y an d can th olysis Failure to rein sert th e lateral can th us appropriately w ith per-
m ust be perform ed at bedside. m an en t suture fixation .

79
Rhinoplast y

19 Rhinoplast y
Amy M. Moore & Albert S. Woo

Fig. 19.1 (a-c) A 23-year-old wom an presents to your office with concerns about the appearance of her nose.

81
Rhinoplast y

19.1 Descript ion 19.3 Treat m ent


Youn g w om an w ith prom in en t dorsal h um p. Open approach : Most com m on tech n ique
Th e n ose is lon g an d n arrow, w ith out sign ifican t deviation . Access is ach ieved w ith a t ran scolum ellar (stair-step or

Th e n asal t ip is w ell defin ed, w ith som e prom in en ce of th e inverted-V in cision exten din g in to in ferior m argin s of th e
ceph alic m argin s of th e low er lateral n asal cartilage. low er lateral n asal cartilage.
Th e n asolabial an gle (colum ella to upper lip) is acute Allow s direct access to th e septum (for cartilage h ar vest/

(< 90 degrees). septoplast y) by separatin g th e low er lateral n asal cart ilages


an d accessin g th e septum via th e an terior septal an gle.
19.2 Work-up Closed approach : Less com m on ly used an d criticized for
decreased visualization an d control durin g th e procedure
19.2.1 Hist ory Access to th e cartilages m ay be establish ed th rough in ter-

cartilagin ous, tran scartilagin ous, or m argin al in cision s


Iden tify specific con cern s w ith appearan ce of n ose. w ith out th e tran scolum ellar com pon en t .
Di cult y w ith breath ing or h istory of sn orin g. Septum m ay be approach ed w ith tran sfixion , h em i-
Prior n asal surgeries or sm okin g h istory. tran sfixion , or Killian in cision s.
Motivatin g factors: Person al (in tern al) desire or extern al Tech n iques to con sider
pressure. Dorsum /radix

Reduction : Dorsal h um pectom y w ith rasping of bon e an d


19.2.2 Physical exam inat ion excision of redun dan t cartilage.
Evaluate pat ien t in fron t of a m irror. Augm en tation : cartilage graft (crush ed or diced cartilage,
Iden tify skin t ype, skin th ickn ess, sym m etr y, an d balan ce of w h ich m ay be w rapped in tem poroparietal fascia or
facial aesth et ic un its. Surgicel [Eth icon 360, Som er ville, NJ] for addition al
Describe extern al n ose by assessin g fron tal view, lateral view, con trol of m aterial), AlloDerm (LifeCell, Bridgew ater, NJ)
an d base view. graft an d bon e graft.
Spreader grafts: Ben eficial to open in tern al valve, close
Fron tal view : Allow s assessm en t of balan ce, sym m et ry, sh ape,
an d tip con tour, in cludin g th e follow in g: n asal bon es an d open roof deform it y, an d add suppor t to th e n asal dorsum .
Septal resection : Must leave an L-strut of at least 1 cm to
w idth , dorsal aesth etic lin es, n asal deviation , con tour
irregularities, upper an d low er lateral cartilage irregularities, preserve adequate septal suppor t. Perform on ly after h um p
alar w idth reduction to preven t over-resection of th e cartilage.
Low er lateral cartilages: Ceph alic t rim m ay be perform ed
Tip assessm en t: Evaluate bulbosit y, tip -defin in g poin ts, alar

sh ape, n ost ril size an d sh ape. leavin g 8 m m of cartilage.


Tip sh apin g: Colum ellar strut graft (preven ts loss of t ip
Lateral view : Allow s assessm en t of n asal len gth , dorsum , tip,
project ion , rotat ion , alarcolum ellar relation sh ip, radix project ion ), tran sdom al an d in terdom al sutures (to n arrow
h eigh t , fron ton asal an gle, ch in projection , an d an th ropo- th e n asal tip), tip graft (for addition al n asal tip projection ).
Osteotom ies: Lateral low -to-h igh osteotom ies t ypically
m orph ic lan dm arks
Critical an gles are th e n asolabial an gle (90 to 100 degrees in perform ed to n arrow a w ide n asal base (w ith in fracture).
w om en , 90 degrees in m en ) an d fron ton asal an gle (115 to Medial osteotom ies as n eeded. May be perform ed in tern ally
130 degrees). th rough n asal m ucosa w ith protected-tip osteotom es, or
Hypoplastic/retruded ch in : May a ect overall balan ce of extern ally w ith a 2-m m osteotom e th rough th e skin .
In ferior turbin ates: May be outfractured, crush ed, or
face. Can con sider con curren t gen ioplast y.
Base view : Allow s assessm en t of n ostril sh ape an d size, resected to im prove n asal airw ay.
colum ellar w idth , alar base w idth , len gth of m edial crura, Cartilage grafting: Donor sites include nasal septum , ear, and rib.
cur vature of lateral crura, alar lobule th ickn ess, septal Postoperative splin t in g
Internal: Petroleum gauze nasal packings, Doyle (silicone) splints.
position
Extern al: Denver (alum in um ) splin ts, Aquaplast (Medco,
Ideal base view is an isosceles trian gle in w h ich th e upper

th ird is tip lobule an d low er t w o-th irds is colum ella/n are. Ton aw an da, NY) m old.
In tern al exam in at ion : In cludes evaluation of th e n asal
septum , in tern al an d extern al n asal valves, turbin ates, 19.4 Com plicat ions
an d lin in g
Cottle m an euver an d exam in at ion w ith vasocon striction Septal h em atom a: Needs im m ediate drain age to preven t
sh ould be perform ed to assess for airflow. septal n ecrosis.
Malposit ion ed cartilage grafts.
19.2.3 Pert inent im aging or Open roof deform it y from aggressive over-resect ion /rasping
of bony dorsum .
diagnost ic st udies Saddle n ose deform it y from overly aggressive septal resec-
Ph otograph ic docum en tation durin g preoperative con sulta- tion , lack of dorsal suppor t.
tion is advocated. Pollybeak deform it y m ay result from in adequate reduct ion of
Ph otograph face an d n ose in th e an teroposterior, lateral, th e dorsum or decreased n asal tip project ion due to loss of
w orm s-eye, an d birds-eye view s. support.

82
Rhinoplast y

Over-reduction of n asal t ip st ruct ures can lead to alar


pin ch ing, lateral n asal w all collapse, retracted ala an d/or
19.5 Crit ical Errors
retracted colum ella. In adequate preoperative assessm en t an d plan n in g.
Inverted-V deform it y from disruption of th e upper lateral Lack of appreciation of patien t physical ch aracterist ics.
cartilages from th e dorsal septum an d n asal bon es w ith Lack of coh eren t operat ive plan .
failure of restabilizat ion . Failure to evaluate structures of th e face oth er th an n ose (i.e.,
Prom in en t scarrin g or in fect ion . retruded ch in ).

83
Facial Paralysis

20 Facial Paralysis
Alison K. Snyder-Warwick & Thomas H. H. Tung

Fig. 20.1 A 6-year-old boy presents with inabilit y to sm ile on left side, present since birth

85
Facial Paralysis

20.1 Descript ion 20.2.3 Pert inent im aging or


Com plete left-sided facial paralysis. diagnost ic st udies
Facial asym m etr y: Left palpebral fissure w iden in g, left Var y by case.
n asolabial fold e acem en t, righ t-sided deviation of Hem atologic w ork up: Com plete blood cell count (evaluate for
Cupid s bow, an d in ferior m alposit ion of th e left oral in fection , leukem ia), Lym e titer.
com m issure, w h ich dem on st rates n o m ovem en t Tem poral bon e com puted tom ography.
w ith sm ilin g. Magn etic reson an ce im agin g: To evaluate brain , facial n er ve,
Th e ch ild h as a fairly balan ced brow position an d m in im al or parotid glan ds.
extern al n asal valve asym m etr y. Biopsy: Facial n er ve, lip (for salivary tum ors), fin e n eedle
aspiration of parotid m ass.
Electrodiagn ostic studies: Nerve con duct ion studies,
20.2 Work-up electrom yography (EMG).
Electron eurography (ENoG): Com pares am plitude of
20.2.1 Hist ory sum m ation poten t ials of paralyzed side of face w ith th at
of n orm al side.
On set of sym ptom s
Con gen ital or acquired.

Acute, subacute, or ch ron ic.

Duration an d rate of progression .


20.2.4 Consult at ions
Com plete or in com plete; un ilateral or bilateral. Depen ds upon situation : Possibilities in clude oph th alm ology,
Associated syn drom es or syn drom ic features. otology, n eurology, psych iatr y, speech , physical an d
Associated sym ptom s: Headach es, blurred vision , dry eyes, occupation al th erapy, an d/or psych ology.
vertigo, h earin g loss, otorrh ea, oral in com peten ce, speech
di cult ies, sn orin g, n asal obst ruction .
History of th e follow in g: Traum a; in fection (Bell palsy, 20.3 Treat m ent
Ram say Hun t syn drom e, Lym e disease, tuberculosis);
n eurom uscular disease (m yasth en ia gravis, Ch arcot- 20.3.1 Nonsurgical m anagem ent
Marie-Tooth disease, Guillain Barr syn drom e); tum ors
Steroid treatm en t for idiopath ic, autoim m un e, or certain
(n eurofibrom atosis t ype 2); diabetes; travel h istor y;
traum atic injuries.
pregn an cy; fam ily h istory; surgical h istory (otologic,
Corn eal protection
rhyt idectom y, parotidectom y).
Lubr ica t ion, especially at n igh t, w ith eye oin tm en t to

preven t injur y an d dr yin g.


Eye patch w h en n ecessar y.
20.2.2 Physical exam inat ion An tibiotics or a ntivira ls for specific in fection s, if iden tified.
Perform com plete h ead, n eck, an d cran ial n er ve For Bells pa lsy, steroid course an d valacyclovir (Valtrex;
exam in ation . GlaxoSm ith Klin e, Ph iladelph ia, PA) w ith in 10 days of
Exam in e all bran ch es of th e facial n er ve. sym ptom on set.
Tem poral (fron tal): Elevation of foreh ead. Neurom uscular retrain in g
Zygom at ic: Closure of orbicularis oculi. To facilitate sym m etric m ovem en ts an d m in im ize un desired

Buccal: Elevation of ch eek an d oral com m issure. gross m otor activit y (e.g., syn kin esis).
Margin al m an dibular: Depression of oral com m issure an d Mirror train in g, n egative biofeedback, st retch ing exercises,

low er lip. m assage.


Cer vical: Con t ract ion of plat ysm a. Ch em oden er vation : Helps to m in im ize un desired m ovem en ts
Eyes: Evaluate eye closure, vision , corn eal defects, ectropion . an d h elps to ach ieve facial sym m etr y
Schirmer test (see Case 18). Useful for m an agem en t of un ilateral m argin al m an dibular

Bells phenomenon (see Case 18): If absen t, greater con cern bran ch paralysis.
for corn eal injur y.
Evaluate facial m ovem en ts at rest an d in m ult iple di eren t
expression s. 20.3.2 Surgical m anagem ent
Assess m idlin e deviation , m easure am oun t of excursion

w ith m ovem en t . Goals: Corneal prot ect ion, norm al


Assess brow m ovem en t , n asal valve fun ction , an d synkinesis rest ing t one, oral com pet ence,
(involun tar y con traction of addit ion al facial m uscles sym m et ric sm ile
w ith volun tar y facial m ovem en t due to aberran t
n euroregen eration ).
Assess overall m uscle status (hyperton ic, n orm al, or atroph ic),
Det erm inant s of t reat m ent
volun tar y an d involun tar y m ovem en ts (syn kin esis, Duration of injur y/presen ce of m otor en d un its.
fasciculation s). Nature an d exten t of injury/in sult .

86
Facial Paralysis

Acut e repair follow ing nerve injury tim e, especially in youn ger ch ildren w ith greater plast icit y
of th e brain .
Direct n er ve repair: Acceptable if ten sion -free coaptation is Don or m uscles: Gra cilis, latissim us, pectoralis m in or,
possible in th e acute period (en sure outside of any zon e of serratus.
injur y). Oth er possible don or n er ves: Partial XII, partial XI.
In terposit ion al n erve graft in g: Sh ould be perform ed if Access ach ieved w ith faceliftt ype preauricular in cision s
ten sion -free coaptation n ot possible exten din g past earlobe for a sh ort distan ce alon g posterior
Don or site option s: Sural (reversed to preven t bran chin g),
border of m an dible.
split sural, great auricular. Oth er sym m etr y procedures
Useful in plan n ed on cologic facial n er ve resection s.
Pla t inum weights placed in upper eyelid to allow eyelid
Cross-facial n er ve gr aft in g from con tralateral facial n er ve closure.
(cran ial n er ve VII) to on e or m ore bran ch es of injured n er ve Ca nthopexy/ca nthopla st y to im prove paralytic low er eyelid
to rein n er vate acute un ilateral palsy ectropion .
Can be perform ed on ly if early recon struct ion an d if
Brow lift (en doscopic, open , or direct brow lift above
opposite side is com pletely n orm al. eyebrow ) to im prove brow ptosis due to paralysis.
In delayed recon struction , m otor en d un its are n ot fun c-
Ch em oden er vation , rhytidectom y, m yom ectom y can be
tion al after 12 to 24 m on th s, an d a free m uscle t ran sfer is perform ed to aid in facial sym m etr y.
required (see below ). Post op erat ive care: Physical th erapy, in cluding m uscle
retrain in g, m ay optim ize outcom es. Oral com m issure splin ts
Opt ions for delayed surgical reconst ruct ion m ay be used to preven t descen t in th e early postoperative
period.
St at ic slin gs: Provide restin g sym m etr y on ly
Ten sor fasciae lata, tem poroparietal fascia, palm aris,

plan taris, derm al allograft .


Region al m u scle t ran sfers (tem poralis m uscle slin g or 20.4 Com plicat ions
m asseter m uscle tran sfer) Facial n er ve recon struction is ch allengin g an d, even w ith th e
Avoids free t issue tran sfer an d allow s dyn am ic m ovem en t.
best tech n iques, does n ot result in a com plete restoration of
Patien t m ust con sciously bite dow n on a ected side to
facial fun ction an d m ovem en t.
sm ile. Asym m etr y (static/dyn am ic) an d poor m uscle fun ct ion are
Free m u scle t r an sfer for dyn am ic m ovem en t (t w o m ain com m on fin din gs after recon struct ion .
option s for in n er vation source) Hem atom a: As in facelift procedures, patien ts sh ould be
Crossfacial n er ve graft w ith free m uscle tran sfer
return ed to th e operatin g room im m ediately for evacuation .
(t w o-stage procedure) Syn kin esis an d dyskin esis are com m on fin din gs durin g n er ve
Stage 1: Sural n er ve graft sut ured to redun dan t bran ch es regrow th follow in g injur y an d m ay n ot n ecessarily be
of cran ial n er ve VII on un a ected side. En ds are ban ked in avoidable.
upper lip of a ected side. Disin ser t ion of m uscle.
Stage 2: Free m uscle t ran sfer driven by crossfacial n er ve Nerve graft or flap failure.
graft. Perform ed ~ 9 to 12 m on th s later (follow Tin el sign
in n er ve graft to determ in e readin ess for free m uscle
tran sfer). 20.5 Crit ical Errors
Most com m on ly used in n er vation source for free m uscle
tran sfer in facial rean im ation . Establish in g un realist ic expectation s.
Can provide spon tan eous sm ile w ith out m uscle Failure to address con cern s about eyelid closure an d
retrain in g. preven tion of corn eal abrasion s an d xeroph th alm ia.
Sin gle-stage free m uscle tran sfer driven by ipsilateral In adequately educatin g patien t regarding option s an d
m asseteric bran ch of cran ial n er ve V procedures.
Gain ing in creasin g acceptan ce. Failure to evaluate etiology of paralysis.
Patien t m ust con sciously bite dow n to obtain sm ile. Failure to prom ptly return to operatin g room if h em atom a
Reports exist of spon tan eous sm ile developm en t over develops or if th ere is concern for free flap failure.

87
Part 5

Sect ion V. Foot and Low er


Ext rem it y Reconst ruct ion
Open Wound: Upper Third of Leg

21 Open Wound: Upper Third of Leg


Leahthan Domeshek & Thomas H. H. Tung

Fig. 21.1 A 15-year-old girl presents following an all-terrain vehicle (ATV) accident with soft-tissue injury to the right leg.

91
Open Wound: Upper Third of Leg

21.1 Descript ion 21.2.3 Pert inent im aging or


Open w oun d involving th e proxim al h alf of th e righ t low er diagnost ic st udies
extrem it y Plain film s: Evaluation of bony injuries.
Th e proxim al th ird of th e an terior tibia is exposed w ith n o Arteriography: Em ergen t if vascular status th reaten ed or
eviden ce of periosteum . How ever, n o clear fract ure of th e elective if plan for free flap.
bon e is visible.
Th e m edial gastrocn em ius m uscle is exposed.
21.2.4 Consult at ions
Tissue loss is present over th e proxim al h alf of th e an terior

m edial righ t leg m easurin g ~ 25 cm in len gth (based on Vascular surgery: If vascular repair required an d surgeon does
visible ruler). n ot h ave m icrovascular expertise.
Orth opedic surgery: Man agem en t of bony injur y.

21.2 Work-up 21.3 Treat m ent


21.2.1 Hist ory 21.3.1 Principles of low er ext rem it y
Etiology reconst ruct ion
Traum atic: Mech an ism of injur y. Evaluate for concom itan t
Dbridem en t
injuries. Rem ove all devitalized, con tam in ated, an d in fected t issue.
Tum or resect ion : Exten t of resect ion .
Multiple dbridem en ts m ay be n ecessary before coverage.
Ch ron ic: Etiology of w oun d an d h istory of previous
Fixation
m an agem en t. In tern al fixation : Closed fractures an d low -en ergy open
Age, com orbidities (diabetes, periph eral vascular disease, fract ures
coron ary artery disease, sm okin g h istor y), n utrition al stat us, In tram edullar y rods or plate fixation .
steroid use, h istor y of radiation treatm en t . Extern al fixat ion : Severe com m in ution , exten sive soft-

tissue dam age, poor bon e stock, or segm en tal bon e loss
Extern al fixator or Ilizarov distractor for stabilization /
21.2.2 Physical exam inat ion treatm en t.
In traum a cases, evaluate ABCs, use ATLS protocol. May place an tibiotic spacer beads if bon e gap an d con-
Gu st ilo classificat ion of open t ibial fract ures ( Table 21.1). tam in ation are presen t. Th ese w ill n eed to be replaced
Vascular status: Pulses, tem perature, color, turgor, an kle-arm w ith a bon e graft at a later tim e.
in dices. Tem porizing m easures
Vacuum -assisted closure (VAC) or tem porar y dressin g:
Neurologic exam in at ion (especially sen sation on plan tar
surface of foot). Useful betw een dbridem en ts before defin itive coverage
Evaluate for com part m en t syn drom e. procedure.
Defin itive recon struct ion m ay be perform ed on ce ach ieve

adequate debridem en t , patien t is stable, an d recon structive


plan com plete.

Table 21.1 Gustilo classification of open tibial fractures


21.3.2 Soft -t issue reconst ruct ion
Grade Wound Bony injury
(upper t hird of leg)
I < 1 cm , clean, minim al soft- Sim ple, with m inim al com mi- Skin graft: Healthy vascularized bed necessary for adequate take.
tissue injury nution Pedicled m uscle flap
II > 1 cm , moderate contam i- Moderately com m inuted Gastrocn em ius m uscle flap

nation, m oderate soft-tissue fracture Workh orse for recon structin g upper th ird of leg.
injury Muscle is split at m idlin e. Th e m edial h ead (larger) or
III A < 10 cm , crushed tissue and/ Significant contam ination or lateral h ead or both m ay be used.
or contam ination; local cov- segmental bone loss, possible Supplied by m edial (m edial h ead) an d lateral (lateral
erage usually possible vascular injury, highly
h ead) sural arteries, w h ich arise from th e popliteal artery
contam inated wound,
high-velocit y injury
an d en ter distal an d deep to m uscle origin . Coverage w ith
split-th ickn ess skin graft.
III B > 10 cm , crushed tissue and/ As above
Tibialis an terior
or contamination; inadequate
soft tissue; requires regional or Im portan t for an kle dorsiflexion an d th us n ot expen dable.
free flap Split an d used as bipedicled flap (preserves fun ct ion ).
III C Major vascular injury requir- As above Supplied by perforators from an terior tibial artery.
ing repair for limb salvage; Proxim ally based soleus m uscle

am putation necessary in Supplied by popliteal arter y, posterior tibial artery, an d


some cases peron eal artery

92
Open Wound: Upper Third of Leg

Distally based vast us lateralis m uscle Loss of sen sation to plan tar surface of foot sign ifies poor
Based on th e descen din g bran ch of th e lateral circum flex progn osis for fun ction al recover y.
fem oral artery
Less reliable
Free flap 21.4 Com plicat ions
If exten sive, soft-t issue t raum a precludes use of local

m uscle flaps.
Ch ron ic osteom yelitis: Requires rad ical dbridem en t ,
Muscle (latissim us, rectus, gracilis) or fasciocutan eous flaps
rem oval of in fected h ardw are, closure of dead space
(an terolateral th igh ). w ith w ell-vascularized tissue (m uscle flap), an d lon g-
term an tibiot ics (6 w eeks after dbridem en t
an d closure).
21.3.3 Bony reconst ruct ion Flap loss: May require an oth er flap, if possible. Am putation
rem ain s an option .
Man agem en t of bon e gaps
Nonvascularized can cellous bon e graft: For defects < 6 cm .
Fracture n on un ion /m alun ion : Dbridem en t , bon e graft in g,
an d fixation .
Im portan t to en sure h ealthy, vascularized soft-tissue
coverage for graft sur vival.
Vascularized bon e graft: For defects > 6 cm . Free fibula flap

com m on ly used.
21.5 Crit ical Errors
Dist ract ion osteogen esis: For defects > 2 cm . Failure to adequately dbride n onviable or in fected t issue.
Not h avin g a com plete plan for both soft-tissue an d bon e
recon struction .
21.3.4 Am put at ion Un n ecessary delay in treatm en t . Th is w ill in crease th e ch an ce
If extrem it y can n ot be salvaged (com plete disruption of for osteom yelitis an d poor outcom e.
posterior tibial n er ve, crush injuries w ith w arm isch em ia In adequate m an agem en t of com plication s.
tim es > 6 h ours, serious associated life-th reaten in g injuries). Failure to recogn ize com partm en t syn drom e.

93
Open Wound: Middle Third of Leg

22 Open Wound: Middle Third of Leg


Louis H. Poppler & Terence M. Myckatyn

Fig. 22.1 A 20-year-old man presents to the em ergency departm ent after being shot in the right leg, with resulting tibial bone loss, fibula fracture,
and transection of the anterior tibial and peroneal arteries .

95
Open Wound: Middle Third of Leg

22.1 Descript ion 22.3 Treat m ent


Open w oun d of th e m iddle th ird of th e righ t leg 22.3.1 Init ial m anagem ent
Gust ilo grade III C (see Table 21.1): Severely
com m in uted bon e an d soft-tissue defect w ith Stabilize fract ure.
vascular com prom ise. Restore vascular in flow, if n ecessar y.
A 35 20-cm soft-t issue defect , an d a 16-cm tibial Assess com part m en ts an d perform fasciotom ies w h en
bicort ical bony defect . required.
Dbride an d w ash out w oun d un til ready for recon struction .
Serial dbridem en t usually required.

Vascular structures require im m ediate coverage.


22.2 Work-up
22.2.1 Hist ory 22.3.2 Tim ing of reconst ruct ion: Three
Etiology phases of w ound progression
Traum atic: Mech an ism of injur y. Evaluate for concom itan t
Acute (1 to 5 days): Con tam in ated but n ot in fected, edem a-
injuries.
tous, h em orrh agic.
Tum or resect ion : Exten t of resect ion .
Subacute (1 to 6 w eeks): Colon ized, in fected, bony dem arca-
Ch ron ic: Etiology of w oun d an d h istory of previous
tion still n ot clear.
m an agem en t.
Ch ron ic (> 6 w eeks): Gran ulatin g, con tractin g w oun d;
Com orbidit ies of progn ost ic sign ifican ce
in fection lim ited to scar; bony dem arcation clear.
Periph eral vascular disease, cardiovascular disease, diabetes,
Ea rly definitive reconst r uct ion (< 72 h ours, according to
sm okin g h istory, n utrit ion al status, steroid use, radiation
Godin a) h as th e low est flap failure rates, low est postoperat ive
treatm en t .
in fection rates, an d fastest tim e to bony un ion in th e pre-
n egative pressure w oun d th erapy (NPW T) era.

22.2.2 Physical exam inat ion


In traum a cases, evaluate ABCs (airw ay, breath ing,
22.3.3 Soft -t issue reconst ruct ion
circulation ). Surgical recon struction of soft-tissue w oun ds divides leg in to
Woun d assessm en t th ree zon es.
Soft-t issue dam age: Size of w oun d, depth , zon e of injury. Upper th ird (see Case 21).

Degree of contam in ation , exposure of vital structures. Mid d le t h ird .

Vascular supply to low er extrem it y, exten t of bony Low er th ird (see Case 23).

defect . Direct closure: Rem ain s an option in sim ple injuries w ith
Vascular exam in at ion adequate tissue.
Exam in e pulses, tem perature, color, turgor. Skin graft: Healthy vascularized bed n ecessar y for adequate
An klearm in dex (AAI) m easurem en ts, Doppler take
exam in ation . Sh ould n ot perform over vital structures, such as n erves,

Neurologic exam in at ion : Ch eck for peron eal or tibial n er ve vessels, an d bon e.
injuries. Local m uscle flaps
Rule out compa rtment syndrome. Gold stan d ard for recon struct ion of defects of m iddle th ird

Com prom ised n eurovascular stat us. of low er extrem it y


Pain out of proport ion to injur y on flexion an d exten sion of Covered w ith skin graft .
extrem it y. Soleus m uscle flap

Com part m en t pressures > 30 m m Hg. Workh orse flap for m iddle th ird defects.
Can be split lon gitudin ally (h em isoleus) for sm aller
defects in w h ich th e en tire m uscle is n ot n eeded for
22.2.3 Pert inent im aging or recon struct ion .
Supplied by bran ches of popliteal artery, posterior tibial
diagnost ic st udies artery, an d peron eal artery.
Plain film s: Evaluation of bony injuries. Gastrocn em ius flap

Arteriography: Em ergen t if vascular status th reaten ed; May be useful in m iddle th ird defects, alth ough m ost
elective procedure if plan for free flap recon struction . com m on ly used for recon struct ion of proxim al th ird
(see Case 21).
Muscle can be divided in to m edial (larger) an d lateral
22.2.4 Classificat ion: When t he injury h eads.
Flexor digitorum lon gus: Will cover on ly sm all defects in
involves a fract ure low er h alf of m iddle th ird.
Gust ilo classification system of open t ibial fractures Exten sor digitorum lon gus: Can cover defects < 5 cm in size.

(see Table 21.1).

96
Open Wound: Middle Third of Leg

Exten sor h allucis lon gus/flexor h allucis lon gus: Can cover Nonvascularized bon e graft: Not recom m en ded for
on ly ver y sm all w oun ds. defects > 6 cm , alth ough successful reports of up to 10 cm
Tibialis an terior: Can be taken as a w h ole or lon gitudin ally h ave been described. An in tact fibula keeps extrem it y at
split for coverage of sm aller defects. Sign ifican tly fun ction al len gth .
don or m orbidit y. Free osseous or osteocutan eous flap tran sfer: In dicated for
Free t issue tran sfer (see Case 23) defects > 6 cm
Rem ain s an option for coverage of large or com plex defects Com m on ch oices: Fibula, iliac crest, scapula.
th at can n ot oth erw ise be m an aged w ith local or region al Distract ion osteogen esis (Ilizarov m eth od): Can be used for
flaps. bon e gaps up to 12 cm . Durin g dist raction , soft-tissue defect
In tegra (bilayered derm al substitute; In tegra LifeScien ces, m ay be grafted, covered w ith a flap, or m an aged w ith local
Plain sboro, NJ) w oun d care.
Has been used successfully for coverage of clean , stabilized, Requires pat ien ce an d patien t com plian ce.
w ell-vascularized w oun ds w ith exposed vital structures.
Outer silicon e layer is rem oved, an d a th in skin graft is used

to cover th e n ew ly vascularized m aterial rough ly 2-3 w eeks 22.4 Com plicat ions
follow in g in itial application . In fect ion (cellulit is, osteom yelitis, h ardw are in fection ).
May ser ve as a salvage m easure w h en oth er procedures Flap loss/exposure of bony h ardw are.
h ave failed. Non un ion /m alun ion of fracture.
Vascular com prom ise.
Com part m en t syn drom e.
22.3.4 Bony reconst ruct ion
If th ere is a bony defect , bon e recon struction m ust be per-
form ed first .
22.5 Crit ical Errors
Essen tial elem en ts of osseous h ealin g are good blood supply In abilit y to recogn ize an d dbride all devitalized tissue.
an d stabilization . Failure to obtain adequate stabilization .
Broken fragm en ts distal to a fract ure rely en tirely on perios- Delay in obtain ing stable soft-tissue coverage.
teal blood supply un til en t r y of th e m etaphyseal vessels. Failure to recogn ize com partm en t syn drom e.
Preser ve per iosteum w h erever possible. Perform in g vascular or n erve recon struction w ith in th e zon e
Option s for bon e gap recon struction s of injur y.

97
Open Wound: Lower Third of Leg

23 Open Wound: Low er Third of Leg


Santosh Kale & Thomas H. H. Tung

Fig. 23.1 A 35-year-old m an presents with an open wound to the left leg following a high-speed m otorcycle accident. He has undergone open
reduction/internal fixation (ORIF) of left tibia and fibula fractures.

99
Open Wound: Lower Third of Leg

23.1 Descript ion Fasciotom ies (if in dicated): Main tain h igh suspicion for com -
part m en t syn drom e.
Gust ilo grade III B (see Table 21.1) open bilateral m alleolar Wou n d ir r igat ion an d d br id em en t : Th orough dbridem en t
fract ure w ith exposed distal t ibia an d h ardw are. is param oun t to successful recon struction . May require m ult i-
Full-th ickn ess defect of th e m edial distal th ird of leg w ith ple session s to ach ieve clean w oun d bed.
in adequate soft-tissue coverage. Coverage of vital structures (n erves, vessels, bon e).
In fect ion con trol
Irrigation an d dbridem en t .
23.2 Work-up An tibiotic coverage.

23.2.1 Hist ory


23.3.2 Bony reduct ion and st abilizat ion
Mech an ism of injury/etiology of w oun d (t raum atic, on cologic,
vascular in su cien cy, oth er). Im m obilization w ith cast, in tern al or extern al fixation .
Med ical com or bid it ies: Cardiopulm on ar y or periph eral Man agem en t of bony gaps
Defects up to 6 cm : May be m an aged by n onvascularized
vascular disease, diabetes, obesit y, h em atologic disorders,
n ut rition al status, collagen /vascular disorders, steroid use. bon e graft un der m uscle flap.
Defects > 6 cm : Require vascularized osseous (or osteocuta-
Toba cco use.
Preoperative functiona l sta tus. n eous) flap (e.g., free fibula).
Support n et w ork. Defects 10 to 12 cm : Distraction osteogen esis. Not com -

m on ly used in settin g of traum a.

23.2.2 Physical exam inat ion


23.3.3 Soft -t issue reconst ruct ion
Prim ar y sur vey
Airw ay, breath ing, circulat ion . Goal: Stable soft tissue coverage w ith m in im al don or
Assess for vascular com prom ise. m orbidit y.
Distal pulses. Don or tissues an d any vascular an astom oses sh ould be
Secon dar y sur vey outside zon e of injur y.
Con com itan t injuries. May require vein grafts.

Exten t of low er extrem it y injur y: Neurologic an d m usculo- Eradicate in fection before recon struct ion .
ten din ous exam in ation s. Recon st r u ct ive lad d er
Assess exposed st ructures: Ner ves, vessels, join ts, ten don s. Prim ar y closure: Typically n ot applicable.

Healin g via secon dar y in ten tion n egative-pressure w oun d


Poten t ial don or sites.
Fract ures: Gu st ilo classificat ion system of open tibial th erapy (NPW T).
Skin graftin g: If appropriate recipien t bed, poten tially
fract ures (see Table 21.1).
applicable after NPW T.
Bilam in ate n eoderm is (In tegra; In tegra LifeScien ces,
23.2.3 Pert inent im aging or Plain sboro, NJ): If clean w oun d bed an d on ly ver y sm all
diagnost ic st udies area of exposed bon e/ten don /vasculature.
Local/region al flaps
Plain film s: In cluding on e join t above an d on e below site of
Con sider reverse sural artery flap, dorsalis pedis flap, FHL
injur y.
(flexor h allucis lon gus), tibialis an terior.
An giography Free t issu e t ran sfer (gold stan dard for w oun ds of low er
Em ergen t sett in g: If con cern for vascular com prom ise.
th ird of leg)
Subacute sett in g: If n o vascular com prom ise, to evaluate
Muscle w ith split-th ickn ess skin graft (i.e., latissim us,
zon e of injury an d vascular access for recon struct ion .
rectus abdom in is, serratus an terior, gracilis).
Musculocutan eous (i.e., latissim us, parascapular, TRAM
23.2.4 Consult at ions [tran sverse rectus abdom in is m yocutan eous]).
Fasciocutan eous (i.e., an terior lateral th igh [ALT], radial
Traum a surgery, orth opedic surgery, vascular surgery forearm ).
(if vascular injur y). Osteocutan eous (i.e., fibula).
Am putation : Rem ain s a fin al option

23.3 Treat m ent Severely traum atized extrem it y

Involvem en t of th ree or m ore com partm en ts.


Treat m en t of em ergen t an d life-th reaten in g issues durin g Multilevel or severe vascular injury.
prim ar y sur vey. Severe crush or loss of m uscle.
Posterior tibial n er ve t ran sect ion .

Failed vascular recon struction .


23.3.1 Acut e m anagem ent Medical com orbidities.

Fract ure stabilizat ion . Patien t unw illin g to un dergo n ecessar y reh abilitation w ith

Restoration of vascular in flow (if in dicated). recon struction .

100
Open Wound: Lower Third of Leg

23.4 Com plicat ions In fect ion


Avoid w ith adequate dbridem en t of soft tissues a nd bone,

In fect ion . rem oval of in fected h ardw are, an d prom pt recon struct ion .
Flap loss: part ial or com plete. Low er extrem it y vascular com prom ise
Low er extrem it y vascular com prom ise. Avoid by investigatin g vascular supply to distal extrem it y

Bony n on un ion /m alun ion . after injury, usin g en d-to-side an astom osis if sin gle vessel
perfusion to foot , an d establish ing appropriate in flow
(vascular in terven tion ).
23.5 Crit ical Errors
Microvascular an astom osis w ith in zon e of injury
Long pedicle or vein grafts m ay be required to avoid th is

com plication .

101
Foot and Ankle Reconst ruct ion

24 Foot and Ankle Reconst ruct ion


Justin B. Cohen

Fig. 24.1 A 36-year-old m an presents to the


em ergency department following a gunshot
wound to his right foot.

103
Foot and Ankle Reconstruction

24.1 Descript ion Careful exam in ation of th e exten t of th e w oun d (un der
tourn iquet).
Rough ly 11 7 3-cm open w oun d to th e plan tar surface of Con sider w oun d vacuum -assisted closure (VAC) placem en t

th e righ t foot. bet w een procedures.


En com passes .large aspect of w eigh t-bearin g surface. Repeat w oun d exploration an d dbridem en t after 48 h ours.

Likely ten din ous an d bony disrupt ion . Preoperative an tibiotics to reduce risk for w oun d in fect ion .
Exposed m etatarsal h eads. Appropriate m an agem en t of fractures as in dicated.
Woun d appears clean an d w ell perfused w ith viable tissue Defin itive closure on ly after w oun d is clean an d bony
proxim ally an d distally. stabilization is obtain ed
Stable biom ech an ical align m en t is th e first goal of

acceptable foot fun ct ion .


24.2 Work-up
24.2.1 Hist ory and 24.3.2 Surgical algorit hm
physical exam inat ion Sim ple closure is frequen tly not possible because of w oun d
Obtain patien ts baselin e fun ction al an d am bulator y status. size.
Determ in e m edical com orbidities. Closure by secon dary in ten tion or skin graftin g is not a good
Vascular disease, sm okin g, n ut rit ion al status, im m un o- option because of th e exposed crit ical structures an d th e
suppression , ren al disease, autoim m un e disease, radiation , location on th e w eigh t-bearin g surface.
coagulopathy. Th e plan tar surface n eeds to be able to tolerate sign ifican t
Assess for eviden ce of im paired periph eral blood flow. repetitive w eigh t bearin g an d sh ear forces. Form , fun ction ,
Palpat ion an d Doppler exam in at ion of dorsalis pedis an d an d aesth etics m ust be con sidered.
Th e abilit y to w ear a n orm al sh oe is a sign ifican t
posterior tibial arteries, ch eck of capillar y refill, pulse
oxim eter readin g on each toe to assess viabilit y, con siderat ion .
Durable skin coverage w ith solid attach m en t to deeper
observation of bleedin g w oun d edges.
Motor an d sen sor y exam in ation to assess exten t of injur y. structures is essen tial.
Tetan us status. Local flaps
Lim ited by th eir size.

Length -to-w idth ratio sh ould n ot exceed 1:1.5 in th e low er

24.2.2 Pert inent im aging or extrem it y.


diagnost ic st udies Flaps sh ould be design ed outside th e zon e of injur y.

Pedicled flaps
Redun dan cy to evaluate bony fram ew ork an d possible foreign Math es-Nah ai classificat ion of m uscle flaps ( Table 24.1).
bodies (i.e., bullet fragm en ts). Often provide on ly sm all am oun ts of tissue an d leave
Con sider an giography for possible vascular injury an d sign ifican t don or defects.
preoperative surgical plan n in g. Few good m uscle flaps exist in th e low er extrem it y because
Magn et ic reson an ce an giography an d com puted
m ost are t ype IV an d h ave segm en tal m in or pedicles.
tom ograph ic an giography are addition al option s w h en Sm all defects (< 6 cm 2 ) can be recon structed w ith t ype II
th e patien t is n ot a can did ate for an invasive in ter ven tion al m uscles, such as abductor h allucis brevis, abductor digit i
procedure w ith con trast dye injection un der gen eral m in im i, an d flexor or exten sor digitorum brevis flaps.
an esth esia. Fasciocutan eous an d cutan eous flaps are m ore useful on
Ren al status m ay be pertin en t to decidin g th e appropriate
n on w eigh t-bearin g portion s of th e foot.
m odalit y. Pedicled flaps in clude m edial plan tar, lateral calcan eal,
dorsalis pedis, an d fillet of toe flaps.

24.2.3 Consult at ions


Traum a evaluation .
Orth opedic surgery, for m an agem en t of bony injur y. Table 24.1 Mathes-Nahai classification of muscle flaps
Vascular surgery, if vascular in flow is a con cern . Type Vascular pedicle Exam ple
I One vascular pedicle Tensor fasciae latae,
gastrocnem ius
24.3 Treat m ent II Dominant pedicle(s) and Gracilis, soleus, trapezius
m inor pedicle(s)
24.3.1 Acut e m anagem ent III Two dominant pedicles Gluteus m axim us, rectus
Th orough operative irrigation an d dbridem en t perform ed abdom inis, serratus,
temporalis
em ergen tly
All n onviable t issue n eeds to be rem oved an d sh arply IV Segm ental vascular pedicles Sartorius, tibialis anterior
dbrided. V One dom inant pedicle and Latissimus dorsi, pectoralis
Copious irrigation an d rem oval of foreign bodies. secondary segm ental pedicles major

104
Foot and Ankle Reconst ruct ion

Free m icrovascular flaps Ch opart am putation rem oves th e forefoot an d m idfoot ,


Frequen tly used option for recon struction . preservin g th e talus an d calcan eus.
Success rate is h igh (> 90%). How ever, failure usually en tails Sym e am putation in cludes an kle disarticulation an d
com plete loss of th e flap. rem oval of m alleoli.
Foot is t ypically recon structed w ith free m uscle flaps
an d split-th ickn ess skin graft (STSG) or fasciocutan eous
flaps.
24.4 Com plicat ions
En d-to-side arterial an astom oses w ith t w o ven ous In fect ion .
outflow s are preferable to optim ize distal blood flow Hem atom a.
to foot. Flap loss (part ial or com plete)
Free m uscle flaps w ith STSG provide w ell-vascularized Local flaps ten d to un dergo partial n ecrosis (usually at th e

tissue to th e w oun d bed. critical, m ost distal edge). Flaps sh ould be design ed to be
Microvascular m uscle flaps in clude gracilis, rectus larger th an n ecessary to m in im ize ten sion .
abdom in is, serratus an terior, lat issim us dorsi (less Free flap loss is m ost likely com plete an d w ill require

often used because of in creased m orbidit y w ith crutch dbridem en t an d closure w ith VAC, local flap, or an oth er
w alkin g). free flap.
Microvascular fasciocutan eous flaps in clude radial forearm , Free flap: Vessel th rom bosis or com prom ised arterial flow
an terolateral th igh , scapular, an d parascapular flaps. Patien t m ust be taken back to th e operatin g room for

Postoperative care is essen t ial, especially for plan tar exploration immedia tely.
w oun ds. Vascular com plication s can be due to un derappreciated

Elevation of th e extrem it y in th e im m ediate postoperative zon e of vascular injur y, en doth elial disruption , baselin e
period to aid in ven ous drain age. vascular disease, an d in creased th rom bogen icit y secondar y
Follow ed by dan gling of th e extrem it y at 1-2 w eeks, ligh t to traum a.
w eigh t bearin g at 1 m on th , an d full w eigh t bearin g at Hyperkeratosis at th e border of th e flap an d n orm al tissue
2 m on th s. can be m an aged w ith secon dary Z-plast ies or keratin olytic
Am putat ion rem ain s a reason able option , especially in sh avin gs.
patien ts w h o are poor can didates for exten sive recon struct ion
or w h o m ay n ot be able to tolerate a lon g reh abilitation
period.
24.5 Crit ical Errors
Tran sm etatarsal am putation (TMA) m ain tain s sign ifican t Ch oosin g a poor flap, especially a local flap th at can n ot
lim b fun ct ion alit y by preser ving th e m idfoot, distal to th e adequately cover th e defect .
an kle join t. Design in g a free flap w ith m icrovascular recon struction
May provide adequate skin for direct closure. w ith in th e zon e of injur y.

105
Part 6

Sect ion VI. Breast


Breast Cancer Reconstruction

25 Breast Cancer Reconst ruct ion


Jessica M. Belz, Albert S. Woo, & Thomas H. H. Tung

Fig. 25.1 A 43-year-old woman with a history of m astectom y for left breast cancer desiring breast reconstruction.

109
Breast Cancer Reconstruction

25.1 Descript ion 25.3 Treat m ent


Absen ce of th e left breast w ith w ell-h ealed tran sverse 25.3.1 Preoperat ive considerat ions:
m astectom y scar
Mastectom y skin flaps are teth ered to an terior ch est
Three im port ant decisions
w all w ith out eviden ce of radiation -associated skin Tim in g: Immedia te versus dela yed recon struction
ch anges. Im m ediate recon struct ion m ay h ave better cosm etic out-
Th e righ t breast h as grade I ptosis, good skin ton e, an d com e by allow in g skin -sparin g m astectom y pattern s.
elast icit y. Allow s recon struct ion in reduced n um ber of surgical
Th ere are n o st riae, disch arge, or dim pling. procedures.
Th ere is a rough ly 2-cm w ell-h ealed tran sverse ch est w all Delayed recon struction m ay be preferred in certain sit ua-
scar just superior to th e righ t breast, consisten t w ith tion s (e.g., autologous recon struct ion if adjuvan t radiation
previous port placem en t for ch em oth erapy. plan n ed).
Type: Prosthetic versus a utologous recon struction
Expan der/im plan t recon struct ion

25.2 Work-up Ideal can didates are w om en w ith sm all to m oderate-sized


breasts un dergoing bilateral recon struct ion .
25.2.1 Hist ory Radiation is a relative con train dication (h igh er in ciden ce
of w oun d-h ealin g problem s, capsular con tractures,
Type, size, an d staging of t um or (t um or, n ode, m etastasis
in fection s, im plan t extrusion ).
[TNM] classification h elpful).
Adva ntages: Shorter operation s an d n o don or-site
On cologic surgical tech n ique (e.g., m odified radical
m orbidit y.
m astectom y, lum pectom y)
Disa dva ntages: Frequen t trips to th e m edical cen ter for
If already treated, len gth of t im e in rem ission an d
fills, lon ger overall course un til fin al recon struct ion .
any eviden ce of recurren ce.
Autologous tissue recon struct ion
History of ch em oth erapy/radiation th erapy, plan s for any
Abdom in al tissue is th e m ost com m on don or site (i.e.,
furth er treatm en t .
pedicled TRAM, free TRAM, DIEP [deep in ferior epigastric
Curren t breast size, desired breast size.
perforators], an d SIEA [superficial in ferior epigast ric
Fam ily h istory of breast can cer, in cluding BRCA testin g
artery] flaps).
(if perform ed).
Oth er option s are latissim us dorsi flap (usually w ith an
Date an d results of m ost recen t m am m ogram .
im plan t), superior or in ferior gluteal artery perforator
History of sm okin g/tobacco use.
flaps, tran sverse upper gracilis (TUG) flap, Ruben s flap
Patien ts recon structive desires an d expectation s.
(deep circum flex iliac vessels), an terolateral th igh flap.
Adva ntages: Breast w ith m ore n atural look an d feel an d
better sym m etr y in un ilateral procedures.
25.2.2 Physical exam inat ion Disa dva ntages: Lon ger surgery an d don or-site m orbidit y.
Body ma ss index (BMI): Weigh t (kg)/[h eigh t (m )]2 Con t ralateral breast sym m etr y: Reduct ion /m astopexy,
BMI > 35: Pat ien t is poor can didate for free TRAM augm en tation , or n eith er
(tran sverse rect us abdom in is m yocutan eous) Con tralateral m atch ing procedure, if n eeded, can be don e at

recon struction . th e sam e tim e or as a second stage.


Mastectom y site deform it y: Qualit y an d quan tit y of skin ,
presen ce of radiation ch anges, location of scar(s).
Un a ected breast: Size, sh ape, project ion , skin qualit y, degree 25.3.2 Surgical considerat ions
of ptosis, presen ce of m asses an d lym ph aden opathy.
Expan der/im plan t recon struct ion
Overall body h abitus an d don or site availabilit y.
Expan der size ch osen based on breast w idth an d h eigh t.
Abdom in al w all an d back scars.
Midlin e, in fram am m ar y fold, an d lateral m am m ar y fold

m arked preoperatively.
Skin -sparin g or n ipple-sparin g m astectom y perform ed. Skin
25.2.3 Pert inent im aging or flaps assessed for viabilit y.
diagnost ic st udies Expan der placed in total subpectoral posit ion or partial

subpectoral position w ith acellular derm al m atrix (sut ured


Mam m ogram (especially if operat in g on un a ected
to in ferolateral border of pectoralis m ajor an d in fram am -
breast).
m ar y fold) coverin g th e in ferior aspect .
Expan der in flated in traoperatively, w ith th e volum e based

on appearan ce of skin flaps.


25.2.4 Consult at ions Expan der filled ever y 2 to 3 w eeks to desired fin al volum e,

Gen eral surger y/surgical on cology. th en overfilled by ~ 30%.


Medical on cology. After a period of pocket consolidation , patien t taken to

Radiation on cology (if n eeded). operatin g room an d expander exch anged for a perm an en t

110
Breast Cancer Reconstruction

im plan t. Capsule m odification can be don e to provide Adva ntages: Total m uscle sparin g results in m in im al
optim um sh ape. abdom in al w all m orbidit y.
Autologous tissue recon struct ion Disa dva ntages: Techn ically dem an din g.
Pedicled TRAM flap Pedicled lat issim us dorsi m yocutan eous flap
Flap is m arked on abdom en , based on ipsilateral or con - Typically used w ith an im plan t.
tralateral rect us abdom in is m uscle, to in clude perium bili- In th e presen ce of previous radiation , provides n on radi-
cal perforators. ated soft-tissue cover for im plan t.
Flap is elevated, and zone 4 and part of zone 3 are discarded. Good option if abdom in al w all tissue n ot available for
Flap is brough t th rough a subcutan eous t un n el an d in set recon struction or abdom in al w all m orbidit y n ot
in to ch est w all. acceptable to pat ien t .
If abdom in al fascia can n ot be closed prim arily, m esh is
required.
A delay procedure (dividing th e deep in ferior epigast ric 25.4 Com plicat ions
pedicle) can in crease flap reliabilit y in th e presen ce of risk Mastectom y skin flap loss
factors like sm okin g, obesit y, an d radiation . Partial th ickn ess: Can m an age w ith local w oun d care.
Contra indica t ions: In su cien t abdom in al w all tissue or Full th ickn ess or risk for im plan t exposure: Take to
previous subcostal in cision th at h as tran sected th e
operatin g room , dbride, an d close.
superior epigastric vessels. Expan der in fect ion
Adva ntages: Safe procedure th at can be perform ed If cellulit is: Start oral or in traven ous an tibiotics.
relatively quickly. If fails to resolve or suspect purulen ce: Take to operatin g
Disa dva ntages: Requires sacrifice of rectus abdom in is
room for w ash out an d likely im plan t rem oval.
m uscle, w h ich can result in abdom in al w all w eakn ess, Fat n ecrosis: Dbridem en t an d flap reposition in g. Large areas
h ern ia, an d bulges. Bilateral procedure results in decrease
m ay require an oth er flap or an im plan t.
in abdom in al w all stren gth . Total flap loss: If pedicle th rom bosis picked up early, take to
Free TRAM flap
operatin g room em ergen tly for attem pt at salvage.
Based on deep in ferior epigast ric vessels. Abdom in al w all h ern ia or bulge: Fascial repair or m esh
Recipien t vessels are th oracodorsal or in tern al m am m ar y
placem en t.
vessels,
Muscle-sparin g free TRAM decreases abdom in al w all
m orbidit y, 25.5 Crit ical Errors
Adva ntages: Based on dom in an t vascular system better
blood supply. Th is results in abilit y to use larger volum es Recom m en ding prosth etic recon struction in th e presence of
of t issue an d decreased risk for fat n ecrosis. radiation .
Disa dva ntages: Techn ically dem an din g. Do n ot con sider in Discussing an autologous breast recon struction option th at
patien t w ith m orbid obesit y (BMI > 35). you do n ot kn ow ver y w ell.
Free DIEP flap In abilit y to m an age com plication s.
Based on on e or t w o deep in ferior epigastric perforators. Failure to screen rem ain in g breast for can cer preoperatively.

111
Tuberous Breast Deform it y

26 Tuberous Breast Deform it y


Jessica M. Belz & Terence M. Myckatyn

Fig. 26.1 A 44-year-old woman requesting


correction of breast asym m etry.

113
Tuberous Breast Deform it y

26.1 Descript ion 26.2.4 Consult at ions


Tuberous breast deform it y on th e left Psych iatr y/developm en tal psych ology: Som e pat ien ts,
High in fram am m ar y fold, deficien cy of low er m edial an d especially adolescen ts, m ay require in ter ven tion given th e
lateral quadran ts of th e breast , en larged areola w ith psych ological m orbidit y associated w ith th is con dition .
h ern iation of breast t issue, an d grade II n ipple ptosis.
On th e righ t, sh e h as hypom ast ia w ith grade II n ipple ptosis. 26.3 Treat m ent
26.3.1 St aging of reconst ruct ion
26.2 Work-up
Sin gle-stage procedure
26.2.1 Hist ory Perm an en t im plan t placed to correct breast asym m et ry.

Tw o-stage procedure: Useful w h en sign ifican t deficien cy of


Person al or fam ily h istory of breast can cer.
skin envelope exists
History of prior breast surgeries.
Tissue expander in itially placed to allow correction of
History of sm okin g/tobacco use.
sign ifican t volum etric asym m etr y.
Plan for future ch ildbirth . An t icipated ch anges in w eigh t.
Perm an en t im plan t placed at secon d stage.
Patien t goals an d expectation s.

26.3.2 Com ponent s of surgery


26.2.2 Physical exam inat ion
Periareolar approach: De-epithelialize and decrease size of areola.
Ch aracterist ics of tuberous breast Un derm in e th e low er pole of th e breast subcutan eously to th e
Reduced breast diam eter, h igh in fram am m ar y fold,
desired posit ion of th e in fram am m ar y fold.
deficien t skin envelope in feriorly, breast hypoplasia, an d Release subareolar constriction ring via radial scoring or dividing
h ern iation of breast t issue th rough th e areola. the inferior pole of the breast vertically or horizontally.
Grolleau classification of t uberous breast deform it y If volum e n eeds to be added, a perm an en t im plan t or tem po-
Type I: Deficien cy of low er m edial quadran t.
rar y t issue expan der is placed in a subglan dular, subm uscular
Type II: Deficien cy of en tire low er pole of breast.
location , or dual plan e.
Type III: Deficien cy of all quadran ts.

Regn ault classification of ptosis ( Table 26.1).


Key m easu rem en ts
26.3.3 Cont ralat eral breast procedures
Distan ce from stern al n otch to n ipple, from n ipple to in fra- Ipsilateral augm en tation procedures can n ot establish n orm al
m am m ar y fold; breast base diam eter. breast ptosis th at m igh t be present on th e n orm al side.
Reduct ion /m astopexy or augm en tation m ay be perform ed to
im prove sym m etr y.
26.2.3 Pert inent im aging or
diagnost ic st udies
26.4 Com plicat ions
Mam m ogram (if clin ically in dicated): For exam ple: patien t
age > 40 years or 10 years prior to age of fam ily m em ber w ith Residual asym m etr y.
previous breast can cer h istory. Persisten t deform it y.
Com plicat ion s of im plan t or t issue expan der.
Woun d h ealin g di cult ies
Nipple Necrosis
Table 26.1 Regnault classification of breast ptosis
Grade Findings 26.5 Crit ical Errors
I Nipple at infram amm ary fold
Failure to correctly iden t ify th e tuberous breast deform it y.
II Nipple below infram am m ary fold
Augm en t in g th e breast w ith out addressin g th e tuberous
III Nipple at m ost inferior aspect of breast qualit ies.
Pseudoptosis Nipple at or above infram am mary fold with Failure to obtain preoperative screen in g m am m ogram in
lower-pole breast ptosis w om en > 35 years of age.

114
Breast Augm entat ion

27 Breast Augm ent at ion


Simone W. Glaus & Marissa Tenenbaum

Fig. 27.1 A 21-year-old wom an presents to your office to discuss breast augm entation.

115
Breast Augm ent ation

27.1 Descript ion Im plan t t ype: Salin e versus silicon e versus form -stable sili-
con e; sm ooth versus textured; roun d versus an atom ical; low,
Hypom astia: Sm all A to AA cup breasts w ith m ild asym m etr y m oderate, or h igh profile
Left in fram am m ar y fold is sligh tly h igh er th an th e righ t Silicon e im plan ts are FDA-approved on ly for prim ar y

in fram am m ar y fold. augm en tation in w om en at least 22 years of age.


Left n ipple is sligh tly h igh er th an th e righ t n ipple. Th e FDA recom m en ds m agn etic reson an ce im aging

screen in g for silicon e im plan t rupture at 3 years after


im plan tat ion , th en ever y 2 years th ereafter.
27.2 Work-up Im plan t placem en t
Subglan dular: Can h ave pleasin g aesth etic results, but w ith
27.2.1 Hist ory h igh er con tracture rates an d im plan t palpabilit y. Th is plan e
Age, m edical com orbidities, an t icoagulan t use, sm okin g m ay com plicate future m am m ography because th e im plan t
h istory. is present adjacen t to glan dular t issue.
Submuscula r: Placem en t is com pletely un der pectoralis
Pregn an cy/breastfeedin g h istory, plan s for future
ch ildbearin g. m ajor m uscle. Decreased capsular contracture rates. Breast
Person al h istor y of breast disease an d/or procedures, m ay be distorted w ith m uscle con traction .
Dua l pla ne: Placem en t un der pectoralis m ajor superiorly,
prior m am m ography or ult rasoun d.
Fam ily h istory of breast can cer. but subglan dular placem en t in feriorly. Decreased cont rac-
Curren t bra size an d desired breast size. ture rates, but allow s expansion of th e in ferior pole.
Motivation for surgery. In cision /approach : Periareolar, in fram am m ar y, axillar y,
tran su m bilical.
Curren t breast augm en tation plan n in g involves a tissue-based
27.2.2 Physical exam inat ion approach th at ackn ow ledges in dividual soft-tissue lim itation s
Evaluate breast sh ape, skin qualit y, an d adequacy of tissue rath er th an a strictly volum etric approach .
envelope (e.g., upper pole pin ch th ickn ess).
Iden tify any a symmetries (volum e, n ippleareola com plex, 27.3.2 Cancer screening
in fram am m ar y fold posit ion ), th oracic w all abn orm alit ies. Breast augm en tation does n ot in crease th e risk for breast
Palpate for breast m asses or axillar y lym ph aden opathy. can cer, but im plan ts m ay in terfere w ith m am m ograph ic
Iden tify skin dim pling or n ipple disch arge. screen in g.
Subm uscular im plan ts in terfere sign ifican tly less th an
27.2.3 Pert inent im aging or diagnost ic subglan dular im plan ts.
Silicon e gel im plan ts do n ot a ect th e in ciden ce of con n ect ive
st udies tissue diseases.
Am er ican Can cer Societ y gu id elin es for clin ical breast exam
(CBE) an d m am m ography sh ould be follow ed. 27.4 Com plicat ions
CBE ever y 3 years for w om en ages 20 to 39 years; CBE ever y

year for w om en ages 40 an d older.


High revision rate (~ 20%).
Yearly m am m ogram s for w om en ages 40 an d older.
Capsular cont ract ure
Baker capsular con tracture classificat ion ( Table 27.1).
Breast m asses or lym ph aden opathy discovered on physical
In fram am m ar y in cision < periareolar in cision .
exam in ation sh ould be evaluated before augm en tation .
Subm uscular placem en t < subglan dular placem en t.

For subglan dular placem en t, textured < sm ooth

27.3 Treat m ent (n o advan tage in subm uscular placem en t).


In fect ion .
Informed consent m ust in clude m an agem en t of patien t Rupt ure
expectation s an d th orough discussion of existin g Salin e: Risk ~ 1% per year.
asym m etries, poten tial com plication s, rupture screen in g Silicon e
recom m en dat ion s, rates of revision al surgery (~ 20%), Risk ~ 0.5% at 3 years (Men tor Core St udy: prim ar y
respon sibilit y for cost of revision s, an d even tual n eed for augm en tation ).
im plan t exch ange or rem oval. Risk 5.5% at 6 years (In am ed Core Study: prim ar y
Stan dard perioperative care augm en tation ).
A sin gle preoperative dose of a ceph alosporin is in dicated.
Ripplin g, palpabilit y.
Sequen tial com pression devices sh ould be used before

in duction if gen eral an esth esia is adm in istered. Table 27.1 Baker capsular contracture classification
Grade Severit y Findings
27.3.1 Im plant select ion I Norm al Natural feel; norm al in size and shape
II Minim al Slightly firm ; norm al appearance
Im plan t size
Salin e im plan ts available up to 1,000 m L.
III Moderate Firm ; appears abnormal and notable to patient
Silicon e im plan ts available up to 800 m L. IV Severe Hard, painful to the touch; appears abnorm al

116
Breast Augm entat ion

Double-bubble deform it y Perform in g a procedure outside th e stan dard of care


Type A: Im plan t sits above breast m oun d. (e.g., silicon e im plan t in patien t youn ger th an 22 years,
Type B: Im plan t sits below breast m oun d. extra-large volum e augm en tation , tran sum bilical
approach ).
In abilit y to h an dle com m on postoperative com plication s.
27.5 Crit ical Errors Failure to obtain preoperative screen in g m am m ogram in
w om en > 35 years of age.
Failin g to recogn ize com m on abn orm alities com plicatin g
augm en tation (e.g., tuberous breast deform it y, th oracic w all
abn orm alit ies, sign ifican t asym m etries).

117
Mastopexy/Augm entation

28 Mast opexy/Augm ent at ion


Simone W. Glaus & Marissa Tenenbaum

Fig. 28.1 A 57-year-old woman presents with a


chief com plaint of sagging breasts.

119
Mastopexy/Augm entat ion

28.1 Descript ion Surgical option s


Augm en tation alon e: Breast en largem en t

Grade III ptosis (see Table 26.1): Nipple below th e A m ild lift m ay be ach ieved by fillin g th e skin envelope.
in fram am m ar y fold (IMF) an d at th e m ost in ferior portion Mastopexy alon e: Lift in g th e NAC an d tigh ten in g th e skin

of th e breast . envelope w ith out volum etric en largem en t.


Deflated breasts w ith large skin envelope relative to Com bin ed augm en tation /m astopexy

paren chym al volum e. May be perform ed as a sin gle or staged procedure (if
Poor skin elast icit y. staged, m astopexy usually first).
Asym m etr y of breast size an d n ipple position . Com bin ed procedure can lead to in creased m orbidit y an d
h as h igh revision rate.
Preoperative m arkin gs (also n ote key m easurem en ts, above)
28.2 Work-up Midlin e, breast m eridian s, IMFs, tan gen t ial lin e betw een

IMFs, m astopexy m arkin gs, proposed n ipple position ,


28.2.1 Hist ory n ipple to m idlin e.
Determ in e pat ien ts m otivation for seekin g surgery an d
prim ar y desired result (lift , in creased volum e, correction
of asym m etr y, or com bin at ion ).
28.4 Augm ent at ion (see Case 27)
Prior h istor y of breast procedures (m ay im pact blood flow In cision placem en t (con sider future m astopexy in your
to n ippleareola com plex [NAC]). decision process): Periareolar, in fram am m ar y, tran saxillar y,
Person al risk or fam ily h istory of breast can cer, prior tran su m bilical.
m am m ography. Im plan t placem en t: Subglan dular, subpectoral, totally
See Case 27 (Am erican Can cer Society guidelin es).
subm uscular, dual plan e.
Pregn an cy an d breastfeedin g h istor y, plan s for future Im plan t t ype: Salin e versus silicon e ( Table 28.1),
pregn an cy. sm ooth versus textured envelope, roun d versus an atom ical
sh ape, size.

28.2.2 Physical exam inat ion


System atic evaluation of th e ptot ic breast
28.4.1 Mast opexy
Relat ion sh ip of n ipple to in fram am m ar y fold. Tech n iques
Regna ult cla ssifica t ion of breast ptosis (see Table 26.1). Periareolar (sim ple, Ben elli): Allow s lim ited lift aroun d th e

Relat ion sh ip of breast t issue to in fram am m ar y fold (vertical NAC.


overh ang). Vertical scar (Lassus, Lejour, Ham m on d, Hall-Fin dlay).

Overall size an d surface area of th e breast. Inverted-T scar (Wise pat tern skin excision , oth er skin

Qualit y of skin (elast icit y, th ickn ess, striae) an d breast in cision pattern s).
paren chym a.
Breast an d/or ch est w all asym m etries.

Key m easu rem en ts


28.4.2 Augm ent at ion/Mast opexy
Stern al n otch to n ipple, n ipple to IMF durin g stretch , breast Gen eral prin ciples
base w idth , superior an d in ferior pole pin ch th ickn ess, Place im plan ts first, th en tailor th e skin envelope to n ew

an terior pull skin st retch , estim ated paren chym al fill. breast volum e.
Clin ical breast exam in at ion for m asses. Tailor/tack skin in traoperatively w ith patien t uprigh t before

com m ittin g to plan n ed m astopexy pattern .


Em ploy di eren t m astopexy pattern s, if n eeded, for breast
28.2.3 Crit ical t opics for discussion asym m etries.
Con ser vative, superficial skin un derm in in g on ly to decrease
Im pact of breast augm en tation on sur veillan ce for
breast can cer. risk for NAC n ecrosis an d w oun d-h ealin g com plication s.
Poten t ial com plication s (e.g., n ipple loss, asym m etr y) Alw ays m ain tain a pedicle to th e NAC.
an d relatively h igh rate (~ 20 to 25%) of revision ary
surgery. Table 28.1 Com parison between saline and silicone im plants
How revision costs w ill be h an dled. Pros Cons
Rates an d detect ion of rupture for salin e versus silicon e Saline Easily adjustable size Rippling
versus form -stable silicon e im plan ts. Low contracture rates Less natural feel
Ruptures noted clinically,
saline absorbed
28.3 Treat m ent Silicone More natural feel Higher contracture rates
Con t rain dicat ion s to treatm en t Lighter weight than saline Larger incisions for placement
Body dysm orph ic disorder, in appropriate m otivation Lower chance of notable Magnetic resonance im aging
(e.g., salvaging m arriage, peer pressure), sign ifican t breast rippling necessary to evaluate for
disease, collagen vascular disease. rupture

120
Mastopexy/Augm entation

Gen eral tech n ique Im plan t displacem en t , extrusion , rupt ure.


Talc-free gloves. Breast asym m etr y/n ipple m alposit ion .

Perioperative an t ibiot ics, an t ibiotic irrigation of im plan t Con tour deform ities, in cluding double-bubble deform it y

pocket. (t ypes A an d B).


No-touch tech n ique for im plan t placem en t. Cost of revision s: Kn ow h ow you w ill address revision s
(e.g., free, operatin g room an d an esth esia costs on ly,
full cost of a n ew procedure). Th is sh ould be discussed
28.5 Com plicat ions preoperatively.
Com plicat ion rate sign ifican tly h igh er for com bin ed augm en -

tation /m astopexy th an for eith er procedure alon e.


Early com plication s
28.6 Crit ical Errors
Hem atom a/serom a. Failure to obtain screen in g m am m ogram in pat ien t older th an
Com prom ised n ipple viabilit y 35 years.
Release sut ures if dusky n ipple iden t ified. Use of salin e im plan t in patien t youn ger th an 18 years or sili-
May n ecessitate im plan t rem oval. con e im plan t in pat ien t younger th an 22 years (based on FDA
Woun d breakdow n . approval for prim ar y augm en tation ; n o age restriction s for
Pn eum oth orax. recon struction ).
Late com plication s Discussing surgical tech n iques w ith w h ich you are n ot
In fect ion . fam iliar.
Ripplin g an d w rin klin g. Not exh ibitin g a sen se of caution w h en un dertakin g a sin gle-
Capsular cont ract ure: Baker classificat ion (see Table 27.1). stage augm en tation /m astopexy.

121
Breast Reduct ion

29 Breast Reduct ion


Louis H. Poppler & Marissa Tenenbaum

Fig. 29.1 A 49-year-old healthy wom an presents for evaluation for breast reduction. She currently wears a size 48DD bra.

123
Breast Reduct ion

29.1 Descript ion Many auth ors recom m en d screen in g all w om en older th an
25 years before surger y.
Obese w om an w ith m acrom ast ia an d asym m et r y Preoperative m am m ogram s (w h en in dicated) an d 3 to 6
Righ t breast larger th an left . m on th s after reduct ion to establish n ew baselin e.
Large, pen dulous breasts con sisten t w ith reported bra size

of 48DD.
Protuberan t abdom en . 29.2.4 Consult at ions
Grade III ptosis: Regn ault classification (see Table 26.1). Con sider psych iatric/psych ological con sultat ion in w om en
w ith gen der iden t it y issues.
29.2 Work-up
29.2.1 Hist ory 29.3 Treat m ent
Age an d sym ptom s
Tech n ique an d scar len gth (Pick a tech n ique an d kn ow h ow to
Pain associated w ith en larged breasts: Back pain , n eck pain ,
draw it! )
sh oulder pain ,
Sh ort scar: Possible in w om en w ith sm aller breasts.
Groovin g in sh oulders from w eigh t of bra.
Lateral L: On ly in pat ien ts w ith m in im al breast ptosis an d
Skin breakdow n alon g in fram am m ar y fold.
good skin elasticit y.
Determ in e desired cup size.
Stan dard inverted-T in cision (W ise pattern )
History of scarrin g
Most Versatile tech n ique, but larger scar.
May con sider lim it in g in cision s in patien ts w ith h istory of
Allow s reduction of lateral an d ptotic breast tissue an d
hypertroph ic scarrin g/keloids. In form ed con sen t in cludes
gives great m obilit y for fin al n ipple placem en t.
discussing m an agem en t of un sigh tly scars.
Breast pedicle design
Patien ts m ust un derstan d th e possibilit y of un sigh tly scars
In fer ior: Versatile, reliable, an d tradition ally most common
from th e procedure.
Noted to bottom out over tim e. Hen ce, NACIMF dis-
Lactation poten t ial
tan ce is kept sh ort.
Preserve lactation poten tial in younger w om en , even if th ey
Bipedicle: Com m on ly vert ically orien ted.
state n o in ten tion to breastfeed.
Medial/superom edial: Allow s less vertical sh ift of n ipple.
Con sider/o er delay of procedure un til ch ildbearin g is
Superior: Preser ves superior fulln ess.
com pleted because breast m ay ch ange w ith pregn an cy.
Lateral.
On cologic h istory: Fam ily an d person al h istory an d risk
Free n ipple graft: Required in patien ts w ith except ion ally
factors for breast can cer
large breasts (distan ce from stern al n otch to n ip -
Obtain baselin e m am m ogram preoperatively in all w om en
ple > 40 cm ).
35 years of age or older.
Eth ical con siderat ion s
In suran ce docum en tation of am oun t of tissue (in gram s) to
29.2.2 Physical exam inat ion be reduced.
Curren t breast size an d ch est size: Th e larger th e th oracic cir- Adjuvan t procedures an d in suran ce billin g (i.e., axillar y

cum feren ce, th e larger th e breast per cup size (i.e., a size 40B liposuction ).
breast is larger th an a size 34B breast).
Location of fulln ess (i.e., lateral versus pen dulous).
Skin qualit y: Elastic versus th in an d in elastic. 29.4 Com plicat ions
Breast qualit y: Elast ic versus fibrous.
Hem atom a.
Nipple size
Ideal n ipple diam eter for a w om an is 4 to 5 cm , depen din g
In fect ion .
Delayed h ealin g (usually caused by excess ten sion ).
on breast size.
Th e n ipple is often larger in w om en w ith m acrom ast ia.
Breast asym m etr y.
NAC loss
Regn ault classification of breast ptosis (see Table 26.1)
The NAC should be rem oved and placed as a graft if there is
Classification based on posit ion of n ippleareola com plex
concern over blood supply from the pedicle in traoperatively.
(NAC) relative to in fram am m ar y fold (IMF).
Nipple sen sation : Gen eral an d t w o-poin t sen sation . May be
Wide or hypert roph ic scars.
Fat n ecrosis.
reduced postoperat ively or im proved (because of decreased
st retch on sen sor y n erves).
Oth er areas of fulln ess: Appearan ce of lateral fat rolls or obese
abdom en m ay be exacerbated by reduction .
29.5 Crit ical Errors
In adequate preoperative discussion to set expectation s an d
29.2.3 Pert inent im aging or determ in e patien t preferen ces.
Overreduction of breast tissue.
diagnost ic st udies Excess ten sion .
Brea st ca ncer screening if a w om an is older th an Failure to appropriately m an age a dusky areola in traopera-
40 years tively, leadin g to NAC n ecrosis.

124
Gynecom astia

30 Gynecom ast ia
Gwendolyn Hoben & Marissa Tenenbaum

Fig. 30.1 A 16-year-old boy referred by his


pediatrician for a 1-year history of bilateral
gynecomastia.

125
Gynecom ast ia

30.1 Descript ion Testicular ult rasoun d.


Urology con sult, en docrin e consult .

Bilaterally sym m etric, m ildly en larged breasts in a m ale Thyroid m ass


patien t. Serum TSH (thyroid-stim ulat in g h orm on e).

Min im al excess skin . En docrin e con sult.

Norm al body h abit us, w ith out eviden ce of obesit y.

30.3 Treat m ent


30.2 Work-up Stop any con tributin g m edication s, treat un derlyin g
30.2.1 Hist ory con dition .
Duration of gyn ecom astia
Tim e course of breast developm en t an d ch anges. < 12 m on th s: Obser ve
New on set of breast pain , lactation , or en largem en t. No FDA-approved ph arm acoth erapy.
Presen ce of test icular m asses. > 12 m on th s: Surgical m an agem en t can be considered.
Curren t an d prior m edication or drug use (i.e., m arijuan a) Excision
An t i-an drogen s (spiron olacton e), an abolic steroids, HIV
Appropriate for fibrous lesion s w ith accom panyin g excess
m edication s, diazepam , tricyclic an tidepressan ts, skin .
an t ibiotics, digoxin , calcium ch ann el blockers, furosem ide, Circum areolar excision .
risperidon e. Leave su cien t t issue deep to th e n ippleareola com plex to
Alcoh ol, am ph etam in es, m arijuan a, h eroin , m eth adon e.
preven t n ipple depression .
Liposuction
30.2.2 Physical exam inat ion In dicated for m ore glan dular/fatt y com position .

Incisions can be lateral, at infram am m ary fold, or periareolar.


Breast exam in at ion More di cult to rem ove th e fibrous tissue below th e
Fin din gs con cern in g for m align an cy: Eccen tricit y, ch est w all
n ippleareola com plex
fixation , n ipple disch arge. Com bin ation w ith ultrason ic tech n iques or open
Tender ness: > 70% of cases of ben ign gyn ecom astia w ill h ave
approach es m ay be h elpful.
ten dern ess. Ultrasou n d-assisted liposuction
Presen ce of den se fibrous tissue.
Can use h igh er-en ergy settin gs to treat m ore fibrous tissue.
Degree of skin excess
Do n ot excise excess skin con com itan tly, assess at follow -up
Di eren t iate from pseudogyn ecom astia. to allow m axim al skin retraction .
Oth er fem in izing ch aracterist ics. Path ology evaluation :
Testicular exam in at ion . < 1% risk for atypical ductal hyperplasia.
Thyroid exam in ation . Postoperative period
Com pression garm en t: Wear for at least 4 w eeks.

30.2.3 Pert inent im aging or


diagnost ic st udies 30.4 Com plicat ions
W h en concern in g breast exam in ation fin din gs are present: Nipple depression or crater deform it y: Due to over-
Im aging: Mam m ogram an d ultrasoun d are equally sen sitive
resect ion of tissue.
an d specific. Hem atom a/serom a.
Surgical on cology con sult.
In adequate resect ion w ith liposuct ion -on ly approach .
Fem in izin g ch aracteristics
Serum LH (lutein izin g h orm on e), FSH (follicle-st im ulatin g

h orm on e), DHEAS (dehydroepian drosteron e sulfate),


testosteron e.
30.5 Crit ical Errors
Adren al scan , test icular ultrasoun d. Failure to fully assess for un derlyin g causes of gyn ecom astia
Kar yot ype to evaluate for Klin efelter syn drom e (XXY). th at require t reatm en t.
En docrin e con sult, gen et ics con sult. Failure to assess fibrous versus fatt y n ature of th e tissue to
Testicular m ass determ in e w h en liposuction is appropriate.
Serum testosteron e, DHEAS, LH, estradiol. Failure to assess skin excess to determ ine need for skin excision.

126
Part 7

Sect ion VII. Trunk


Ischial Pressure Sores

31 Ischial Pressure Sores


Neil S. Sachanandani & Thomas H. H. Tung

Fig. 31.1 A 35 year paraplegic m ale with a right-sided ischial decubitus wound.

129
Ischial Pressure Sores

31.1 Descript ion Tissue biopsy: For path ology in ch ron ic w oun ds an d for
cult ure.
Stage IV isch ial pressure ulcer w ith exposed bon e an d Bon e biopsy m ay be useful to rule out osteom yelit is,

fibrin ous slough . especially if suggested on MR im aging.

31.2 Work-up 31.2.4 Consult at ions


Clean , pin k gran ulation tissue at w oun d base w ith n o In tern al m edicin e an d n utrition : Optim ize m edical status.
eviden ce of gross con tam in at ion . Physical th erapy, physical m edicin e an d reh abilitation :
Mult iple scars in dicative of prior surgical m an agem en t w ith Man age reh abilitation of patien t.
likely posterior th igh an d gluteal rotation flaps. Social w ork.
Orth opedic surgery, gen eral surgery, urology: May be
involved in dbridem en t an d surgical m an agem en t of
31.2.1 Hist ory associated issues.
Risk factor assessm en t: Age, nutr itiona l sta tus, comorbid In fectious disease: Assistan ce in m an agem en t of in fection
condit ions (diabetes, vascular disease), am bulator y status, an d an tibiotic treatm en t.
spin al cord injur y, spasm an d previous treatm en t , continence
(urin e an d fecal), toba cco an d substan ce abuse, presen ce of
sh ear forces, m en tal status 31.3 Treat m ent
Support n et w ork
For t reatm en t an d cont in ued care.
Educate patien t an d fam ily: Can n ot be over-em ph asized.
Hom e environ m en t an d any pressure-reducin g devices.
Preven t ion is critical.
Optim ize un derlyin g m edical status
Curren t w oun d an d skin care regim en s.
Optim ize nutr ition: Supplem en ts as appropriate.
Previous w oun ds an d in terven tion s.
Con t rol/elim in ate spa sm (baclofen , diazepam ,
History of curren t w oun d: Duration , previous in fection ,
an d dan trolen e).
ch anges in size.
Preven t con tract ures (physical th erapy, ten otom y).

Long-stan din g w oun ds sh ould raise concern for Ma rjolin

31.2.2 Physical exam inat ion ulcer.


Multiple biopsies alon g periph er y.
Location an d dim en sion s of w oun d, qualit y of surroun din g
Elim in ate pressure
tissues, focused sen sor y exam in at ion .
Turn in g ever y 2 h ours an d lift in g for 10 secon ds (seated)
Presen ce of spasm , m oist ure, soilage.
ever y 10 m in utes: Reduces th e cycles of ischem ia an d
Eviden ce of in fect ion .
reperfusion , preven ts breakdow n .
Pressure ulcer staging ( Table 31.1).
Avoid shea r ing durin g tran sfers.

Low -air-loss m attress; Proper cush ion or w h eelch air.

31.2.3 Pert inent im aging or Sea t ma pping to evaluate for localized pressure.

Man age in fect ion


diagnost ic st udies

Dbr id e all n onviable t issues an d bon e.


Laborator y tests: Com plete blood coun t (CBC), com plete An tibiotic treatm en t w h en in dicated.

electrolyte pan el, album in /prealbum in , h em oglobin A1C,


er yth rocyte sedim en tation rate (ESR), C-react ive protein
(CRP). 31.3.1 Wound care
Magn et ic reson an ce (MR) im aging: Osteom yelitis is suggested Dressings: Can decrease bacterial burden
by th e presence of T2 hyperin ten sit y an d low in ten sit y on T1 Silver sulfadiazin e.
im ages; sen sit ive an d specific for osteom yelitis. Dakin solut ion (sodium hypoch lorite)

Sh ort-term use for local Pseudomona s in fection .


Negative-pressure w oun d th erapy.

Table 31.1 Pressure ulcer staging Application of grow th factors (e.g., becaplerm in [Regran ex;
Stage Findings Health poin t Bioth erapeutics, Fort Worth , TX]).
I Intact skin with nonblanching erythem a, usually over a bony
prom inence.
31.3.2 Surgical m anagem ent
II Partial-thickness derm al loss. Appears as a shallow open ulcer
with a redpink wound bed without slough, or as a serum - Stage I an d II ulcers: Usually treat w ith m edical m an agem en t
filled bullous lesion (intact or ruptured). on ly.
III Full-thickness tissue loss. Subcutaneous fat m ay be visible. Stage III an d IV w oun ds often require surgical in terven t ion ,
Bone, tendon, or muscle is not exposed; these are prefascial but treat on ly if con dition s are optim ized to preven t
wounds. May have underm ining. recurren ce.
IV Full-thickness tissue loss through the fascia with exposed bone, MR im aging an d bon e biopsy n egative for osteom yelit is
tendon, or m uscle. Often includes underm ining and tunneling. dressin g ch anges an d sch edule for coverage.

130
Ischial Pressure Sores

Fig. 31.2 Ham string m usculocutaneous v-y advancem ent flap. Fig. 31.3 Posterior thigh fasciocutaneous flap. This may be superiorly
based (as shown) or based m edially/laterally to allow advancem ent in a
superior direction.

MR im aging con firm s osteom yelit is of th e sacrum , ischium ,


or troch an ter resect ion of th e a ected bon e, poten t ially
6-w eek course of in traven ous an t ibiotics, poten tially
6 w eeks of recom bin an t platelet-derived grow th factor
(PDGF), follow ed by defin it ive closure.
Alw ays con sid er fu t u re p roced u res in operat in g room
plan n in g.
Ver y h igh level of recurren ce in patien ts w ith pressure

sores.
Fla ps should be la rger tha n needed to a llow re-eleva tion a nd

a dva ncement.
Flap option s by location
Isch ium

Ham st rin g m usculocutan eous V-Yadvan cem en t flap


( Fig. 31.2).
Posterior th igh fasciocutan eous flap ( Fig. 31.3).
Ten sor fasciae lata V-Yadvan cem en t flap.
Gluteal rotat ion flap.
Lateral an d an terolateral th igh fasciocutan eous flaps.
Gracilis m yocutan eous flap.
Pedicled rectus abdom in is m yocutan eous flap.
Sacrum

Gluteus m axim us rotation flap ( Fig. 31.4).


V-Yadvan cem en t flap based on superior gluteal
vessels.
Fig. 31.4 Gluteal rotation flap. This may be perform ed with fasciocu-
taneous or m usculocutaneous tissue.

131
Ischial Pressure Sores

Lum bosacral flap. Poor com plian ce leads to recurren t or n ew pressure ulcers
Superior gluteal artery perforator (SGAP) flap. over tim e.
Troch an ter Must plan on m ultiple repeat surgeries in th e future: Design
Ten sor fasciae latae flap. la rge fla ps tha t ca n be rea dva nced or rota ted a nd reused.
Vastu s lateralis flap.
Gluteal flap.
Gird lest on e p r oced u re: Proxim al fem ur resect ion w ith 31.5 Crit ical Errors
vastu s lateralis in terposit ion .
Failure to con trol bacterial colon izat ion of w oun ds,
treat in fection , or adequately dbride before surgical
31.4 Com plicat ions
closure.
Design in g a flap th at is too sm all for closure or does n ot
Hem atom a/serom a. an ticipate n eed for re-elevation an d reuse of th e flap in th e
Woun d deh iscen ce. future (because of likely future recurren ce).
In fect ion . Failure to adequately m an age w h ole patien t or to recogn ize
High recur rence ra tes after flap closure: 13 to 82% over w oun d etiology.
5 years Failure to biopsy ch ron ic w oun d/evaluate for Marjolin ulcer.

132
Body Contouring after Massive Weight Loss

32 Body Cont ouring aft er Massive Weight Loss


Simone W. Glaus & Marissa Tenenbaum

Fig. 32.1 A 57-year-old woman requests body contouring following m assive weight loss.

133
Body Contouring aft er Massive Weight Loss

32.1 Descript ion


Presen ce of breast m asses.
Presen ce of abdom in al scars, h ern ias, Lap -Ban d port .
Breasts Sign s of n utrition al deficien cy (e.g., pale m ucous m em bran es,
Grade III ptosis w ith sign ifican t deflation (see Table 26.1). brittle n ails an d h air).
Mild volum e asym m etr y (L> R).

Striae superiorly.

Trun k, abdom en , buttocks 32.2.3 Pert inent im aging or


Well-h ealed abdom in al laparoscopic in cision s (di cult to

visualize).
diagnost ic st udies
Redun dan cy of skin an d fat in th e low er abdom en exten ding Laborator y an alysis: Com plete blood coun t (CBC), electrolytes
on to th e flan ks an d low er back. w ith album in , prealbum in , an d blood urea n itrogen (BUN)/
Ptot ic gluteal region . creatin in e, liver fun ction tests (LFTs), proth rom bin tim e (PT),
Medial th igh s: Ptotic, redun dan t tissue w ith poor skin qualit y partial th rom boplast in tim e (PTT) m icron ut rien ts (e.g., iron ,
an d elast icit y. vitam in B12 , th iam in e).
Arm s: Upper arm bat w in g deform it y. Guided by physical exam in ation results an d t ype of bariatric
procedure.

32.2 Work-up
32.2.1 Hist ory 32.2.4 Consult at ions
Nutrition ist: If con cern for n utrition al deficien cies.
Origin al an d curren t body m ass in dex (BMI)
BMI: w eigh t (kg) /[h eigh t (m )] 2 .
Hem atology: Prior h istory of deep ven ous th rom bosis (DVT).
Obesity classification ( Table 32.1)
Weigh t loss tim elin e
How m uch over h ow lon g? 32.2.5 Crit ical t opics for discussion
Sh ould be w ith in 10 to 15%of goal w eigh t. Expected scars
Length of t im e w eigh t h as been stable
Many are lon g, w ith som e visible w h en patien t cloth ed.
Weigh t m ust be stable over a 6-m on th period prior to Dog ears m ay be eviden t.
body con tourin g procedures. In abilit y to ach ieve perfection .
Exception is for pan n iculectom y or breast reduction if Patien t priorities an d stagin g of procedures for safety
h in derin g exercise an d furth er w eigh t loss. Decide w h at you are com fortable o erin g in term s of
Meth od of w eigh t loss, in cluding bariatric procedures grouped procedures an d len gth of operatin g tim e.
Sh ould kn ow exam ple procedures an d th eir physiologic
Avoid procedures w ith con flict ten sion forces.
con sequen ces/n ut rit ion al deficien cies in case you are asked. Most procedures sh ould be perform ed w ith in a 6-h our
Restr ictive: Laparoscopic ban din g (Lap -Ban d), vertical
tim e period.
ban ded gastroplast y. Poten tial com plication s, in cluding serious com plication s
Ma la bsor pt ive: Biliopan creatic diversion duoden al sw itch .
(see Com plication s).
Combina tion rest r ictivema la bsor ptive: Rou x-en -Ygastric
Revision policy
bypass. Discuss costs an d t im ing after in itial procedure.
Curren t diet an d exercise h abits, n ut rition al supplem en tation , Th ere is a h igh likelih ood th at th e patien t w ill request a
sym ptom s of n ut rit ion al deficien cy (e.g., fatigue, h air loss, revision follow in g th e th e in it ial procedure.
poor w oun d h ealin g, n europathy).
Curren t an d pre-w eigh t-loss-m edical an d psych iatric
com orbidities.
Risk factors for poor w oun d h ealin g (e.g., sm okin g, steroids 32.3 Treat m ent
an d im m un osuppressive m edication s). Gen eral sequen ce for recon struction : Th ere is n o righ t
an sw er.
32.2.2 Physical exam inat ion Tailor to pat ien t n eeds an d budget.

Exa mple: (1) trun k, abdom en , buttocks, lateral th igh s;


Com preh en sive assessm en t of body con tour, skin an d tissue
(2) upper th orax, breasts, arm s; (3) m edial th igh s; (4) face.
qualit y, degree of ptosis an d/or deflation . Wait a m in im um of 3 to 6 m on th s betw een stages.
Wait 6 to 12 m on th s betw een trun k, buttocks, lateral th igh s

Table 32.1 Obesit y classification an d m edial th igh s.


Description Body m ass index In traoperative m an agem en t issues
DVT prophylaxis (sequen tial com pression devices, post-
Overweight 2530
operative an t ith rom botics).
Obesit y 3035
Position in g (paddin g pressure poin ts, pillow un der kn ees,
Severe obesit y 3540
preven tin g hyperexten sion or extrem e flexion ).
Morbid obesity 4050 Patien t tem perature (w arm fluids, w arm in g blan kets).
Super obesit y > 50 In traven ous fluids (m on itor blood loss, urin ar y cath eter).

134
Body Contouring after Massive Weight Loss

32.3.1 Procedures (descript ions of


t ypical procedures, t heir m arkings, and
t he surgical t echnique for each region)
Trun k, abdom en , buttocks, lateral th igh s
Vertical abdom in oplast y (see Case 38), circum feren tial belt

lipectom y, low er body lift.


Treat as on e un it for best results. Markin gs frequen tly m ade

w ith patien t stan d in g.


Optim ize posit ion in g of scars in relation sh ip to an atom ical

lan dm arks (i.e., w ith in bikin i lin e).


More aggressive w ith an terior an d lateral resect ion s th an

w ith posterior region s.


Upper th orax, breasts, arm s
Upper th orax: Direct excision of upper back rolls.

Breasts: Mastopexy augm en tation (see Case 28),

reduct ion (see Case 29)


Breast borders (e.g., lateral border, in fram am m ar y fold)
are frequen tly lost in patien ts w ith m assive w eigh t loss
an d n eed to be redefin ed.
Tradition al tech n iques are frequen tly in su cien t .
Longevit y m ay be im proved w h en sh apin g relies m ore on
glan dular m an ipulation (paren chym al plication , derm al
suspen sion , autoaugm en tation ) th an on sim ple redrapin g
of th e skin envelope.
Augm en tation , if used, sh ould be con ser vative in th is
population , given th e relatively un stable skin envelope.
Arm s: Brach ioplast y alon e versus staged liposuction +

brach ioplast y
Upper arm excess in pat ien ts w ith m assive w eigh t loss
crosses th e axilla on to th e ch est w all, so excision m ust
also exten d to lateral ch est w all.
Fig. 32.2 Brachioplasty incision.
In cision design sh ould attem pt to preven t lin ear scar
con tracture (e.g., Z-plast y at axilla; Fig. 32.2).
Medial th igh s Early recogn ition an d diagnosis.
Vertica l media l thigh lift (m ore e ect ive th an h orizon tal Treat m en t (e.g., an t icoagulation , filter).
m edial th igh lift) liposuction .
Disruption of lym ph atic drain age, labial spreading (m edial
Do n ot perform in pat ien ts w ith h istor y of DVT or th igh lift).
preexistin g lym ph edem a.
Nerve injur y
Avoid injury to saph en ous vein an d lym ph atics of fem oral Uln ar n er ve, m edial an tebrach ial cutan eous n er ve
trian gle. (brach ioplast y).
Tack st ructures to deep (Colles) fascia. Lateral fem oral cutan eous n erve (abdom in oplast y).
Avoid a h orizon tal scar tech n ique to reduce risk for labial
Over-resect ion : Avoid if possible w ith careful tailorin g
spreading. before defin itive excision .
Face (see Cases 15 an d 16): Stan dard rhytidectom y tech n iques Tem porary dressing (i.e., vacuum -assisted closure) m ay
w ith m odification s allow decrease in edem a before repeated attem pt at closure.
Skin redun dan cy exceeds SMAS (superficial m usculo- Skin graft m ay be placed un til tissues stretch an d allow
apon eurotic system ) redun dan cy. re-excision .
More skin un derm in in g an d less SMAS elevation t ypically

required. 32.5 Crit ical Errors


Safet y is a critical issue.
32.4 Com plicat ions Avoid un safe practices.

In adequate DVT prophylaxis, too m any procedures

Typical: Hem atom a, serom a, w oun d deh iscen ce, skin n ecrosis, (> 6 h ours).
in fect ion , persisten t laxit y or laxit y w ith in a year, n eed for In appropriate pat ien t selection (e.g., before w eigh t
revision surgery. stabilization or w h en n utrition al deficien cies exist).
Poten t ially devastatin g In abilit y to discuss proposed tech n ique
DVT, pulm on ar y em bolism : Th is is a m ajor safety issue. Be prepared to discuss th e m arkin gs, position in g, an d

Appropriate prophylaxis. surgical steps for any tech n ique you m en tion .

135
Major Liposuct ion

33 Major Liposuct ion


Justin B. Cohen & Terence M. Myckatyn

Fig. 33.1 A 41-year-old wom an presents to the clinic to discuss possible surgical options to im prove the appearance of her saddlebags.

137
Major Liposuction

33.1 Descript ion Ideal for fibrous region s: Buttocks, lum bar region ,
gyn ecom ast ia.
Sign ifican t, di use lipodystrophy n oted bilaterally in Precaut ion s to avoid cutan eous th erm al injury.
saddlebag region s of upper lateral th igh s. La ser-a ssisted liposuction (LAL).

Skin redun dan cy an d residual adiposit y n oted on th e Fluid m an agem en t for large-volu m e liposuction (cr it ical
cen tral t run k. safet y issu e)
Replace preoperative deficits.

Em ploy super w et or tum escen t tech n ique.


33.2 Work-up Ad m in ister m ain t en an ce in t raven ou s flu id (IVF) + IVF

rep lacem en t of 0.25 m L/1 m L of asp irat e over 5 L.


33.2.1 Hist ory Tit rate IVF to pat ien ts clin ical picture (e.g., urin e out put,

Weigh t stabilit y. vital sign s).


Medical com orbidities. Main tain in t raoperative fluid ratio: (IVF + in filt rate)/

Patien t con cern s, expectation s, an d goals of treatm en t . aspirate = 1.2.


Older tech n ique (Pitm an ): IVF + in filtrate = 2 aspirate.

25 to 30% of in filtrate is rem oved w ith aspirate.


33.2.2 Physical exam inat ion If large-volum e liposuct ion ( 4 to 5 L) is perform ed, it m ust
Evaluate region s of subopt im al contour, asym m etr y, be don e in an acute-care h ospital or accredited facilit y.
lipodystrophy. Mon itor vital sign s an d fluid balan ce w ith Foley cath eter.
Evaluate skin qualit y an d ton e (th ickn ess an d elasticit y): Overn igh t in patien t observation .
Pin ch test. Warm patien t , fluids, an d operatin g room to avoid
Exam in e for h ern ias, diastasis. hypoth erm ia.
Dilute lidocain e furth er if greater volum e of in filtration is

n ecessary.
33.3 Treat m ent Deep ven ous th rom bosis (DVT) prophylaxis
Liposuction is a con tourin g procedure. Mech an ical: sequen t ial com pression devices.

Best in areas of th ick, elast ic skin w ith un derlyin g con tour Am bulate day of surgery.

irregularit y of fat. Ch em oprophylaxis n ot stan dardly required.

Does NOT address cellulite or obesit y. Postoperative care


Does NOT resect skin . Early am bulation .

Perform preoperative m arkin gs w ith pat ien t uprigh t to Com pression garm en ts for 4 to 6 w eeks.

determ in e treatm en t areas an d asym m etries, an d outlin e


zon es of ad h eren ce.
Target deep fa t la yer an d cross-tunnel to preven t con tour 33.4 Com plicat ions
irregularities. Excessive ecchym osis, discoloration , h em atom a, or blood loss
Wetting solut ion tech n ique ( Table 33.1) related to disruption of vasculature.
Lidocain e, epin eph rin e, an d bicarbon ate solut ion added to
Fat em bolus, DVT, or pulm on ar y em bolus.
salin e or lactated Rin ger solut ion . Fluid sh ifts, pulm on ar y edem a.
Provides an esth esia an d h em ostasis.
Lidocain e toxicit y.
Maxim um lidocain e w ith epin eph rin e: 35 m g/kg.
Serom a.
Liposuction m odalit y Skin n ecrosis.
Suct ion-a ssisted liposuction (SAL): Tradit ion al liposuction
Th erm al injury (UAL).
tech n ique. Con tour deform it ies.
Power-a ssisted liposuction (PAL): Motorized oscillatin g
Prolon ged paresth esias.
h an d piece. In fect ion .
Ult ra sound-a ssisted liposuction (UAL): Ultrason ic en ergy
Perforation of abdom in al viscera.
is applied after w ett in g solut ion to em ulsify fat before
aspiration .
33.5 Crit ical Errors
Table 33.1 Wetting solutions for liposuction
Lidocain e toxicit y (dosin g > 35 m g/kg).
Technique Infiltrate Estim ated blood
loss (% volum e)
Failure to m on itor fluid balan ce.
Failure to require in pat ien t m on itorin g after large-volum e
Dry None 2045
liposuction .
Wet 200300 m L per area 430 Failure to take precaution s again st th erm al injury w ith UAL.
Superwet 1 m L of infiltrate per 1 m L of aspirate 1 Adding sign ifican t liposuction to an already exten sive
Tum escent 23 mL of infiltrate per 1 m L of 1 recon struction involvin g oth er procedures, result in g in
aspirate (or to skin turgor) exten sive operative tim es.

138
Abdom inal Wall Defect

34 Abdom inal Wall Defect


Michael J. Franco & Ida K. Fox

Fig. 34.1 A 55-year-old m an with a history of exploratory laparotomy and ventral hernia repair with m esh now presents with recurrence.

139
Abdom inal Wall Defect

34.1 Descript ion


Preexistin g in cision s.
Pertin en t com orbid con dition s (diabetes, autoim m un e
Large m idlin e abdom in al w all h ern ia con sistin g of m yofascial diseases, coron ary artery disease, etc).
defect w ith overlyin g skin .
Th e rect us abdom in is m uscles h ave m igrated laterally.
Th ere is n o eviden ce of visceral in carceration . 34.2.3 Pert inent im aging or
diagnost ic st udies
34.2 Work-up Com puted tom ography of th e abdom en w ith contrast m ay be
h elpful to delin eate th e exten t of th e defect, th e related
34.2.1 Hist ory an atom y, an d oth er issues (e.g., bow el adh esion s, abscesses).
Etiology of defect: Congenital, previous surgery, traum a, resection. Pulm on ar y fun ction testin g sh ould be perform ed if th ere is
Duration of defect, m an agem en t th us far. preexistin g respirator y com prom ise or suspicion for loss of
Nut rition al status. dom ain from a large h ern ia.
History of sm okin g.
Steroids or im m un osupp ressive m edication s.
34.2.4 Consult at ions
34.2.2 Physical exam inat ion Gen eral surgery
May n eed to excise skin present on bow el, lyse adh esion s,
Body m ass in dex (BMI): w eigh t (kg)/[h eigh t (m )] 2 .
an d repair any iatrogen ic bow el injur y durin g th is in it ial
Abdom in al w all defect description
process to obtain access for recon struction .
Location

Midlin e or lateral.
Upper, m iddle, or low er abdom en .
Tissue defect
34.3 Treat m ent
Skin an d subcutan eous t issue. Preoperative preparation sh ould in clude w eigh t loss, sm okin g
Myofascial. cessation , an d correct ion of m aln utrition .
Full th ickn ess. It is best to delay abdom in al recon struction for at least
Size of defect. 6 m on th s after in itial injury or surgery to m in im ize
Con dit ion of surroun din g tissues. in flam m ation an d edem a.

Fig. 34.2 Planes of separation: indicated by the


dashed line as it proceeds posteriorly to the
posterior axillary line bet ween the external and
internal oblique m uscles.

140
Abdom inal Wall Defect

34.3.1 Reconst ruct ive opt ions perforators to overlyin g skin in tact w h en ever possible
m ay im prove perfusion of th is skin flaps.
Decision in fluen ced by th e t issue defect, size of defect, an d Th e extern al oblique apon eurosis is in cised vertically
location . 1 cm lateral to th e sem ilun ar lin e from th e costal m argin
Skin an d subcutan eous defects to th e in guin al ligam en t. Th e extern al oblique is raised o
Prim ar y repair.
th e in tern al oblique in a relatively avascular plan e, up to
Local tissue rearran gem en t .
th e m idaxillar y lin e.
Skin graft .
If addition al advan cem en t is n eeded, th e posterior rectus
Tissue expansion can be perform ed for large defects, w ith a
sh eath m ay be in cised, an d th e rect us m uscle m ay be
skin graft over th e defect as a tem porizing m easure. separated from th is layer.
Myofascial defects Tissue expansion
Prim ar y repair: On ly for sm all defects w ith sign ifican t skin
Com pon en ts separation is n ot possible in all cases (e.g.,
laxit y. lateral defects).
Prosth etic m aterial for recon struction of fascia w ith
An expan der can be placed betw een th e extern al an d
overlyin g skin flap coverage in tern al oblique m uscles.
Polypropylen e m esh (n on absorbable). Full-th ickn ess defects
Acellular derm al m atrix (biological). Prim ar y repair: Sm all defects w ith adequate tissue laxit y
Com p on en t s sep arat ion : Useful for central defects up to
on ly.
20 cm in w idth ( Fig. 34.2 an d Fig. 34.3) Pedicled flaps.
Th e h ern ia is taken dow n an d separated from th e Rectus abdom in is: Superiorly based (upper abdom in al
abdom in al flaps. defects) or in feriorly based (low er abdom in al defects).
Skin flaps are elevated laterally from th e abdom in al Extern al oblique: Defects of upper tw o-th irds of th e
m usculature to th e an terior axillar y lin e. Leavin g abdom en .

Fig. 34.3 Com ponents separation technique.


External oblique is incised lateral to the semilunar
line and released from the internal oblique
(dashed lines 1 and 3). Posterior rectus sheath
is released (dashed line 3). The resulting
m yofasciocutaneous flaps are advanced
toward the m idline.

141
Abdom inal Wall Defect

Latissim us dorsi: Lateral defects of th e upper tw o-th irds


of th e abdom en .
34.4 Com plicat ions
Ten sor fasciae latae: Defects of low er t w o-th irds of th e Woun d in fection .
abdom en . Delayed w oun d h ealin g.
Rect us fem oris: Defects of low er t w o-th irds of th e Deh iscen ce.
abdom en . Recurren ce.
Free flaps: For ver y large defects (e.g., Ten sor Fasciae Latae,

latissim us dorsi)
Most com m on ly used recipien t vessels: Superior
34.5 Crit ical Errors
epigastric, deep in ferior epigast ric, deep circum flex Failure to optim ize m edical status before surgery.
iliac, in tern al th oracic, an d saph en ous vein loop Failure to elim in ate risk factors for recurren ce (e.g., w eigh t
grafts. loss, sm okin g cessation , oth er).
Peak airw ay pressures are m easured by th e an esth esia team In abilit y to describe in detail th e surgical option ch osen .
durin g closure. If peak airw ay pressure in creases w ill n ot In adequate preparation for com plication s (i.e., bow el
allow closure, m esh in terposit ion m ay be n ecessary. perforation ).
If th e abdom in al w all defect is in a radiated field, n on radiated Failure to evaluate for h ern ias preoperatively.
tissue w ill be n eeded (distan t pedicled or free flap) for Failure to con sider backup or salvage m easures w h en closure
recon struction . is n ot possible.

142
Sternal Wound Infection

35 St ernal Wound Infect ion


Louis H. Poppler & Thomas H. H. Tung

Fig. 35.1 Intraoperative consultation on a 67-


year-old wom an who had undergone three-vessel
coronary artery bypass (left internal m amm ary
and saphenous vein grafts) with subsequent
sternal infection and wound dehiscence.

143
Sternal Wound Infection

35.1 Descript ion tigh tened or replaced. Oth erw ise, rem ove w ires an d close
w ith vascularized tissue (e.g., bilateral pectoralis m ajor
Patien t w ith eviden ce of an an terior m idlin e ch est w all m yocutan eous flaps).
w oun d m easurin g rough ly 15 8 cm . Subacute: Secon d to four th postoperat ive w eeks
Th e stern al edges an d m ediast in um are exposed w ith out Purulen t m ediastin itis, fever/sepsis, leukocytosis.

eviden ce of gross purulen ce or exten sive n ecrotic tissue. Decom press w oun d at bedside or in th e operat in g room .

No vascular grafts are visible. Follow w ith local w oun d care (dressin g ch anges or
vacuum -assisted closure [VAC]).
On ce w oun d controlled, take to operatin g room . Dbride
35.2 Work-up exposed cartilage an d stern um to h ealthy tissue. Close
w ith flaps.
35.2.1 Hist ory Ch ron ic: Treatm en t after th e fourth w eek
Etiology: Stern al w oun d in fection (follow in g m edian stern ot- Ch ron ic osteom yelitis an d sin us tracts.

om y), t um or resect ion , radiation (ulcers, osteoradion ecrosis). Radical dbridem en t an d rem oval of foreign bodies.

Duration of w oun d. In stitute local w oun d care w ith VAC or dressin g ch anges.
Curren t w oun d care. On ce w oun d is clean , cover w ith flaps.

Com orbidit ies: Respirator y in su cien cy, sepsis, cardiac Long-term in t raven ous an t ibiot ics.

disease.
Review previous operative repor ts (e.g., vessels used,
ribs resected).
35.3.3 Flap coverage opt ions
Pectoralis m ajor
35.2.2 Physical exam inat ion Workh orse flap for stern al coverage. May disin sert m uscle

at th e h um erus for addition al len gth .


Vital sign s: Is th e patien t stable? Muscle flap (based on th oracoacrom ial vessels), turn over
Size an d depth of defect. m uscle flap (based on in tern al m am m ar y perforators), or
Presen ce of in fected or n ecrotic t issue. m usculocutan eous flap.
Exposed grafts, vascular devices, or m ediastin um . Bilateral flaps sutured togeth er provide stern al stabilit y.
Prior surgical scars on ch est or abdom en . Flaps based on th oracoacrom ial pedicle m ay n ot reach
Con gen ital abn orm alit ies: Polan d syn drom e, pectus in ferior stern um . Turn over flaps cover in ferior stern um
excavatum /carin atum . but can n ot be used if in tern al m am m ar y vessel h as been
tran sected.
35.2.3 Pert inent im aging or Om en t um
Based on left or righ t (preferable) gastroepiploic vessels.
diagnost ic st udies Tun n eled in to th e th oracic cavit y over th e costal m argin or

Ch est X-ray: Presen ce of stern al w ires an d evaluation of lun g th rough th e diaph ragm .
fields. Excellen t for coverage of exposed grafts an d vascular

Com puted tom ography: Evaluation for deep abscesses if devices an d th e in ferior part of th e stern um . Requires
persisten t fevers an d sepsis. in tra-abdom in al access for h ar vest.
Magn et ic reson an ce im agin g: Most useful in ch ron ic stern al Rect us abdom in is
defects for evaluation of exten t of in fection an d/or Muscle or m usculocutan eous (vertical rectus abdom in is

osteom yelit is. m yocutan eous [VRAM]) flap.


An giography: Allow s st udy of available vessels an d th eir Excellen t coverage of th e in ferior stern um .

paten cy. Bipedicled flap con sistin g of pectoralis m ajor con tin uous

w ith ipsilateral rectus abdom in is (based on th oracoacrom ial


an d deep in ferior epigastric arter y [DIEA] pedicles, respec-
35.3 Treat m ent tively) m ay be used if bilateral in tern al m am m ar y artery
(IMA) pedicles an d om en tum un available.
35.3.1 Goals Latissim us dorsi
Dbride all n onviable t issue, ach ieve clean w oun d. Can be used for lim ited defects.

Restore stabilit y an d st ructure. As a free flap, provides w ide coverage.

Protect vital st ruct ures an d provide durable coverage.


Obliterate dead space.

Ach ieve cosm etically acceptable result.


35.4 Com plicat ions
Hem atom a
Most com m on ly due to early start of an ticoagulation .
35.3.2 Pat t ern of present at ion Platelets an d fresh frozen plasm a can be t ran sfused
Acute: First postoperative w eek if in dicated.
Stern al in stabilit y, serosan guin ous drain age, deh iscen ce. Usually requires operative evacuation .
Return to operatin g room , drain , an d dbride to h ealthy Serom a
bon e. If th ere is good-qualit y bon e, th e stern al w ires can be Can be m in im ized w ith liberal use of drain s.

144
Sternal Wound Infection

In fect ion
Most likely due to in com plete in it ial dbridem en t or w oun d
35.5 Crit ical Errors
preparation . Failure to cover exposed vascular grafts.
Decom press an d in st it ute local w oun d care. In adequate dbridem en t of n ecrotic/in fected tissue.
Flap failure Not en surin g in tact vascular supply to proposed flap.
En sure th at th e dom in an t vessel to th e flap h as n ot been Not leavin g in drain s or takin g out drain s too soon .
sacrificed in a previous operation .
May n eed to create an oth er flap for coverage.

145
Chest Wall Defect

36 Chest Wall Defect


Gwendolyn Hoben & Ida K. Fox

Fig. 36.1 A 46-year-old woman with a history of right breast cancer and radiation therapy. She presents with an open chest wound and exposure of
several ribs.

147
Chest Wall Defect

36.1 Descript ion Recon struct ion of poten tial m issing layers: Pleural cavit y,
th oracic skeleton , soft tissues.
Large ch est w all defect, in cludin g th e in ferior portion of th e Obliteration of in trath oracic dead space w ith soft tissue
pectoralis m ajor, lateral port ion of th e serratus, an d th e fourth (pedicled m uscle or om en tal flaps over ch est t ube)
an d fifth ribs. Latissim us dorsi, pectoralis m ajor, serratus an terior, rectus

Clear eviden ce of osteom yelit is (w ith exposed, n ecrotic bon e). abdom in is, om en tum .
Healthy-appearin g tissue in lateral w oun d. May require n ew th oracotom y in cision to in set: En sure

Left m astectom y scar. pedicle is n ot stran gled or t w isted.


Skeletal defect recon struction
Skeletal support is gen erally n eeded in defects involving

36.2 Work-up m ore th an four con secutive ribs.


Sm aller defects m ay require recon struct ion if severe
36.2.1 Hist ory pulm on ar y disease present.
Coron ar y artery disease Larger defects m ay n ot require recon struct ion in sett in g
History of coron ary artery bypass graftin g: Possible absen ce of radiation -in duced ch est w all fibrosis (sti en s ch est
of in t ern al m am m ar y ar t er y. w all, resultin g in greater stabilit y an d less paradoxical
Pulm on ar y disease (ch ron ic obstruct ive pulm on ar y disease m otion ) or location un der scapula.
Recon struct ive option s
[COPD], asth m a): In creased risk for respirator y com prom ise
in th e absen ce of ch est w all skeletal recon struction . Autogen ous: Pectoralis m ajor, latissim us dorsi, rectus
Previous h istory of ch est , back, or abdom in al surger y/traum a: abdom in is, serratus an terior, om en tum .
Poten t ial com prom ise of specific flaps. Alloplast ic: Mesh (polypropylen e, ePTFE [expan ded poly-
Oth er com orbidities. tetrafluoroethylen e]), m ethylm eth acr ylate, bon e grafts.
Tobacco use. Split-rib, iliac crest, or fibula grafts.
Nut rition al status. Hardw are.
Etiology of ch est w all w oun d/deform it y
Soft-t issue coverage
Locoregion al or free flaps.
Traum atic, on cologic, in fect ious, radiation , congen ital.
Latissim us flap
If on cologic, ben ign versus m align an t: Histor y of (or plan

for) rad iat ion t h erapy. Can reach contralateral axillar y fold.
If th oracodorsal pedicle is injured or un available, m ay be
pedicled on serratus bran ch of th e lateral th oracic artery.
36.2.2 Physical exam inat ion With th oracotom y, latissim us m uscle m ay be
com prom ised.
Defin e defect or m ass: Location , depth , fixed or m obile.
Serratus an terior flap
Perform lym ph n ode exam in at ion .
Good for an terior an d posterior ch est coverage.
Assess m uscle involvem en t in th e ch est: Is th e pectoralis
Risk for scapular w in ging if en tire m uscle rem oved.
m ajor involved?
May be com prom ised if prior th oracotom y.
Assess abdom en for h ern ias, diastasis recti.
Pectoralis m ajor flap
Evaluate back m usculature an d soft-t issue laxit y.
Useful for superioran terior ch est .
Assess for ch est w all, back, or abdom in al scars.
Based on in tern al m am m ar y artery or pectoral bran ch of
th e th oracoacrom ial trun k.
36.2.3 Pert inent im aging or Prior coron ary bypass (loss of in tern al m am m ar y artery)
m ay lim it option s.
diagnost ic st udies Om en t um

Com puted tom ography (CT) to evaluate exten t of m ass, Useful in coverage of exposed pericardium .
w oun d, or deform it y an d any involved or absen t structures. Requires en tran ce to abdom in al cavity. Con com itan t
An giography (or m agn etic reson an ce/CT an giography) if h ern ia risk.
un certain about vascular an atom y. Excellen t backup option because it is far from th e zon e of
Pulm on ar y fun ction tests m ay be in dicated: Help determ in e injur y an d w ill n ot be injured in a prim ar y recon struct ion
n eed for recon struct ion in sm all defects. w ith m ore local flaps.
Rect us abdom in is flap

Good for an terior ch est w all.


36.2.4 Consult at ions If in tern al m am m ar y is n ot available, th e flap can be
based on th e eigh th in tercostal vessels.
Cardiac/th oracic surger y for assistan ce in dbridem en t an d
m an agem en t of ch est w all recon struct ion .

36.4 Com plicat ions


36.3 Treat m ent Flail segm en t: Avoid w ith adequate skeletal recon struction /
Com plete resect ion an d dbridem en t of all tum or, n onviable stabilization .
tissues, an d in fect ion . In fected m esh : Requires m esh rem oval.

148
Chest Wall Defect

In flam m ator y process m ay result in fibrosis of su cien t


m ech an ical stabilit y to obviate th e n eed for m esh
36.5 Crit ical Errors
replacem en t. If th ere is sign ifican t concern for in fection , Failure to recogn ize on CT gross lym ph aden opathy or disease
n on -biologic m aterials sh ould n ot be used. progression alterin g resectabilit y of th e prim ar y lesion .
Hem atom a/serom a: Requires prom pt drain age. In adequately assessing a patien ts cardiac h istor y to
Don or-site m orbidit y, in cluding h ern ia, scar/con tracture, determ in e if th e in tern al m am m ar y artery is in tact.
w oun d deh iscen ce, h em atom a/serom a. Failure to assess n eed for skeletal recon struction .

149
Perineal Reconst ruct ion

37 Perineal Reconst ruct ion


Noopur Gangopadhyay & Ida K. Fox

Fig. 37.1 (a-b) A 44-year-old wom an with recur-


rent vulvar cancer has just undergone wide local
excision of tum or and now requires
reconstruction.

151
Perineal Reconst ruct ion

37.1 Descript ion Radiation on cologist: Evaluation for postoperative or


in traoperative radiation th erapy, in cluding possible
Wide resect ion of perin eal con ten ts, in cluding m on s pubis, placem en t of brachyth erapy cath eters at tim e of tum or
vulva, an d clitoris. resect ion .
Resect ion area exten ds to ureth ral an d vagin al orifices. Medical on cologist: Con sider n eed for n eoadjuvan t
ch em oth erapy.

37.2 Work-up
37.2.1 Hist ory 37.3 Treat m ent
Person al or fam ily h istory of can cer. 37.3.1 Goals of t herapy
Previous radiation treatm en t or exposure.
Previous urin ar y in con t in en ce. Prom ote rapid w oun d h ealin g.
Decrease pelvic dead space an d restore pelvic floor.
Reestablish n orm al sexual fun ction an d body im age.
37.2.2 Physical exam inat ion
Evaluate surgical defect an d classify as partial (an terior,
lateral, posterior, upper t w o-th irds) or total loss 37.3.2 Reconst ruct ive opt ions
of vagin a.
Vertical rectus abdom in is m yocutan eous (VRAM) flap
Evaluate for dead space, h ern ias, fist ulas, in fection , devascu-
Access via m idlin e laparotom y in cision .
larized t issue, region al lym ph aden opathy; exam in e abdom en
Cover defects of an terior or posterior vagin a by in sett in g
an d low er extrem ities to assess possible recon struct ive
flap alon g w oun d m argin s.
option s.
Can be t ubed for circum feren tial vagin al recon struction .
Assess radiation e ects to surroun ding tissues.
Based on deep in ferior epigastric arter y.

Gracilis m yocutan eous flap


37.2.3 Pert inent im aging or Exam in e fem oral pulses preoperatively to evaluate

paten cy of in flow vessel (m edial fem oral circum flex


diagnost ic st udies
ar tery).
Assess t ran sferrin , album in , an d prealbum in levels. Useful if laparotom y in cision n ot required for on cologic
Com puted tom ography to evaluate n odal spread in th e resection an d in total vagin al recon struct ion .
pelvis. Con sider bilateral flaps for large defects an d to create a
Positron em ission tom ography (PET) h as im proved sen sitivity n eovagin a.
to detect sm all n odal m etastasis. Puden dal th igh (m odified Sin gapore) flap ( Fig. 37.2)
Recon struct an terior or lateral vagin al defect.

Useful w h en con siderin g postoperative sen sation .


37.2.4 Consult at ions May be un ilateral or bilateral.
On cologic surgeon : Wide local excision w ith pelvic lym ph Based on posterior labial vessels an d posterior labial

n ode dissect ion , as in dicated. bran ch es of puden dal n er ve.

Fig. 37.2 Pudendal thigh flap.

152
Perineal Reconst ruct ion

Th igh flap ( Fig. 37.3)


Useful for defects confin ed to perin eum .

Can be design ed an teriorly, posteriorly, laterally, or m edially

Most frequen tly posteriorly based.


Does n ot provide su cien t bulk for large defects.
Di cult to m obilize in obese patien ts.

37.4 Com plicat ions


Pressure to th e flap can result in partial flap loss, w oun d
deh iscen ce, an d delayed h ealin g.
Serom a accum ulation in depen den t areas.
Ven ous congestion due to pedicle kin kin g durin g in set.
Distal th ird of skin paddle for gracilis m yocutan eous flap m ay
be un reliable.
Puden dal th igh flap m ay be dam aged by irradiation an d
suboptim al for recon struction .

37.5 Crit ical Errors


In adequately fillin g soft-tissue defect left in th e perin eal
cavit y after resect ion .
Failure to discuss w ith patien t postoperative goals for sexual
fun ction (creation of n eovagin a, sen sation , oth er).
Failure to accoun t for previous abdom in al an d low er
extrem it y scars leadin g to injur y to pedicles for flap
recon struction .
Attem pts to recon struct th e perin eum w ith skin graft w ill
result in a h igh rate of failure in an irrad iated bed.

Fig. 37.3 Thigh flap.

153
Abdom inoplast y

38 Abdom inoplast y
Elizabeth B. Odom & Terence M. Myckatyn

Fig. 38.1 A 39-year-old woman with t wo previ-


ous pregnancies and a 40-lb weight loss has
excess abdom inal skin and subcutaneous tissue
and m ultiple striae.

155
Abdom inoplast y

38.1 Descript ion In cision m arkin gs m ade preoperatively


E orts m ade to keep in cision w ell h idden un der cloth in g

Excess skin an d subcutan eous tissue of th e cen tral abdom en . (bikin i lin e).
Laxit y of th e abdom in al w all m usculature (con sisten t w ith Markin gs m ade tran sversely at th e level of th e pubic bon e,

w eigh t loss an d pregn an cies). exten din g laterally an d superiorly tow ard, but stayin g just
Residual localized adiposit y of both flan ks. in ferior to th e an terior superior iliac spin e.
With th e patien t flexed at th e w aste, perform a pin ch test of
th e abdom in al apron to predict th e am oun t of skin th at m ay
38.2 Work-up be rem oved to determ in e th e superior in cision .
In itiation of sequen t ial com pression devices preoperatively to
38.2.1 Hist ory m in im ize th e risk for ven ous th rom bosis.
Assess patien t suitabilit y for th e procedure an d gen eral
an esth esia, as w ell as risk factors for deep ven ous th rom bosis
(DVT) an d w oun d-h ealin g problem s. 38.3.2 St andard abdom inoplast y
Previous abdom in al surger y (in cluding laparoscopic surger y). t echnique
History of pregn an cies an d th eir e ect on th e abdom en .
Possibilit y of fut ure pregn an cies. 1. Full in ferior in cision is m ade an d taken straigh t dow n to th e
History of w eigh t ch anges: Weigh t sh ould be stable an d m uscular fascia.
w ith in 10 lb of fin al desired w eigh t for ~ 3 m on th s before 2. Skin an d fat are elevated aw ay from th e un derlying fascia to
surgery. th e um bilicus.
Hear t disease, periph eral vascular disease, diabetes, steroid 3. Um bilicus is in cised circum feren tially, w ith dissection dow n
use, con n ect ive t issue disease. to th e rectus sh eath .
Sm okin g h istory: Must stop sm okin g 6 w eeks before surgery. 4. Elevation of skin an d fat con tin ued to th e costal m argin s
History of DVT or pulm on ar y em boli (PE). laterally an d th e xiph oid centrally.
5. Iden tify th e degree of diastasis w ith in th e rectus fascia an d
m ark th e area to be im bricated.
38.2.2 Physical exam inat ion 6. Place perm an en t in terrupted sutures alon g th e m arked area
Exam in e excess skin an d soft tissue w ith th e patien t in th e of plication th at run s from th e xiph oid to th e um bilicus
stan din g, sittin g, an d supin e posit ion s. an d from th e um bilicus to th e pubis. A secon d layer of
Docum en t any h ern ias, diastasis recti, or asym m etries. rein forcing run n in g perm an en t suture m ay be utilized.
Note and docum en t th e location and size of all abdom in al scars. 7. Th e w aist is flexed to ~ 60 degrees, an d th e am oun t of skin
A th orough un derstan din g of th e abdom in al blood supply an d fat th at can be resected to allow a ten sion -free closure
is essen t ial. is m arked an d resected. Preoperative m arkin gs can n ot be
trusted to determ in e th e superior m argin of th e resect ion .
8. Jackson -Pratt drain s sh ould exit th rough th e h air-bearin g
38.2.3 Pert inent im aging or skin of th e pubic region .
diagnost ic st udies 9. Th e level of th e um bilicus is m arked, an d an open in g is
created th rough th e skin an d subcutan eous tissue to
Com plete blood cell coun t (CBC), basic m etabolic pan el,
tran spose an d in set th e um bilicus.
proth rom bin t im e (PT)/in tern ation al n orm alized ratio (INR),
10. Th e superficial fascia is closed w ith sem iperm an en t sut ures,
activated partial throm boplastin tim e (aPTT) m ay be considered.
follow ed by th e deep derm al an d subcutan eous layers.
Urin e -h um an ch orion ic gon adotropin level to confirm
11. An abdom in al bin der is placed.
absen ce of pregn an cy.
Album in /prealbum in level to assess n utrition al status
(especially in patien ts w ith w eigh t loss).
38.3.3 Variat ions t o t echnique
Urin e cot in in e level to gauge patien t com plian ce w ith
sm okin g cessation (if in dicated). Con com itan t liposuction w ith abdom in oplast y
May be used prim arily in th e flan ks follow in g a stan dard

abdom in oplast y for con com itan t con tourin g, stayin g deep
38.2.4 Consult at ions to th e superficial fascia layer to m ain tain th e subcutan eous
If an abdom in al w all defect or h ern ia is en coun tered on vascular n etw ork.
exam in ation , a gen eral surgery con sultation m ay be m ade for Sh ould be perform ed before th e abdom in oplast y procedure

in traoperative assistan ce. because it w ill redist ribute con tours an d create redun dan cy
in overlyin g tissue.
Brazilian tech n ique: Full-th ickn ess liposuction is perform ed
38.3 Treat m ent alon g th e flan ks an d th e in ferior pan n us. Above th e um bilicus,
liposuction an d un derm in in g are lim ited to th e tissue deep
38.3.1 Preoperat ive m anagem ent to th e superficial fascia to m in im ize dam age to th e blood
Sm okin g cessat ion for 6 w eeks before th e operation . supply th rough th e subcutan eous vascular n etw ork. Lateral
Strict glucose control if the patien t is diabetic. Confirm satisfac- dissection is m in im ized durin g th e abdom in oplast y to
tory w eight loss and correction of m aln utrition (if in dicated). decrease th e risk for vascular com prom ise in region s w h ere

156
Abdom inoplast y

m ore exten sive liposuction h as been perform ed. Skin of th e Main ten an ce of patien t in a flexed position for several w eeks
in ferior pan n us m ay th en be excised. postoperat ively to m in im ize ten sion on w oun d m argin s.
Fleur-de-lis: An addition al vertical in cision is added to allow
rem oval of supraum bilical h orizon tal skin excess.
Min i abdom in oplast y: Perform ed in patien ts w ith prim arily a 38.4 Com plicat ions
diastasis rect i an d a m odest excess of in fraum bilical tissue. A
Patien t dissatisfaction : Can did discussion s regarding
12- to 16-cm in cision is m ade w ith a conser vative excision of
expectation s, scar qualit y, an d poten t ial w oun d problem s
skin an d fat. Th e um bilicus is n ot t ypically excised, but it m ay
m ust occur before th e operation .
be floated w ith its stalk severed an d displaced in feriorly.
Com m on com plication s in clude con tour im perfection s,
Reverse abdom in oplast y: Less conven tion al tech n ique, per-
m argin al w oun d n ecrosis, in fection , serom a, h em atom a,
form ed in patien ts w ith excess supraum bilical skin or a sub-
w oun d deh iscen ce, hypertroph ic scars/keloids, an d um bilical
costal scar. A t ran sverse in fram am m ar y in cision is m ade, an d
m alposit ion .
dissect ion is carried in feriorly w ith excision of superior
abdom in al fat an d skin .

38.5 Crit ical Errors


38.3.4 Post operat ive m anagem ent Failure to provide DVT prophylaxis leadin g to DVT, PE, or
En courage early am bulation because of in creased risk for death .
DVT. High -volum e liposuction or len gthy procedure (> 6 h ours),
DVT ch em oprophylaxis w h ich m ay com prom ise patien t safety.
Weigh t-based en oxaparin regim en begin n in g w ith in 8 In adequate preoperative discussion of th e possibilit y of poor
h ours after surger y an d cont in uin g th rough out th e in pa- or im perfect outcom e, th e possible n eed for revision , an d h ow
tien t stay h as been sh ow n to decrease th e risk for DVT an d such cases m ay be h an dled (e.g., paym en t).
PE in h igh -risk pat ien ts (i.e., th ose w ith a body m ass in dex Failure to con sider previous abdom in al or ch est w all scars
[BMI] > 40, sm okin g h istory, oral con traceptive use, fam ily th at m ay h ave disrupted blood supply. Tissue m edial to lateral
or person al h istory of DVT, or kn ow n coagulation disorder) abdom in al scars m ay be com prom ised.
an d th ose w ith a h ospital stay of 4 days. Failure to exam in e for abdom in al w all defects or h ern ias m ay
Low er-risk pat ien ts m ay ben efit from ch em oprophylaxis lead to bow el injur y durin g abdom in oplast y.
an d sh ould be assessed on an in dividual basis after a Excision of m arked specim en w ith out confirm in g th at
prolon ged case (> 6 h ours) or prolon ged postoperative abdom en can be defin itively closed, causin g excess ten sion
stay (> 4 days). on w oun d m argin s or in abilit y to close th e w oun ds.

157
Part 8

Sect ion VIII. Burn


Acute Burn Injury

39 Acut e Burn Injury


Amy M. Moore & Ida K. Fox

Fig. 39.1 (a,b) 8 year old presents to the


em ergency department after sustaining burns
from cam pfire explosion.

161
Acute Burn Injury

39.1 Descript ion Fla me: Most com m on . Can lead to superficial to deep burn ,
depen din g on degree of exposure.
Flam e burn injur y to port ion s of th e face, th e left ch est, an d Oil or grea se burn s: Must be careful n ot to un derestim ate

left arm . severit y of such burn s. Oil w ill contin ue to burn over
Superficial an d deep part ial-th ickn ess burn s. len gthy periods of tim e if n ot w ash ed o im m ediately.
Approxim ately 20% of body surface area. Elect r ica l (h igh or low voltage): Raises con cern for deeper

Possible circum feren t ial involvem en t of th e forearm s. injury to th e un derlyin g struct ures. Greater con cern for
Con cern for in h alation al injur y. com par tm en t syn drom e an d rh abdom yolysis.
En closed versus open space: En closed location s in crease

likelih ood of in h alation al injur y.


39.2 Work-up In h alation injur y
Exam in e for sin ged facial h air, soot in airw ay.

39.2.1 Hist ory and physical History of asth m a or ch ron ic obstructive pulm on ar y disease

(COPD) can com prom ise oxygen at ion .


exam inat ion Any sign ifican t con cern w arran ts in tubation .
Traum a evaluation Exten t of burn
ABCs (airw ay, breath in g, circulation ): Assess for critical Rule of nines ( Fig. 39.2): Calculation of exten t based on

injuries durin g th e prim ar y sur vey. secon d- an d th ird-degree burn s. Does n ot in clude first-
Mech an ism of injur y degree burn s.

Fig. 39.2 Rule of nine for estim ation of burn


injury. Note the increase in proportion of the size
of the head in children.

162
Acute Burn Injury

Assess depth of burn : Part ial (superficial or deep) versus full Nutrition : Metabolic dem an ds are in creased, en teral feeds are
th ickn ess. ideal.
If electrical: Iden t ify en tran ce an d exit w oun ds to Place feedin g t ube if patien t n ot takin g adequate n ut rition

determ in e path of injur y. orally or if in t ubated.


Ext rem it ies involved Dressings an d topicals: After dbridem en t , m ultiple option s
Circum feren t ial burn s: Assess n eed for esch arotom ies or exist.
fasciotom ies. Face: An tibiotic oin tm en t 3 tim es daily.

Com part m en t syn drom e (see Case 40) Ears an d n ose: Mafen ide (Sulfam ylon ; Mylan Pharm aceuti-

Com part m en tal pressures m ay be m easured w ith STIC cals, Morgan tow n , W V) because of im proved cartilage
pressure m on itor (St r yker; Kalam azoo, MI). pen etration .
Con cern if pressures > 30 m m Hg. Body an d extrem it ies: Apply silver sulfadiazin e (Silvaden e;

Assess distal perfusion . Pfizer, New York, NY) to areas 2 tim es daily.
Face involved Splin tin g, early ran ge of m otion (ROM) w ith occupat ion al
Eyes: con sider oph th alm ology con sult. th erapy.
Cartilage exposure: Assess for presence of exposed t issues. Tan gen tial excision an d graftin g
As soon as pat ien t is stable, plan for m ultiple trips to th e

operatin g room .
39.2.2 Diagnost ic st udies Surgeries perform ed in a w arm environ m en t.

Ch est X-ray. Begin w ith largest areas first .

Carboxyh em oglobin level: Treat w ith supplem en tal oxygen . Address h an d burn s by 14 days an d address th e

Electrocardiography, h ear t m on itor: especially in th e patien t face last .


w ith an electrical burn . Surgical en d poin ts: 2 to 3 h ours of operatin g tim e or
Urin e creatin e kin ase level: w h en con cern for m yoglobin uria tran sfusion of 10 un its of blood (packed red blood cells).
exists. Graft option s: Cadaver, xen ograft, autografts
Split- versus full-th ickn ess grafts.

Mesh ed versus sh eet grafts (con sider sh eet grafts for face
39.3 Treat m ent an d h an ds an d across join ts).
Secure th e airw ay if you suspect in h alation injury.
Supplem en tal oxygen if pat ien t n ot in tubated.

In t raven ous (IV) access for m ain ten an ce an d resuscitation


39.4 Com plicat ions
fluids. Burn sepsis: Fevers, ch ange in m en tal status, hypoten sion ,
Resuscitation : Adjust form ula for adequate urin e output ch ange in w oun ds.
(ch ild, 1 to 2 m L/kg per h our; adult , 0.5 to 1 m L/kg per h our). Scar/con tracture: Avoid w ith early excision an d graftin g,
Pa rkla nd formula : 4 m L/kg per % burn per 24 h ours
splin tin g, ROM, com pression garm en ts.
% Burn = total secon d-degree an d deeper burn s. Electrical burn s: cardiac arrhyth m ias, m yoglobin uria, m uscle
Apply form ula for burn s > 20% of body surface area. n ecrosis.
Give h alf of IV fluids in first 8 h ours, secon d h alf over
n ext 16 h ours.
Early dbridem en t: Rem ove dead skin an d tissue to fully
assess exten t of burn s.
39.5 Crit ical Errors
Esch arotom ies (see Case 40): In cision s design ed to optim ize Failure to recogn ize in h alation injur y an d secure airw ay.
fun ction of extrem ities an d ch est , m in im ize m orbidit y an d Failure to recogn ize oth er concom itan t injuries an d traum a.
con tracture. Not perform in g esch arotom ies w ith circum feren t ial burn s
Fasciotom ies in th e patien t w ith an electrical burn : Bon e an d/or fasciotom ies w ith electrical burn s.
con tin ues to con duct h eat an d m ay lead to con tin ued Failure to excise an d graft deep par t ial- an d full-th ickn ess
soft-t issue n ecrosis. burn s.

163
Hand Burn

40 Hand Burn
David T. Tang & Ida K. Fox

Fig. 40.1 A 28-year-old m an involved in a house fire has sustained noncircum ferential flam e burns to both upper extrem ities. After initial stabilization
and resuscitation, his cutaneous burns still require m anagem ent.

165
Hand Burn

40.1 Descript ion


Act ive an d passive ran ge of m otion (ROM) of each join t.
Presen ce of con tractures
Non circum feren t ial second- an d th ird-degree burn s to th e Discern in trin sic from extrin sic join t cont racture.
upper extrem it y. Assess degree of soft-tissue deficit.
Dorsal h an d an d fin gers involved.
No sign ifican t palm ar burn s presen t (n ot sh ow n in
ph otograph ). 40.2.3 Pert inent im aging or
Neurovascular status is in tact distally. diagnost ic st udies
Stan dard radiography (th ree view s of th e h an d).
40.2 Work-up An giography if required for plan n ed free tissue tran sfer
recon struction .
40.2.1 Hist ory Blood w ork: Com plete blood cell coun t (CBC), electrolytes,
blood urea n itrogen (BUN), creatin in e, in tern ation al n orm al-
Age, gen der, h an dedn ess, an d occupation of th e patien t .
ized ratio (INR), partial th rom boplast in t im e (PTT), glucose,
Tim in g an d m ech an ism of burn injur y
blood t ype.
Th er m al: Type of burn (flam e, con tact , scald, steam ,
Con sider arterial blood gases for associated in h alation al
grease); duration of con tact; associated injur y; tetan us
injuries or certain ch em icals.
status; suspicion of abuse.
Cardiac en zym es, urin e m yoglobin , creatin e kin ase, 12-lead
Ch em ical: Type of ch em ical (alkali, acid, organ ic com -
electrocardiography for electrical burn .
poun d); duration of con tact; n eut ralization attem pted.
Elect r ical: Type of curren t (AC or DC), voltage, duration of

con tact , path w ay of curren t flow. 40.2.4 Consult at ions


Previous injur y or surgery to th e h an d in question .
Man ual dem an ds of daily living an d overall lifestyle. Gen eral surgery or critical care team if burn s are exten sive.
Past m edical an d surgical h istory. Poison con trol cen ter if ch em ical is involved an d m an agem en t
Medication s an d allergies. is un clear.
Social h istory, in cludin g sm okin g stat us an d substan ce abuse.

40.3 Treat m ent


40.2.2 Physical exam inat ion
In it ial assessm en t of h an d burn s pertain s to vascular
40.3.1 Acut e burn m anagem ent
perfusion an d to th e depth an d dist ribution of th e ABCs (airw ay, breath in g, circulation ) an d prim ar y sur vey
burn injur y. En sure th at in itial life-th reaten in g con cern s regardin g
Han d is scrubbed of any soot, dirt , or debris. airw ay, breath ing, an d circulation h ave been m an aged
Poten t ially const rict in g jew elr y an d w atch es are rem oved. Proper acute advan ced burn life suppor t (ABLS)/advan ced
Acute injur y traum a life suppor t (ATLS) guid elin es sh ould be adh ered to
Location an d total surface area of burn injury. before h an d burn s are m an aged.
Depth of burn injur y (first-degree, superficial second- Esch arotom y ( Fig. 40.2)
degree, deep second-degree, th ird degree). In dication s
Exposure of deep st ructures (e.g., ten don s, bon es, Necessar y in clear-cut, full-th ickn ess circum feren t ial
n eurovascular st ruct ures). burn s.
Vascular status of h an d. Partial-th ickn ess circum feren t ial burn s th at m ay cause
Motor an d sen sor y fun ction . com partm en t syn drom e w ith on set of post-resuscitation
Com part m en t syn drom e: Lim b-th reaten in g con dition edem a.
Mostly seen in com bin ed crush or oth er sign ifican t injury Clin ical sign s consisten t w ith vascular com prom ise.
(oth erw ise see n otation on esch artom y below, w h ich is Pain on passive exten sion , flexed post urin g, decreased
m ore pertin en t to isolated burn m ech an ism s of injury). capillar y refill, decreased pulses, cyan osis, an d n eurologic
High in dex of suspicion n ecessar y. ch ange.
Pa in out of proportion to injur y, especia lly w ith movement. Perform ed em ergen tly in operatin g room or at bedside

Five Ps (late sign s): pain , pallor, paresth esias, paralysis, to preven t furth er soft-tissue death due to vascular
pulselessn ess. com prom ise.
In t racom part m en tal pressures > 30 m m Hg require In cision s design ed to m in im ize m orbidit y an d optim ize

in terven tion . even tual h an d fun ction .


Needle pressure gauge (STIC pressure m on itor; Stryker, Fasciotom y
Kalam azoo, MI) if con cern ed about com partm en t In dicated follow in g h igh -voltage electrical injur y (> 1,000 V)

syn drom e. or severe burn injur y.


Un derlying fract ure assessm en t. Decom pression of th e carpal tun n el sh ould also be
Secon dar y recon struct ion con sidered.
Status of soft-t issue coverage (th ickn ess, durabilit y, Fascial com par tm en ts.

sen sibilit y, elasticit y). Forearm ( Fig. 40.3)

166
Hand Burn

Fig. 40.2 Escharotomies of the hand and


forearm .

Th ere are 3 com par tm en ts: Volar, dorsal, lateral Reduced pain an d com plication s associated w ith
(m obile w ad). prolon ged im m obilization .
Han d ( Fig. 40.4) Late excision (3 to 6 w eeks) advan tages
Th e 10 fascial com partm en ts of th e h an d m ust be Early excision is m ore com plex an d tim e-con sum ing.
assessed an d released, if n ecessary. No sign ifican t di eren ce in ultim ate h an d fun ct ion .
Dorsal in terossei (4 com part m en ts), palm ar in terossei Preservation of all residual, viable derm al elem en ts.
(3 com partm en ts), adductor pollicis, th en ar,
an d hypoth en ar.
Can be ach ieved th rough carpal t un n el release, 2 dorsal
40.3.2 Skin resurfacing
in cision s, th en ar an d hypoth en ar in cision s. Tem porar y skin replacem en t
If fin gers are th reaten ed, m idaxial in cision s over Cadaver allograft.

n on dom in an t sides m ay be perform ed. Biobran e (nylon m esh + th in silicon e m em bran e; UDL

Burn esch ar excision Laboratories, Rockford, IL).


Con sider a brief period of obser vation (~ 3 days) un t il th e Tran sCyte (porcin e collagencoated nylon m esh w ith

depth of th e burn injur y is w ell dem arcated to avoid h um an cultured fibroblasts; Advan ced BioHealin g,
un n ecessary excision of h ealthy t issue. New York, NY).
Early excision advan tages Perm an en t skin replacem en t
Im proved ult im ate h an d fun ct ion . Split-th ickn ess skin graft (sh eet or m esh ed)

Reduced risk for abn orm al scarrin g. Mesh ed grafts: Trun k, upper arm , an d forearm .
Reduced n um ber of recon struct ive procedures. Sh eet grafts: Dorsum of th e h an d an d fin gers.
Decreased len gth an d cost of h ospital stay. Full-th ickn ess skin graft: Palm ar surface (glabrous skin ).

Fig. 40.3 Fasciotom ies of the forearm .

167
Hand Burn

Fig. 40.4 Fasciotomies of the hand. A. Markings for incisions to achieve access to dorsal interossei. B. Midaxial incisions over non-dominant sides of the
finger. C. Axial cross-section dem onstrating sites for compartment release.

Non autogen ous m aterials Splin t in g to preven t cont ractures (static, staticprogressive,
AlloDerm (h um an cadaveric acellular allogen eic derm al dyn am ic).
m atrix; LifeCell, Bridgew ater, NJ) Con t in uous passive m otion devices.
In tegra (bovin e collagen derm al regeneration sca old; Kirsch n er w ires across join ts (in h eren t risk for in fection ).
In tegra, Plain sboro, NJ).
Apligraf (bovin e collagen + h um an -derived fibroblasts
bilayered livin g skin equivalen t; Organ ogen esis, Can ton ,
40.3.4 Secondary burn m anagem ent
MA). Hypertroph ic scarrin g an d contracture ban ds
Derm agraft (h um an -derived fibroblast bilayered bio- Com pression garm en ts.

absorbable livin g skin equivalen t; Advan ced BioHealin g, Silicon e sh eet th erapy.

New York, NY). Early active m otion th erapy.


Cult ured epiderm al autograft Appropriate splin tin g.

Cult ured epiderm al sh eets from skin biopsy of th e In tralesion al steroid injection s.

patien t . Scar ban d release an d Z plast y recon struction .

Expen sive, require 2 to 3 w eeks to cult ure, an d are th in Scar ban d release an d skin graft recon struct ion (split-

an d un stable. th ickn ess or full-th ickn ess skin graft).


Flap recon struction option s First w eb space con tracture release
Local flaps. Skin + adductor pollicis fascia cont ract ure release.
Pedicled flaps. First dorsal in terosseous m uscle release, if n eeded.
Free flaps Adductor pollicis m uscle release at origin , if n eeded.

Fasciocutan eous. Soft-t issue recon struct ion

Muscle flap + split-th ickn ess skin graft. Local flaps: Four-flap Z-plast y ( Fig. 40.5), V-M plast y,
five-flap Z-plast y.
Region al flap: Reverse radial forearm , reverse posterior
40.3.3 Prevent ion of secondary injury in terosseous arter y (PIA).
Edem a con trol: Early m otion an d elevation . Free flap: Lateral arm flap, rad ial forearm flap from
Physical th erapy an d reh abilitation . con tralateral arm .

168
Hand Burn

Fig. 40.5 Reconstruction of a first web space


contracture with four-flap Z-plast y.

40.4 Com plicat ions 40.5 Crit ical Errors


Failure of recon struction (poor graft take, partial or total Failure to perform early esch arotom y or fasciotom y as
flap loss). n eeded.
Hypert roph ic scarrin g. Poor design of esch arotom y or fasciotom y, exposing critical
Burn scar cont ract ure. structures or in adequately releasin g tissues.
Claw h an d deform it y: In adequate splin tin g, th erapy, or early In adequate assessm en t of all com partm en ts of th e h an d or
operative m an agem en t . extrem it y, especially in circum feren t ial burn s.
Woun d breakdow n . Poor graft ch oice (m esh ed grafts on th e h an d in stead of sh eet
In fect ion . grafts to m in im ize cont racture, especially over join t surfaces).

169
Scalp Burn Reconst ruct ion

41 Scalp Burn Reconst ruct ion


Gwendolyn Hoben & Albert S. Woo

Fig. 41.1 (a,b) A 26year-old m an burned in a


house fire requesting reconstruction following
initial treatm ent of scalp burns.

171
Scalp Burn Reconstruct ion

41.1 Descript ion Con tin ue un til su cien t skin to cover defect .
Available tissue = dom e of expander base w idth of expander.

Irregular scarrin g an d alopecia to th e righ t occipital scalp Create flap ~ 20% larger th an th e defect to accoun t for recoil.

Exten sion to th e superior n eck an d retroauricular region . Secon d stage sh ould be perform ed on ce adequate

Defect involves ~ 25% of n orm al h air-bearin g scalp surface. expan sion is ach ieved.
Design flaps w ith a com bin at ion of advan cem en t an d rotation
based on at least on e n am ed vessel as th e pedicle.
41.2 Work-up Facilitate flap advan cem en t an d ten sion -free closure w ith
galeal scorin g at 1-cm in tervals.
41.2.1 Hist ory Score in a direction perpen dicular to th e direct ion of

Etiology of scar, in cludin g m ech an ism an d depth of burn s. desired tissue gain .
Tim e in terval sin ce injur y an d recon struct ion . Use caution because scorin g m ay com prom ise vascularit y of

Medical com orbidities overlyin g skin .


Woun d- h ealing problem s. Approxim ately 1 m m of addition al len gth en in g is ach ieved

Sm okin g h istory. per score.


Bleedin g disorders. Do not excise dog ea rs. Th ese settle over tim e.
Social support n etw ork.

41.3.4 Reconst ruct ion by region


41.2.2 Physical exam inat ion An terior scalp defects: Goal is to re-create an terior h airlin e.
Assess size of scar an d degree of scalp laxit y. Tissue expansion .
Assess direction alit y of rem ain in g h air. Advan cem en t rotat ion , V-Yadvan cem en t , rh om boid flaps.
Assess for oth er scars or a ected body region s. Or t icoch ea flap s ( Fig. 41.2)

Tw o flaps based on superficial tem poral vessels to fill

41.3 Treat m ent defect.


On e large occipital flap to fill don or-site defect.
Establish patien t expectation s for recon struction . Parietal scalp defects: More scalp m obilit y present th an
Correction of alopecia (brin g in n ew ha ir-bea r ing tissue). an teriorly
Im provem en t in h airlin e. Tissue expansion .

Im provem en t in facial appearan ce (excise grafted region s V-Yadvan cem en t , rh om boid flaps for sideburn s.

an d replace w ith local tissue, if possible). Rotation advan cem en t, bipedicled fron to-occipital flaps.

Occipital scalp defects


Tissue expansion .
41.3.1 Flap coverage Rotation advan cem en t flaps.

Viable option for sm aller defects of th e scalp. Or ticoch ea th ree-flap tech n ique.

Scalp tissue h as less m obilit y th an tissue in oth er parts of th e Vertex scalp defects: Lim ited scalp m obilit y h ere.
body. Tissue expansion .

Large flaps sh ould be design ed to optim ize result an d Pinw h eel ( Fig. 41.3), rh om boid, rotation advan cem en t

m in im ize ten sion . flaps.


Com m on flap option s: Rotat ion , advan cem en t (V-Y), Large rotation flaps requirin g n early com plete scalp

tran sposition , pinw h eel, Orticoch ea. un derm in in g.


Nearly com plete scalp defects: Com plete coverage w ith
h air-bearin g skin m ay n ot be possible. Goal m ay sim ply be
41.3.2 Tissue expansion scalp coverage w ith h ealthy tissue.
Defects of up to 50% of th e scalp can be recon structed. Free t issue tran sfer

Preferred tech n ique for scalp recon struction . Muscle flaps create n ice con tour w ith atrophy (e.g.,
Mult iple expan ders m ay be used for a sin gle defect. More latissim us dorsi).
th an on e expan sion m ay be perform ed. Om en tum , radial forearm , an terior lateral th igh .
In cision s are design ed perpen dicular to axis of expan sion , can In tegra (bovin e collagen derm al regeneration sca old;

be placed w ith in lesion to allow future excision . In tegra, Plain sboro, NJ) an d split-th ickn ess skin graft.
Subgaleal placem en t. Hair t ran splan t
In tern al ports are less conven ien t but h ave a low er risk for Rem ain s an option if adequate h air-bearin g scalp is

in fection com pared w ith extern al ports. available.


Requires excision of h air-bearin g region s of th e scalp w ith

direct closure of don or site.


41.3.3 Expansion t echnique Tran splan t can be perform ed w ith separation of h air in to

Begin ~ 2 w eeks after tissue expan der placem en t; con tin ue at n aturally occurrin g follicular un its. Th ese are separately
w eekly in tervals. in serted in to region s of alopecia.
With each session , fill un t il patien t experien ces discom fort or Micrograft: 1 to 2 h air follicles.
n otable skin ch anges occur. Min igraft: 3 to 6 h air follicles.

172
Scalp Burn Reconst ruct ion

Fig. 41.2 Orticochea three-flap technique for


coverage of large defects of the scalp.

41.4 Com plicat ions


Expan der exposure
Exposed im plan ts m ust be rem oved.

If sign ifican t expan sion h as already taken place, th e

expan der sh ould be rem oved an d th e tissues sh ould be


advan ced as m uch as possible.
In fect ion : W h en an expan der is involved, th is sh ould be
rem oved an d th e t issues advan ced.
Hem atom a, serom a.
Expan der pun cture an d deflation .
Skin n ecrosis.
In su cien t tissue to recon struct th e en tire defect: Advan ce
flaps an d re-expan d.

41.5 Crit ical Errors


In cision for t issue expan der placem en t in th e h air-bearin g
scalp m ean t to be expan ded.
Failure to assess skin w h en fillin g expan der.
Failure to advan ce th e flaps w h en rem ovin g an in fected or
exposed expan der.
Excision of en t ire defect before advan cin g th e flaps an d
determ in in g if th ere is su cien t t issue for coverage.
Fig. 41.3 Multiple pinwheel flaps for closure of circular defect.
Poor design of flaps (i.e., flaps th at are too sm all to correct
th e defect).

173
Neck Burn Contracture

42 Neck Burn Cont ract ure


Gwendolyn Hoben & Albert S. Woo

Fig. 42.1 A 14-year-old girl with a history of burns from a house fire several years prior enters with difficult y m oving her neck.

175
Neck Burn Cont racture

42.1 Descript ion Fu ll-t h ick n ess gr aft in g


Possible don or sites: Abdom en , th igh , back.
Exten sive burn con tract ure involving th e n eck, breasts, an d May con sider preoperative t issue expan sion to cover
an terior trun k larger sites.
Eviden ce of previous split-th ickn ess grafts to th e n eck. Im proved aesth etic outcom e an d reduced risk for
Multiple teth erin g ban ds. con tracture.
Lim itation in n eck rotation : ~ 50 degrees of lateral rotation . Split-th ickn ess graftin g
Lim itation in exten sion : 30 degrees of cervical superior Perform ed as sh eet grafts to m in im ize con tract ure.
exten sion . Th igh or back w ould be appropriate don or sites.
High er risk for con tracture recurren ce.
Poor aesth etic outcom e.
42.2 Work-up In tegra (bovin e collagen derm al regeneration sca old;
In tegra, Plain sboro, NJ)
42.2.1 Hist ory and physical No don or site, but n eeds addition al skin graftin g.
exam inat ion Advan tageous in con sideration for later recon struction of
th e ch est an d breast burn s.
Mech an ism , depth , an d exten t of previous burn s.
Poor aesth etic outcom e.
Tim e in terval sin ce injur y an d recon struct ion perform ed.
High risk for recurren ce.
Histor y of droolin g, di cult y eatin g, speech deficien cies.
Iden tify con tracture ban ds.
Assess for don or-site availabilit y. Flap coverage
Medical com orbidities. Local pedicled flaps
Supraclavicular flap: For less exten sive burn defects.

42.2.2 Pert inent im aging or Occipital artery flap: Don or site w ould require graftin g.

Dorsal scapular flap


diagnost ic st udies Bilateral flaps m ay be h ar vested for larger burn s.
Man dible series: Assess for m en tal (ch in ) retrusion . Don or site w ould require graft in g.
Preoperative an esth esia assessm en t: May be an airw ay Free flaps
ch allenge given reduced exten sion . Appropriate option s: Radial forearm , an terolateral th igh

flap.
Good aesth etic outcom e.
42.3 Treat m ent High rate of m orbidit y.

Postoperative m an agem en t
42.3.1 Surgical planning of A n eck brace is ben eficial to m in im ize sh ear w ith

involved areas m ovem en t.


Tisseel (fibrin glue; Baxter Health care, Deerfield, IL),
Neck con tracture
Establish im proved ran ge of m otion an d release sign ifican t
vacuum -assisted closure (VAC) m ay be h elpfu l adjun ctive
m easures to m ain tain graft adh eren ce.
con tractures.
Nutrition al issues m ust be con sidered.
Restrict ion of m ovem en t m ay a ect skeletal m aturation an d
How w ill patien t eat postoperatively?
speech .
Regular diet, n asal feedin g tube, percutan eous en doscopic
Men tal retrusion
Con sider slidin g gen ioplast y (w h en skeletally m ature).
gastrostom y (PEG)/gastrostom y-tube feedin g.
Ch est an d breast con tract ures
Breast recon struction option s (see Cases 26 an d 27)
42.4 Com plicat ions
m ay be considered (upon skeletal m aturit y or if
sign ifican tly a ectin g developm en t of th e breast). Con t ract ure recurren ce.
Loss of graft secondar y to in adequate preven tion of sh earin g.

42.3.2 Surgical m anagem ent


Scar excision
42.5 Crit ical Errors
Respect aesth et ic subun its. Poor operative procedure (e.g., usin g split-th ickn ess graft
Low er lip an d ch in . w h en a full-th ickn ess graft is possible an d yields a better
Subm en tal. result).
An terior n eck un it . Absen ce of postoperat ive plan to preven t graft loss (e.g., n eck
Scorin g of th e plat ysm a or full excision m ay be n eeded for brace, possible feedin g t ube).
full con tracture release. Lack of early an esth esia involvem en t
Z-plast y of in dividual cont ract ure ban ds un likely to give Th e air w ay can be ver y di cult in th e presence of

su cien t fun ction al im provem en t . sign ifican t n eck contracture.


Graft coverage Failure to recogn ize th at m ultiple procedures w ill be required
Each aesth et ic subun it sh ould be grafted separately. to restore ran ge of m otion an d aesth etic appearan ce.

176
Part 9

Sect ion IX. Hand


Flexor Tendon Laceration

43 Flexor Tendon Lacerat ion


Justin B. Cohen & Thomas H. H. Tung

Fig. 43.1 A 20-year-old right handdominant m an presents to the em ergency departm ent with a laceration sustained while he was trying to open a
broken m ason jar. (Im age shows patient at tem pting to flex at the interphalangeal joint of the thum b.)

179
Flexor Tendon Laceration

43.1 Descript ion 43.2.3 Pert inent im aging or


Lacerat ion over th e volar first w eb space, exten din g on to th e diagnost ic st udies
th en ar em in en ce an d resultin g in injur y to th e flexor ten don X-ray of h an d w ith th ree view s (an teroposterior, lateral,
in zon es T2 an d T3. oblique): Evaluate for bony injur y an d foreign bodies.
Physical exam in at ion reveals in abilit y to actively flex th e
th um b at th e in terph alan geal (IP) join t . No oth er ran ge of
m otion (ROM), sen sor y, or st ren gth deficits n oted. 43.3 Treat m ent
Advan ced traum a life support (ATLS) protocol.
An tibiotics an d tetan us prophylaxis.
43.2 Work-up If un able to perform flexor ten don repair im m ediately, any
visible ten don s m ay be tagged w ith suture an d th e skin m ay
43.2.1 Hist ory be closed.
Mech an ism of injur y (e.g., sh arp, blun t , avulsion ). Th e patien t sh ould be splin ted w ith th e w rist an d MCP

Position of h an d an d a ected digit at tim e of injur y (flexed vs join ts in flexion to m in im ize retraction .
exten ded).
Tim e elapsed sin ce injur y. 43.3.1 Flexor t endon repair
Han d dom in an ce.
Occupation .
Tim in g
Ideally, flexor ten don s sh ould be repaired as soon as
Previous h an d injuries.
Any associated injuries an d m edical com orbidities. possible. Im m ediate exploration is w arran ted if n er ve or
arterial dam age is suspected.
In order to avoid staged ten don graftin g for zon e 2 inju-
43.2.2 Physical exam inat ion ries, flexor ten don s sh ould be repaired w ith in 72 h ours.
Longer delays in repair h ave been reported for injuries
Cascade of th e h an d outside of zon e 2 w ith variable outcom es.
In th e restin g posit ion , th e fin gers are flexed, w ith th e Delays > 6 w eeks require ten don substitut ion procedures
degree of flexion in creasin g from th e radial to th e uln ar (ten don grafts, ten don t ran sfers) or salvage procedures
side. (ten odesis, capsulodesis, arth rodesis).
Disruption of th e cascade due to abn orm al exten sion of a Flexor ten don repairs sh ould be perform ed in th e operatin g
digit sign ifies flexor ten don injur y. room w ith a tourn iquet.
Ten odesis e ect
Passive exten sion of th e w rist causes flexion at th e

m etacarpoph alan geal (MCP) an d IP join ts.


43.3.2 Technique
Abn orm al exten sion of a digit sign ifies flexor ten don Exposure obtain ed by in corporatin g existin g laceration
injur y. in to an appropriate in cision . For th e digits, Brun n er zigzag
Assess flexor digitorum superficialis (FDS) an d flexor in cision s or Bun n ell m idaxial in cision s are ut ilized.
digitorum profun dus (FDP) fun ct ion separately alon g w ith Cut en d of ten don is retrieved by flexing th e w rist an d
flexor pollicis lon gus (FPL). m ilkin g th e forearm w ith ten don passers or an 8 Fren ch
FDS: Flexion of fin ger at proxim al in terph alan geal (PIP) pediatric feedin g tube.
join t w h ile h oldin g all oth er digits in exten sion . Ten sion-free repair is perform ed by approxim ating th e cut
FDP: Flexion of fin ger at distal in terph alan geal (DIP) join t en ds and blocking the proxim al end from retracting by passing
w h ile h oldin g PIP join t in exten sion . a n eedle through skin and intact tendon proxim al to the injury.
FPL: Flexion of th e th um b at IP join t w h ile h oldin g proxim al Repair is perform ed w ith a core suture epiten din ous sut ure.
ph alan x an d MCP join t in exten sion . Core sut ure

Sen sor y an d vascular exam in ation . Mult iple tech n iques described (e.g., m odified Kessler,
Partial ten don laceration results in w eakn ess, lim ited Tajim a, Bun n ell, Stricklan d, cruciate; Fig. 43.2 an d
m ovem en t , triggerin g of pain w ith flexion . Fig. 43.3).

Fig. 43.2 The m odified Kessler t wo-strand core


suture repair.

180
Flexor Tendon Laceration

Fig. 43.3 The cruciate-t ype four-strand core


suture repair.

Stren gth of repair in creases w ith n um ber of stran ds an d Tw o-stage recon struction
size of sut ure. First stage involves resect ion of flexor ten don leavin g 1-cm

Four-st ran d repair w ith 30 or 40 perm an en t braided distal cu an d proxim ally 2-cm distal to th e lum brical
suture t ypically used (e.g., Eth ibon d [braided polyester]; origin . Silicon e ten don im plan ts (Hun ter rod) are th readed
Eth icon En do-Surger y, Blue Ash , OH). th rough th e pulleys an d secured to th e ten don edges.
Epiten din ous sut ure (option al) Secon d stage un dertaken 3 m on th s later; involves excision

Mult iple tech n iques described (e.g., sim ple, lockin g, of Hun ter rod an d replacem en t w ith ten don graft in to th e
crisscross lockin g, inverted m att ress; Fig. 43.4). n ew ly created sh eath . Usually, proxim al conn ection to
60 perm an en t m on ofilam en t suture t ypically used (e.g., n eigh borin g FDP is m ade w ith ten don w eave.
Prolen e [polypropylen e]; Eth icon ).
Follow in g repair, th e ten don is exam in ed to en sure free an d
sm ooth ran ge of m otion .
43.3.4 Post operat ive t herapy
Th e A2 an d A4 pulleys sh ould be recon structed if disrupted to Han d th erapists sh ould be involved.
avoid bow -st rin ging of ten don . Early con trolled m obilization is critical to preven t ten don
Partial ten don lacerat ion s: > 60% n eed operat ive repair. adh esion s an d im prove repair stren gth .
Han d is splin ted in a dorsal exten sion -blockin g splin t. Protocols in clude passive m otion program s (e.g., Klein ert,
Duran ) an d active m otion program s (e.g., Stricklan d).
Duran protocol
43.3.3 Flexor t endon reconst ruct ion Day 3: Operative dressing rem oved, dorsal protection
Flexor ten don graftin g used if delay in treatm en t or splin t placed, h ourly exercises w ith in th e splin t of passive
segm en tal ten don loss exten sion of PIP an d DIP join ts in depen den tly.
Typically used grafts are palm aris lon gus, plan taris, lon g Week 4: Dorsal blockin g splin t rem oved an d replaced
toe exten sor, exten sor in dicis proprius, or exten sor digiti w ith elast ic cu w ith flexion retraction ; active flexion
m in im i. an d passive exten sion begun .

Fig. 43.4 Various epitendinous suture techniques


for flexor tendon repair.

181
Flexor Tendon Laceration

Week 5: Wrist cu discon tin ued; blockin g an d Quadriga e ect: Flexion deform it y of repaired digit an d
fist in g exercises begun w ith active exten sion an d in com plete flexion of oth er digits due to sh orten ing of FDP
flexion . ten don .
Week 8: Progressive st ren gth en in g w ith putt y an d n o Lum brical plus fin ger: Paradoxical PIP join t exten sion w ith
h eavy liftin g. flexion of th e fin gers due to retract ion of FDP ten don or an
Week 12: Full use of h an d allow ed. excessively lon g ten don graft.

43.4 Com plicat ions 43.5 Crit ical Errors


Hem atom a. Missed injur y: Nerve, vascular, or oth er ten don injuries
Ten don rupture: May require im m ediate re-repair versus m issed on physical exam ination . Failure to isolate FDS an d
ten don graft in g or ten don tran sfer. FDP ten don s separately.
Adh esion s: Han d th erapy is crit ical to preven t th em . In adequate splin tin g to protect th e flexor ten don repair.
If n ecessar y, surgical release of adh esion s m ay be Failure to in st it ute appropriate early ROM protocol.
perform ed. Failure to repair critical pulleys (A2, A4) at th e tim e of ten don
Join t con tract ures. repair.

182
Soft-Tissue Defect of the Hand

44 Soft -Tissue Defect of t he Hand


David T. Tang

Fig. 44.1 A 32-year-old right handdom inant m an sustained a through-and-through gunshot wound to the ulnar aspect of the right hand.

183
Soft-Tissue Defect of the Hand

44.1 Descript ion W h en possible, replace crit ical tactile surfaces w ith like t issue
th at h as th e poten tial for rein n er vation .
Uln ar h an d soft-tissue defect secondar y to acute gun sh ot Select th e sim plest form of recon struction to m in im ize
traum a. patien t m orbidit y.
No vascular com prom ise distally.
Fract ures of th e fourth an d fifth m etacarpals.
Presum ed injur y to exten sor (an d possibly flexor) ten don s of 44.3.2 Treat m ent opt ions
rin g an d sm all fin gers. Skin graft (split th ickn ess or full th ickn ess)
Likely n eurovascular injur y to uln ar digits. W h en possible, use full-th ickn ess grafts to decrease

secon dary con tracture, im prove graft durabilit y, an d


im prove aesth etics.
44.2 Work-up Local flaps
Tran sposit ion flaps: Z-plast y, rh om boid flap.
44.2.1 Hist ory Advan cem en t flaps: V-Yadvan cem en t.
Age, gen der, h an dedn ess, an d occupation of th e patien t . Axial pattern flaps: First dorsal m etacarpal artery flap,
Tim in g an d m ech an ism of soft-t issue deficit n eurovascular islan d flap.
Traum a: Associated injuries, un derlyin g fract ures, Region al flaps
dislocation s, n eurovascular in sult . Cross-fin ger flaps: Stan dard, in n ervated, reverse
In fect ion : Nature of in fection (bacterial, fun gal, oth er); cross-fin ger, cross-th um b flaps.
operative m an agem en t to date (in cision an d drain age); Fillet flap: Use spare par ts from n onviable segm en ts of

an t im icrobial m edication s; local versus system ic sign s an d injured tissues.


sym ptom s. Radial forearm flap: Fasciocutan eous, fascia on ly,
Tum or ablation : Tum or path ology, m argin s, plan n ed or in n er vated.
radiation an d ch em oth erapy. Reverse radial forearm flap.
Previous injur y or surgery of th e h an d in quest ion . Reverse uln ar arter y flap.
Man ual dem an ds of daily living an d overall lifestyle. Reverse posterior in terosseous artery flap.
Past m edical an d surgical h istory. Distan t flaps (pedicled)
Social h istory, in cludin g sm okin g stat us an d substan ce abuse. Abdom in al/epigastric flaps.

Groin flap.

Distan t flaps (free)


44.2.2 Physical exam inat ion

Tem poroparietal fascia flap.


Location an d size of soft-tissue deficit. Scapular an d parascapular flaps.
Specific deficits (ten don , n er ve, m uscle, skin ). Latissim us dorsi m uscle flap.
Woun d stat us (in fect ion , vascularit y, exposed structures, Serratus an terior m uscle flap.

n onviable skin ). Lateral arm flap.


Vascular status of h an d (in tact palm ar arch ). Dorsalis pedis flap.
Motor fun ction (discern m usculoten din ous deficit from
n eurologic deficit).
Sen sor y fun ction . 44.4 Com plicat ions
Failure of recon struction
44.2.3 Pert inent im aging or Poor graft take, partial or total flap loss.

diagnost ic st udies Han d sti n ess


Join t con tract ures, ten don adh esion s, edem a.
Stan dard radiography (th ree view s of th e h an d). In fect ion .
Com puted tom ography if furth er detail required regarding Don or site m orbidit y.
bony struct ures (especially carpal bon es).
An giography if clin ical Allen test is un clear regarding paten cy
of palm ar arch .
44.5 Crit ical Errors
Perform in g n onviable procedures (e.g., skin graft on bon e or
44.3 Treat m ent exposed ten don ).
Failure to carefully con sider fun ction al dem an ds of th e
44.3.1 Crit ical principles patien t w h en selectin g a strategy for recon struct ion .
Woun d cont rol, w ith eradication of in fection an d establish - Negligen ce in in form in g patien t of addit ion al surgical stages
m en t of a stable, reliable w oun d bed, is a n ecessit y. th at m ay be required for defin itive recon struct ion (e.g.,
Con sider patien ts overall m edical con dition , gen eral m an ual con tracture release, ten olysis, flap th in n in g) an d t im e
dem an ds, an d patien t-directed priorit ies for recon struct ion . n ecessary before return to w ork.

184
Radial Nerve Injury

45 Radial Nerve Injury


John R. Barbour & Ida K. Fox

Fig. 45.1 A 28-year-old m an presents with the inabilit y to straighten his fingers and wrist. He has a history of a high-speed m otorcycle crash and a
m idshaft hum erus fracture.

185
Radial Nerve Injury

45.1 Descript ion Table 45.1 Classification of nerve injury


Seddon Sunderland Fibrillations Motor Im provem ent
Righ t upper extrem it y: Loss of w rist, fin ger, an d th um b unit without
exten sion (radial n erve palsy). potentials intervention
Injur y likely at th e m idh um eral level, given th e h istory of (MUPs)
previous t raum a at th at site. Neurapraxia I +
Axonotmesis II + + +
III + + + /
45.2 Work-up IV +
Neurotm esis V +
45.2.1 Hist ory
VI + Depends Depends on
Critical poin ts on injury injury
Open versus closed m ech an ism of n er ve injury w ill dictate

in itial treatm en t .
In a closed injur y pat tern , w atch ful w aitin g is m ost
appropriate. In gen eral, all patien ts w ith n er ve dysfun ction w ill ben efit
An open injur y poin ts to n erve tran section , an d direct from physical th erapy to assist w ith m ain tain in g passive
exploration is usually in dicated. ran ge of m otion as w ell as m an age any edem a, pain , or oth er
Tim e sin ce injury w ill furth er determ in e available problem s associated w ith th e in citin g injury.
treatm en t option s (at 1 to 2 years after injury, m u scle A w rist cock-up splin t is particularly useful for placin g th e
can n ot be rein n er vated). h an d in a position of fun ction so th at som e use can be m ade
Associated pain an d/or st i n ess. w h ile th e patien t aw aits surgery an d recover y.
Medical com orbidities. Any associated pain syn drom es m ust be aggressively
m an aged; th is m ay require m edication s, such as gabapen t in
(Neuron tin ; Pfizer, New York, NY).
45.2.2 Physical exam inat ion
Evaluate for any scars suggest ive of open injur y or previous
surgery.
45.3.1 Acut e open injuries associat ed
Evaluate for st i n ess, edem a, hypersen sit ivit y, an d oth er sign s w it h nerve dysfunct ion
of com plex region al pain syn drom e CRPS.
Require n er ve exploration because on e m ust assum e th at
Evaluate radial n erve m otor fun ction proxim ally to distally
th ere m ay be a n erve tran section .
(i.e., ch eck abilit y to exten d elbow, w rist , fin gers at th e
Open h um eral fract ures h ave radial n er ve laceration in 60%
m etacarpoph alan geal join t , an d th um b to determ in e level of
of cases.
injur y).
Prim ar y ( 24 h ours), delayed prim ar y ( 1 w eek), or
Evaluate th e oth er upper extrem it y n er ves an d m uscles th at
secon dary (> 1 w eek) repair is reason able, depen din g
you m igh t use as don or m aterial for subsequen t n er ve or
on th e m ech an ism of injur y.
ten don tran sfers.
If th ere is a sign ifican t crush com pon en t, delayed repair w ill
Com plete sen sor y exam in ation , in cluding t w o-poin t
allow th e injured n er ve to dem arcate so th at so th at th e
discrim in ation .
appropriate len gth of dam aged n er ve m ay be trim m ed
Evaluate for Tin el sign : Th is m ay h elp in iden tifyin g th e site
aw ay.
an d level of injur y.
Repair directly or repair w ith in terposed n er ve graft is
reason able.
45.2.3 Pert inent im aging or In th e case of a relatively subacute presen tation an d/or
proxim al n er ve injur y, n er ve tran sfer procedures are also
diagnost ic st udies a reason able option .
X-rays of th e fracture h elpful in confirm in g level of injur y. Distal ten don tran sfers are reason able, as w ell.
For a closed injury pat tern , elect rod iagn ost ic t est s, in clu d in g
elect rom yograp h y (EMG) at 3 m on t h s, m ay be h elp fu l in
ascertain in g n er ve recover y. 45.3.2 Acut e closed injuries associat ed
Fibr illa t ions: In dicate som e m otor injur y.
w it h nerve dysfunct ion
Motor u n it p oten t ials (MUPs): In dicate recover y.
Follow in g closed h um eral fract ure, fun ction w ill return by 3
to 4 m on th s in > 75% of cases. Th erefore, im m ediate
45.3 Treat m ent
exploration is contrain dicated.
Mon itor clin ical exam in ation .
Based on t ype of n er ve injur y If n o fun ction al im provem en t 12 w eeks after injury,
Classification of n er ve injury ( Table 45.1). perform EMG.
Tim in g of presentation : Several di eren t m an agem en t Fibrillation s an d MUPs present: In dicates n erve is

st rategies are reason able. recoverin g, an d con tin u ed w atch ful w ait in g is appropriate.

186
Radial Nerve Injury

Fibrillation s present , no MUPs: Requires operative 45.3.5 Prognosis


in terven t ion to regain fun ction . Option s in clude direct
repair an d repair w ith graft or n erve tran sfer procedures, Closed n er ve injuries th at do n ot require surgical in terven tion
as n oted above. Distal ten don t ran sfers are reason able, m ay recover quite quickly, depen din g on th e degree of n er ve
as w ell. injury. With a sim ple neura pra xia , return to n orm al fun ct ion
If recover y slow s, even w ith MUPs n oted on EMG, is rapid an d com plete in 90% of cases (often w ith in 2 to
con sider release at kn ow n com pression poin t (i.e., arcade 8 w eeks).
of Froh se). W ith a xonotmesis, recover y w ill likely be com plete but w ill
take lon ger (e.g., m on th s).
Recover y after operative repair varies depen din g on th e
45.3.3 Principles of nerve repair repair don e.
Nerve repair, graft, or tran sfer w ill take tim e.
En sure n eural repair is outside the zone of injur y (bread loaf
Nerve regeneration occurs at a rate of an in ch per m on th .
back to h ealthy n er ve).
Especially w ith n er ve tran sfers, exten sive physical th erapy
En sure t en sion -free rep air, n ot depen den t on posture.
If repair un der ten sion , th en perform in terposition al n erve is required to retrain .
If ten don tran sfers are perform ed, a period of
graftin g.
Protect bran ch es to th e brach ioradialis, exten sor carpi radialis im m obilization to protect th e repair an d th en later th erapy
lon gus, an d exten sor carpi radialis brevis ~ 5 to 6 cm proxim al an d m otor retrain in g are n ecessar y.
to elbow.
En sure absen ce of com pression or acute turn s in n er ve
45.4 Com plicat ions

(due to scar, fract ure, callus, oth er).


In fect ion .
Woun d deh iscen ce.
45.3.4 Principles of t endon t ransfers

Un favorable scarrin g.
for radial nerve palsy In com plete fun ction al recover y.
Low radial n er ve palsy
Com plex region al pain syn drom e (CRPS, form erly reflex
With low radial n er ve injuries, w rist exten sion is
sym path etic dystrophy).
m ain tain ed.
Th um b exten sion : Palm ar is lon gu s (PL) (or flexor

digitorum superficialis [FDS] of rin g fin ger) ext en sor


45.5 Crit ical Errors
p ollicis lon gu s (EPL) t ran sfer. Failure to explore an open injur y w ith con com itan t n er ve
Fin ger exten sion : Flexor car p i rad ialis (FCR) exten sor palsy is gen erally con sidered in appropriate. (Sub bullet)
d igit oru m com m u n is (EDC) t ran sfer. Close injuries are m ore often a n eurapraxia th at w ill recover
High radial n er ve palsy w ith out surgical in terven tion .
Loss of w rist exten sion , fin ger exten sion , an d th um b Im m ediate exploration in th e scen ario of a closed n er ve palsy.
exten sion . Failure to recogn ize th at tim in g of injur y is crit ical
Wrist exten sion : Pron ator t eres exten sor car p i rad ialis After m ore th an 1 to 2 years follow in g injury, th e m uscle

brevis t ran sfer. can n ot be rein n er vated, an d a n er ve repair, graft, or t ran sfer
Th um b exten sion : PL (or FDS of rin g fin ger) EPL w ill fail.
t ran sfer. In cases of late presen tation , ten don t ran sfer salvage
Fin ger exten sion : FCR EDC t ran sfer. procedures are th e on ly option for restorin g fun ction .

187
Dupuytren Contracture

46 Dupuyt ren Cont ract ure


John R. Barbour, Albert S. Woo, & Ida K. Fox

Fig. 46.1 A 59-year-old Caucasian m an presents


with progressive loss of motion of the left ring
and small fingers. He is unable to straighten the
joints actively or passively.

189
Dupuytren Contracture

46.1 Descript ion Treat m en t of join t con tractures


MCP join t: Collateral ligam en ts are stretch ed in flexion .

Flexion con tract ure of th e rin g an d sm all fin ger m etacarpo- Th erefore, th ese join ts return to th eir n orm al posit ion after
ph alan geal (MCP) an d proxim al in terph alan geal (PIP) join ts release of th e Dupuytren cord.
w ith palm ar an d digital cords is con sisten t w ith Dupuyt ren IP join t:Join t con tracture at th is level m ay require addit ion al

con tracture. procedures to release join level scarrin g from lon g-stan din g
disease.
PIP join t: Fixed join t con tractures m ay occur in patien ts

46.2 Work-up w ith severe, lon g-stan ding disease. Capsuloligam en tous
release m ay be required, alth ough its e cacy h as n ot been
46.2.1 Hist ory proved.
Sym ptom s an d degree of im pairm en t of act ivit ies.
Age at presen tat ion an d duration of disease. Dupuytren 46.3.1 Surgical opt ions
diath esis den otes pat ien ts w ith a young age at on set , stron g Needle fasciotom y
fam ily h istory, an d h igh in ciden ce of ectopic disease. Th e cord is percutan eously section ed w ith a 25-gauge
Fam ily h istory of Dupuyt ren disease.
n eedle.
Eth n icit y: More prevalen t in n orth ern European s an d Closed m an ipulation can furth er break up th e cord.
Japan ese. En zym atic fasciotom y
Plan tar or pen ile fibrosis. Relat ively n ew tech n ique.
Risk factors: Alcoh ol, epilepsy m edication s, diabetes m ellitus, Collegen ase Clost ridium histolyticum (Xiaflex; Au xilium
sm okin g.
Ph arm aceuticals, Horsh am , PA) is injected at th e poin t of
Previous surgical t reatm en t for th e con dition .
m axim um bow strin ging of th e palpable cord.
Traum a to th e palm can result in t raum atic palm ar fasciitis. After 24 h ours, th e patien t ret urn s for closed digit

m an ipulation to rupture th e cord.


46.2.2 Physical exam inat ion Segm en tal apon eurectom y
Segm en ts of th e diseased cord are rem oved th rough
Observe presen ce an d location of pits, n odules, an d cords. m ult iple sm all in cision s.
Palpate for asym ptom at ic n odules an d cords. Local fasciectom y
Ta bletop test: Patien t is un able to lay th e palm flat on a rigid A portion of th e diseased cord is rem oved.
surface. Region al fasciectom y
Note th e digits an d join ts involved an d m easure th e degree of Diseased cords an d fascia are excised.
con tracture. Skin in cision s ( Fig. 46.2): Num erous option s exist.
Observe for any adduction con tract ure of th um b. If closure is n ot possible after th e digit h as been straigh t-
Measure join t ran ge of m otion an d n ote any fixed join t en ed, th e w oun d can be left to h eal secon darily, a full-
con tractures. Sim ultan eous MCP join t flexion w ith th ickn ess skin graft can be placed, or locoregion al flaps
in terph alan geal join t exten sion poin ts to th e absen ce can be used (e.g., rotation al flaps, cross-fin ger flaps.)
of fixed join t cont ract ures. Derm ofasciectom y
Assess in tegrit y of exten sor m ech an ism . Diseased cords an d fascia are excised alon g w ith th e
Flex w rist an d MCP join t to create tenodesis e ect.
overlyin g skin .
An exten sor lag in dicates th at th e central slip is atten uated, Th e w oun d is closed w ith a full-th ickn ess skin graft.
an d postoperat ive exten sion splin tin g m ay be required. Perform ed in recurren t disease, for replacin g flaps w ith
Th e patien t sh ould be caut ion ed th at full exten sion of th e un certain viabilit y, an d in patien ts w ith Dupuytren
a ected fin ger w ill likely n ot be regain ed. diath esis.
Sen sor y exam in at ion of all digits.
Sites of ectopic disease.
Ga r rod nodes (n odules on dorsum of PIP join t) an d knuckle 46.4 Com plicat ions
pa ds (fibrosing lesion s on dorsum of PIP join t).
Woun d-h ealin g problem s.
Ledderh ose disease (plan tar fibrom atosis).
Hem atom a.
Peyron ie disease (pen ile fibrom atosis).
Vascular an d n erve injur y
Laceration can occur at tim e of release.

46.3 Treat m ent Straigh ten ing a severely con tracted join t m ay cause t ract ion

injury.
Observation of disease th at does n ot a ect fun ction an d/or Flare react ion : Sti n ess, pain , an d edem a.
qualit y of life. Com plex region al pain syn drom e (form erly Reflex
Relat ive in dication s for in terven tion sym path etic distrophy): Sti n ess, pain , edem a, an d
MCP join t flexion con tracture of 30 degrees. vasom otor ch anges
Any flexion con tracture of th e PIP join t. Man agem en t in cludes pain con trol an d/or stellate
Adduct ion cont ract ure of th e th um b th at in terferes w ith sym path etic ganglion block,
activities of daily living or leisure activities. Ten don rupture, especially w ith en zym atic fasciotom y,

190
Dupuytren Contracture

46.5 Crit ical Errors


In atten tion to critical structures durin g in terven tion
Neurovascular structures m ay be displaced superficially an d

tow ard th e m idlin e of th e digit by th e spiral cord an d sh ould


n ot be assum ed to be in th eir n orm al position .
If t ran sected, th e digital n eurovascular struct ures sh ould be

repaired.
Failure to in form th e patien t about th e risks of in ter ven t ion ,
in cluding th e ch an ce of recurren ce (2 to 60%), n eed for
vigorous th erapy postoperatively, possible n eed for prolon ged
w oun d care an d dressin g ch anges, an d risk for n eurovascular
an d/or ten don injuries.
Absen ce of a reason able plan for coverage, if skin can n ot be
closed at tim e of release.

Fig. 46.2 Comm on incisions used for exposure. (Adapted from Shaw
RB, Chong AKS, Zhang A, et al. Dupuytrens disease: history, diagnosis
and treatm ent. Plast Reconstr Surg 2007;120(3):44e54e.)

191
Syndact yly

47 Syndact yly
Michael C. Nicoson & Thomas H. H. Tung

Fig. 47.1 A 2-year-old boy presents to the clinic with fusion of the long and ring fingers.

193
Syndact yly

47.1 Descript ion Com plete/in com plete


Complete syn dact yly: Fusion involves en t ire len gth of th e
Com plete, likely sim ple, syn dact yly involving righ t lon g an d fin ger to distal tip, in cluding n ail fold.
rin g fin gers. Incomplete syn dactyly: Fusion does n ot involve n ail fold,
but w eb depth is distal to n orm al position .
Com p licat ed : In cludes polydact yly.
47.2 Work-up
47.2.1 Hist ory 47.2.3 Pert inent im aging or
Patien ts curren t h an d fun ction diagnost ic st udies
Sym m etric/asym m etric use of h an ds. Han d rad iograp h y: Im age both h an ds to assess for un derlyin g
Grasping st yle.
skeletal deform it y, com plex polydact yly, or h idden digit
Kn ow n m edical com orbidities. (synpolyda ct yly).
Fam ily h istory of syn dact yly or oth er associated con dition An giography m ay be useful in com plex cases or for
(autosom al dom in an t or sporadic). stream lin in g surgical plan n in g.
Di cult ies durin g pregn an cy.

47.2.4 Consult at ions: Based on


47.2.2 Physical exam inat ion
individual pat ient present at ion
Perform full body exam in ation .
Oth er congen ital an om alies m ay h ave n ot yet been
Occupation al th erapy, physical th erapy.
Poten tially: Gen etics, cardiology, h em atology
diagn osed. Con sider syn drom ic etiology if appropriate.
Evaluate feet to rule out addit ion al digits w ith


syn dact yly.
Perform com plete h an d evaluation .
47.3 Treat m ent
Assess for exten t an d location of w ebbin g, as w ell as for th e Surger y is in dicated to optim ize h an d fun ct ion .
n um ber of digits involved. Allow s n orm al digital grow th an d developm en t of pin ch /

Assess for polydact yly. grasp m ech an ism .


Evaluate for digital deviation in th e radial or uln ar plan e Tim in g of surgery
(clinoda ct yly). Typically, 12 t o 18 m on t h s of age is stan dard.

Exam in e con tralateral h an d for com parison . Min im ize an esth esia risks, in crease h an d size, decrease
Th orough ly evaluate en t ire upper extrem it y. in ciden ce of scar con tracture.
Classification Bord er d igit syn dact yly sh ould be released earlier (~ 6

Sim ple/com plex m on t h s of age) to preven t rotatory an d an gular deform it ies.


Simple synda ct yly: Fin ger fusion on ly by a skin br idge. Goals of surgery
Complex synda ct yly: Fin ger fusion involving bone Create a m ore n orm al w eb space to im prove fun ction an d

connect ion. aesth etic appearan ce of th e a ected digit .

Fig. 47.2 Representative surgical markings for


syndact yly release.

194
Syndact yly

For m ult iple w eb syn dact yly, t radition ally release on ly Scar con tracture: Treat by early excision an d regraftin g,
on e side of an a ected digit at a tim e to preven t vascular splin tin g, ran ge of m otion .
com prom ise of digits. Nail deform it y.
Surgical m arkin gs: Man y di eren t tech n iques exist. Join t in stabilit y an d an gulatory deform it y in cases of com plex
On e represen tative tech n ique is discussed. syn dact yly.
Use proxim ally based d orsal sk in flap to lin e n ew w eb Hypertroph ic scarrin g, keloid form ation .
space. Avoid sca rs in web spa ce ( Fig. 47.2).
Design in terdigitatin g, opposin g, zigzag pattern flaps for

digital separation . 47.5 Crit ical Errors


Use tem plates to design full-th ickn ess skin grafts (e.g.,
Failure to evaluate for an d w ork up addition al an om alies.
groin , an tecubital fossa, hypoth en ar em in en ce) to resurface Failure to revise skin graft loss, resultin g in severe scar
th e areas n ot covered by skin flaps.
con tracture.
Perform in g syn dact yly release at an in appropriate age
47.4 Com plicat ions
(< 4 m on th s).
Operatin g on both sides of an a ected digit at th e sam e tim e
Skin graft loss: Sign ifican t areas of loss sh ould be excised an d On ly on e side at a tim e sh ould be operatively approach ed to

regrafted. avoid vascular com prom ise an d flap failure.


Digital n ecrosis: Most severe com plication W h en both sides are n ecessar y, th ese procedures sh ould be

Avoid tigh t or overly com pressive dressin gs. staged.


Must pay careful atten tion to preservation of th e digital Usin g split-th ickn ess skin grafts rather th an full-th ickn ess
ar tery an d n er ve. skin grafts for skin coverage
Web space abn orm alit ies (w eb creep). Results in in creased rates of cont racture.

195
Metacarpal and Phalangeal Fractures

48 Met acarpal and Phalangeal Fract ures


Aaron Mull & Amy M. Moore

Fig. 48.1 A 28-year-old left hand-dom inant man


presents with hand pain after striking som eone
with his left hand. The X-ray is shown above.
On exam ination, overlapping of the patients ring
and small fingers is noted while he m akes a fist.

197
Metacarpal and Phalangeal Fract ures

48.1 Descript ion


Un stable reduction or irreducible deform it y.
Rotation al deform it y w ith scissorin g on exam in ation .
Oblique extra-art icular fract ure of rin g fin ger m etacarpal Sign ifican t an gulation
sh aft w ith an gulation , rotation , an d sh orten ing, An gulation at th e m etacarpal n eck > 15 degrees in th e
in dex an d lon g fin gers, > 30 to 40 degrees in th e rin g
fin ger, or > 40 to 50 degrees in th e sm all fin ger requires
48.2 Work-up in terven tion .
Th e carpom etacarpal join ts of th e sm all an d rin g fin gers
48.2.1 Hist ory h ave m ore m obilit y th an th ose of th e lon g an d in dex
Mech an ism of injur y (e.g., sh arp, blun t , avulsion ). fin gers an d th erefore tolerate m ore degrees of an gulation .
Tim e elapsed sin ce injur y. In tra-articular displacem en t > 1 to 2 m m an d/or > 30% of
Possible con tam in ation durin g injur y (e.g., oral ar ticular surface involvem en t .
con tam in ation , farm injur y). Open fracture.
Han d dom in an ce. Bony sh orten ing (> 3 m m ).
Occupation .
Sm okin g status. 48.3.1 Operat ive t echniques
In quire about prior h an d injuries or operation s.
Closed reduction /percutan eous pin n in g
Preferred operative m eth od of t reatm en t for ph alan geal
48.2.2 Physical exam inat ion fract ures.
Crossed Kirsch n er (K)-w ires across fract ure site or
Assess for skin laceration s/injur y, degree of con tam in ation ,
an d viabilit y of soft tissues. in tram edullar y K-w ires for m etacarpal fractures.
Exam in e for possibilit y of open fract ures an d join t Open reduction /in tern al fixation
Open reduction for displaced or n on reducible fract ures.
involvem en t .
Dorsal approach for ph alan geal condylar or in tra-articular
Assess for an gulation an d rotation of digit w h ile th e patien t
m akes a fist (i.e., scissorin g). fract ures.
Dorsal lon gitudin al in cision over m etacarpal; protect
Assess for n eurovascular in tegrit y of th e a ected digits.
exten sor ten don .
Th in dorsal plate an d screw s.
48.2.3 Pert inent im aging or Lag screw fixation if oblique or spiral sh aft fracture.

diagnost ic st udies Postoperative treatm en t


Im m obilize fract ure for 4 w eeks.
X-ray of h an d w ith th ree view s (an teroposterior, lateral, K-w ires usually rem oved at 4 w eeks.
oblique): Evaluate for bony injur y an d foreign bodies. Passive an d active ran ge of m otion in itiated on ce K-w ires
Dedicated fin ger view s for ph alan geal fracture. rem oved an d patien t is n on ten der over fracture (eviden ce
of h ealin g on exam in ation ).

48.3 Treat m ent


Closed reduct ion for m etacarpal an d ph alan geal fractures 48.4 Com plicat ions
sh ould be attem pted.
Malun ion .
Closed reduct ion of m etacarpal n eck fractures can be
Non un ion .
perform ed w ith th e Jah ss m an eu ver.
Ten don adh esion s from approach an d/or ten don attrit ion
Metacarpoph alan geal (MCP) join ts flexed to 90 degrees
from prom in en t plate.
an d a volar force again st th e distal fragm en t w ith a
K-w ire m alposition in g, m igration , in fection .
com pen sator y dorsal force again st th e proxim al
m etacarpal fragm en t.
With adequate reduct ion , im m obilize join t above an d below
fract ure.
48.5 Crit ical Errors
In t rin sic plus splin tin g w ith w rist exten ded to 30 degrees, Not recogn izin g open injuries: Specifically, w oun ds over th e
MCP join ts flexed to 80 to 90 degrees, in terph alan geal join ts dorsum of th e m etacarpal h eads (i.e., figh t bit e) or oth er
in exten sion . soft-t issue injuries.
Keeps th e collateral ligam en ts on stretch an d decreases Failure to follow fractures treated w ith closed reduction an d
join t sti n ess. splin tin g closely, resultin g in loss of reduction an d m alun ion .
Weekly X-rays to assess reduct ion up to 3 w eeks. Not correct in g an gulation an d/or rotation w ith operative
Operative in dication s reduct ion .

198
Carpal Tunnel Syndrom e

49 Carpal Tunnel Syndrom e


Minh-bao Le, David T. Tang & Susan E. Mackinnon

Fig. 49.1 A 73-year-old right handdom inant woman with a 6-m onth history of increasing num bness over the thumb and index finger of the
right hand.

199
Carpal Tunnel Syndrom e

49.1 Descript ion carpal t un n el release, an d m any surgeon s routin ely obtain
EDS to determ in e patien ts baselin e degree of severit y.
Fin din gs con sisten t w ith m edian n er ve dist ribution of th e In contrast, oth er auth ors state EDS sh ould be used on ly
righ t h an d as a baselin e for m on itorin g un expected outcom es an d
Possible carpal t un n el syn drom e. excludin g oth er associated n eurologic condit ion s.
Moderate th en ar atrophy visible on th e righ t h an d in Ultrasou n d: Can iden tify in creased cross-section al area of
com parison w ith th e opposite side. th e m edian n er ve, but validated n orm al ran ges n eed to be
establish ed.
Magn etic reson an ce im agin g: Con troversial to use in pat ien ts
49.2 Work-up w ith carpal tun n el syn drom e. Allow s th e un derlyin g an atom y
to be establish ed to preven t poten t ial dam age to th e m edian
49.2.1 Hist ory n er ve durin g carpal tun n el release in patien ts w ith abn orm al
Length of t im e th at sym ptom atology h as been present an d an atom y. Also rules out oth er path ology, such as a gan glion ,
h as been a ectin g th e patien t th rough out th e day. h em an giom a, or bony deform it y.
Measures previously taken to preven t sym ptom s (e.g., X-ray: Can detect un suspected w rist path ology.
splin tin g, position in g, avoidan ce of activities).
Pertin en t sym ptom s consisten t w ith n er ve com pression
Noct urn al pain , n um bn ess, t in gling in th e th um b an d on e 49.3 Treat m ent
or m ore rad ial fin gers.
Non surgical: Local steroid injection , splin tin g, oral steroids.
Dayt im e paresth esias elicited w ith activit ies involving
Surgical: Recom m en ded treatm en t after n on surgical t reat-
prolon ged w rist flexion an d/or exten sion .
m en ts h ave been tried an d failed or in patien ts w h o opt out of
Need for sh akin g an d w rin ging th e h an ds to alleviate
n on surgical treatm en t
sym ptom s.
Open carpal t un n el release versus en doscopic carpal t un n el
Gritt y sen sation or n um bn ess in fin gers, grip an d pin ch
release
w eakn ess, dim in ish ed fin ger dexterit y w ith a h istor y of
No defin itive data th at on e m eth od is superior to th e
droppin g objects.
oth er.
Cold in toleran ce, dr yn ess, an d un usual textures in th e
Reportedly, en doscopic carpal tun n el release results in
radial digits.
less postoperative pain an d decreased tim e to return to
fun ction al activities, both procedures h ave equivalen t
49.2.2 Physical exam inat ion results at 1 year postoperatively.

Tin el sign : Percussion elicits t in gling over distribution of th e


a ected n er ve.
Ph alen m an eu ver : Main tain in g w rists in full flexion for
49.4 Com plicat ions
60 secon ds results in t in gling over th e m edian n erve St ructural injuries
distribution . Injur y to th e m edian n er ve.

Lack of t w o-poin t discrim in ation , w eakn ess an d/or atrophy of Injur y to th e m otor bran ch an d palm ar cutan eous bran ch es

th e th en ar m usculature. of th e m edian n er ve.


Exam in ation of soft tissues for skin an d m uscle atrophy, Laceration of th e superficial palm ar arterial arch .

m an ual m uscle stren gth testin g, grip an d pin ch testin g, Hypertroph ic scar form ation , scar ten dern ess.
percussion of all m ajor periph eral n er ves, assessm en t of deep Pillar pain (deep -seated pain or ach e over th e th en ar an d/or
ten don reflexes, an d assessm en t of blood flow to each h an d. hypoth en ar region ).
Sem m es-Wein stein m on ofilam en t or vibrom etr y. In com plete release of th e tran sverse carpal ligam en t .
Cer vical spin e an d en t ire upper extrem it y exam in ation , Ten don or n er ve adh esion s.
active m otion of th e cervical spin e an d all m ajor join ts in In fect ion .
both upper extrem ities to rule out cervical rad iculopathy or Woun d h em atom a.
th oracic outlet syn drom e. Fin ger sti n ess.
Tran sien t n eurapraxias.

49.2.3 Pert inent im aging or


diagnost ic st udies 49.5 Crit ical Errors
Electrodiagn ostic st udies (EDS): Ner ve con duct ion stu dies, Failure to recogn ize path ology th at m im ics CTS, such as
electrom yography m edian n erve com pression in th e forearm , th oracic outlet
Area of cont roversy: Am erican Academ y of Orth opaedic syn drom e, or cervical radiculopathy.
Surgeon s recom m en ds EDS for all patien ts con siderin g In com plete release of th e tran sverse carpal ligam en t .

200
Tendon Transfers

50 Tendon Transfers
John R. Barbour & Ida K. Fox

Fig. 50.1 A 47-year-old man sustained a deep penetrating stab wound to the right arm 1 year ago. The hand is at rest, and the patient is unable to
actively flex thum b interphalangeal and index or long finger distal interphalangeal joints.

201
Tendon Transfers

50.1 Descript ion 50.3.1 Preparat ion


Fin din gs con sisten t w ith in com plete m edian n er ve palsy Tim in g after an injur y depen ds on th e likelih ood of
In tact flexion at proxim al in terph alan geal join ts . rein n er vation an d n er ve recover y.
Loss of distal in terph alan geal join t flexion of in dex an d lon g Determ in in g if adequate recover y is likely is m an dator y
fin ger an d in terph alan geal join t of th um b. before ten don tran sfer is con sidered as a recon structive
Loss of th um b palm ar abduct ion . option . Elect rom yography perform ed im m ediately an d th en
Flexion present in righ t rin g an d sm all fin gers. again at 6 to 12 w eeks h elps to determ in e w h ich fun ct ion s
m ay be expected to recover.
An exception m ay be m ade for ra dia l ner ve pa lsies, even if
50.2 Work-up recover y is still possible.
Ten don tran sfer can act as a substit ute durin g regrow th of

50.2.1 Hist ory th e n er ve.


Ten don tran sfers can add pow er to n orm al rein n er vated
Age, gen der, h an dedn ess, an d occupation of th e patien t .
m uscle fun ction .
Tim in g an d m ech an ism of injury
Traum a: Associated injuries, un derlyin g fract ures,

dislocation s, n eurovascular in sult . 50.3.2 Principles


In fect ion : Nature of in fection (bacterial, fun gal, oth er),
Con sider restorin g at least protective sen sation before or at
operative m an agem en t to date (in cision an d drain age),
th e tim e of ten don tran sfer.
an t im icrobial m edication s, local versus system ic sign s an d
To restore fun ction al m otion to a h an d or forearm , a suitable
sym ptom s.
don or m ust be available. A rein n er vated m uscle is con sidered
Tum or ablation : Tum or path ology, m argin s, plan n ed
a poor ch oice for a don or.
radiation an d ch em oth erapy.
Select don or m uscles th at provide a syn ergist ic action to th e
Previous injur y or surgery to th e h an d in question .
fun ction to be restored.
Man ual dem an ds of daily living an d overall lifestyle.
Wrist exten sors an d fin ger flexors are an exam ple of a
Past m edical an d surgical h istory.
syn ergist ic group.
Social h istory in cludin g sm okin g status an d substan ce abuse.
Wrist flexors an d th um b/fin ger exten sors.

Exten sor in dicis proprius an d exten sor pollicis lon gus.

50.2.2 Physical exam inat ion The strength , excursion , and redun dancy of the brachioradialis
m ake it a frequent ch oice as a donor for m ultiple fun ctions.
Location an d t ype of origin al injury. The pronator teres is a good replacem ent for w rist exten sion.
Fun ct ion al deficit . Work capacit y correspon ds to th e cross-section al area of th e
Motor fun ct ion (discern n eurologic fun ction based on
m uscle, w h ereas excursion is related to m uscle fiber len gth .
m otor exam in ation fin din gs). Alth ough n ot optim al, in cases in w h ich an appropriate don or
Sen sor y fun ction .
can n ot reach th e desired recipien t , an in terposed ten don graft
Vascular status of h an d (in tact palm ar arch ).
is acceptable.
Don ors sh ould be used to provide on e fun ction an d sh ould
50.2.3 Pert inent im aging or cross on e join t.
If crossing m ore th an on e join t is n eeded, stabilization of
diagnost ic st udies on e join t is advised to m axim ize fun ction .
Stan dard radiography (th ree view s of th e h an d).
Com puted tom ography if furth er detail required regarding
bony struct ures (especially carpal bon es).
50.3.3 SEACOAST m nem onic
Th e m n em on ic SEACOAST is a valuable tool for th e prin ciples
of ten don tran sfers.
50.2.4 Consult at ions Syn ergist ic tran sfers.

Physical/occupat ion al th erapy Expen dable don or m uscle.

If join ts are n ot su cien tly supple, th ey m ust be loosen ed, Adequate st ren gth .

preferably by h an d th erapy. Con tractures n eed releasing.

If h an d th erapy fails, surgical release of th e join ts m ay be On e ten don , on e fun ction .

required before ten don tran sfer. Adequate am plitude (len gth ).

Straigh t lin e of pull.

Tissue equilibrium .
50.3 Treat m ent
Ten don tran sfers allow im proved fun ction alit y of an 50.3.4 Funct ions and t he t endons
oth erw ise dysfun ction al extrem it y, usually as th e result
of m ajor n erve palsy.
com m only used for reconst ruct ion
Restorin g m otion s like pin ch an d grip can sign ifican tly Th u m b op p osit ion : Exten sor in dicis proprius, flexor
im prove th e fun ct ion of an extrem it y. digitorum superficialis, abductor digiti m in im i.

202
Tendon Transfers

Th u m b flexion : Pron ator teres, brach ioradialis, flexor Abd u ct or d igit i m in im i: Oppon en s pollicis.
digitorum superficialis. Bicep s: Reroute/rein sert, triceps.
Th u m b exten sion : Brach ioradialis, exten sor in dicis proprius, Tr icep s: Biceps.
palm aris lon gus. Post erior d elt oid : Triceps.
Fin ger flexion : Brach ioradialis, exten sor carpi radialis lon gus, Pect oralis m ajor: Biceps.
adjacen t profun dus. Lat issim u s d orsi: Biceps.
Fin ger exten sion : Brach ioradialis, flexor carpi uln aris,
flexor carpi radialis, adjacen t fin ger exten sor, exten sor
in dicis proprius.
Wrist exten sion : Brach ioradialis, pron ator teres. 50.4 Com plicat ions
Wrist flexion : Rarely recon structed. Th e greatest risk is a gradual loosen in g of th e tran sfers w ith
Elbow exten sion : Posterior deltoid, biceps. loss of m axim al excursion .
Elbow flexion : Pectoralis m ajor, t riceps, latissim us, forearm Woun d problem s: Delayed h ealin g, w oun d breakdow n ,
flexor m ass (Stein dler). adh esion s, in fect ion (all 1 to 2%).
All extrem it y surgery h as th e poten tial for in cit in g com plex
50.3.5 Donor m uscles and region al pain syn drom e, alth ough th is is rare follow in g
ten don tran sfers un less th e patien t h as a previous h istory.
com m on recipient s
Brach ior ad ialis: Exten sor carpi radialis brevis, flexor
digitorum profun dus, flexor pollicis lon gus, exten sor
digitorum com m un is, exten sor pollicis lon gus.
50.5 Crit ical Errors
Ext en sor carp i rad ialis lon gu s: Flexor digitorum profun dus. Relative con train dication s
Pron ator t eres: Exten sor carpi radialis brevis, exten sor Use of m uscleten don un its w ith less th an grade M5

pollicis lon gus. stren gth .


Flexor car p i u ln ar is: Exten sor digitorum com m un is. Use of m uscles th at h ave been previously dam aged an d are

Flexor car p i rad ialis: Exten sor digitorum com m un is, exten sor un dergoing rein n er vation .
pollicis lon gus. Tran sfers plan n ed in in dividuals w ith progressive n euro-
Ext en sor in d icis p rop r iu s: Exten sor pollicis lon gus, oppon en s m uscular diseases sh ould be carefully considered before
pollicis. proceeding because th e un derlyin g disease process m ay
Palm aris lon gu s: Exten sor pollicis lon gus. a ect th e tran sferred un it .
Flexor d igitor u m su p er ficialis: Oppon en s/abductor pollicis, Satisfactor y results are di cult to ach ieve in tran sfers
flexor digitorum profun dus, A1 pulley ten odesis. perform ed to produce m otion in less-th an -supple join ts.

203
Index
A in m iddle leg, recon struction of 97 m an agem en t of Ch lorh exidin e rin se, in dication s for 8
Bon e graft acute 166 Ch opart am putat ion 105
A-fram e deform it y 71 for low er leg 100 secon dar y 168 Claw h an d deform it y, after burn
Abbe flap 26, 27 for m iddle leg 97 m ech anism of injur y in 162, 166 injur y 169
reverse 27 Bon e-an ch ored h earin g aid, assessm en t of an terior trun k, con tracture 176 Cleft care, feedin g in 48, 52, 56
Abdom in al w all defect 139, 139 for 60 of breasts, con tracture 176 Cleft lip
com pon en ts separation 140, 141, Botulin um toxin , in facial of ch est, con tracture 176 bilateral 51, 51
141 rejuven ation 67 of h an d 165, 165 orbicularis recon struction for 52
description of 140 Brach ioplasty 135 first w eb space con tract ure release ph iltral preservation w ith 52
etiology of 140 after m assive w eigh t loss 135 for 168, 169 repair of 52, 52, 53
full-th ickn ess, recon st ruction of 141 Breast can cer, screen in g for of n eck, con tract ure 175, 175 classification of 52
m yofascial, recon st ruction of 141 before breast recon struction 110, of scalp 171, 171 m an agem en t of, t im elin e for 48
recon struction of 141 114 oil or grease 162 repair 52, 52, 53
skin an d subcutan eous t issue, before breast reduct ion 124 rule of n in es for 162, 162 crit ical flaps for 49, 49
recon struction of 141 breast im plan ts an d 116 secon dar y injur y w ith , preven tion crit ical poin ts for 49, 49
tissue expan sion for 141 Breast(s), see Gyn ecom astia of 168 tech n ique for 48, 49
Abdom in oplasty 155, 155 asym m etr y 113, 113 skin resurfacin g w ith 167 tim elin e for 48
Brazilian techn ique 156 augm en tation 115, 115 th erm al 166 un ilateral 47, 47
fleur-de-lis 157 capsular con tract ure w ith 116 Cleft n asal deform it y 48, 51, 52
in cision m arkings for 156 for ptosis 120, 120 recon struction of 53, 53
m in i 157 augm en tation /m astopexy 119120 C tech n ique for 48
reverse 157 after m assive w eigh t loss 135 Cleft palate 53, 55
Can th al laxit y test
tech n ique burn con tracture in 176 bilateral 52
lateral 78
stan dard 156 clin ical exam in ation of, Am erican classification of 52, 56
m edial 78
variation s of 156 Can cer Society guidelin es for 116 feeding w ith 56
Can th al tilt , an alysis of 70
vertical, after m assive w eigh t im plan ts for m an agem en t of, t im elin e for 48
Can th opexy 35, 42, 75, 87
loss 135 an d breast can cer screen in g 116 repair
lateral 78, 79
w ith liposuction 156 capsular con tract ure w ith 116 air w ay obstruction after 56
Can th oplasty 35, 42, 75, 87
Acrylic den tal splin ts double-bubble deform it y 117 bleedin g after 58
lateral 78, 79
for pediatric m an dibular placem ent 116, 120 fistula after 58
lateral can th al str ip procedure
fract ures 20 rupture 116 h ard palate 56, 57
in 78, 78
w irin g tech n iques for 20 size 116 soft palate 56, 57
Can th us
AlloDerm 168 t ype 116, 120 tim elin e for 48
lateral
Alveolar bon e graft in g 48 m astopexy, for ptosis 120 syn drom ic presen tation 56
position of 70
Alveolar cleft 48 ptosis 119, 119 un ilateral 48
recon struction of 35, 35
bilateral 52 after m assive w eigh t loss 134 Clin odact yly 194
m edial, recon st ruction of 35, 35
Alveolar m olding 48 Regn ault classification of 114, 124 Com part m en t syn drom e
Carpal tun n el syn drom e 199, 199
An kle, see Foot an d an kle recon struction 109, 109 in leg, evaluation for 96
Cerebrospin al fluid (CSF), rh in orrh ea
An ti-an drogen s 126 an d con tralateral breast w ith burn injur y 163, 166
exam in ation for 12
An ti-Buch ch on drocutan eous h elical sym m etr y 110, 114 Com plex region al pain syn drom e
w ith fron tal sin us fract ure 12
rim advan cem en t 38, 38 tim in g of 110 186187
Cer vical spin e, see Cran iovertebral
Apligraf, for burn injur y 168 t ype of 110 ch aracteristics of 190
jun ct ion
Apon eurectom y, segm en tal, for w ith autologous tissue 110111 m an agem en t of 190
Cer vicofacial advan cem ent flap 43, 43
Dupuytren con tract ure 190 w ith expan der/im plan t 110 Corn ea, protection of, in facial
Cer vicopectoral flap, for ch eek
Arm , bat w in g deform it y, after m assive reduct ion 123, 123 paralysis 86
recon struction 43, 43
w eigh t loss 134 tech n iques for 124 Corn eal abrasion 36
Ch eek
Audiom etr y, w ith m icrotia 60 tuberous 113, 113 CRPS, see Com plex region al pain
can cer of 41
Axon otm esis 186 an d con tralateral breast syn drom e
recon struction of 41, 43
progn osis for 187 procedures 114 Cutan eous flap(s), for foot an d
cervicofacial advan cem en t flap
ch aracteristics of 114 for 43, 43 an kle 104
Grolleau classification of 114 Cutler beard flap, for upper lid
B recon struction of 114
cervicopectoral flap for 43, 43
recon struction 34
m icrovascular recon struct ion in 44
Basal cell carcinom a Bridle w ire, in dication s for 8 Mustard ch eek rotation flap
of ear 37 Brow lift 70 for 42, 42
of eyelid 33 in facial paralysis 87 by prim ar y closure 42
D
of lip, excision m argin s for 26 Burn injur y 161 skin grafts for 42 Deep in ferior epigastric perforator
of n ose, excision of 30 acute 161 tran sposition flaps for 42 (DIEP) flap, for breast
Bells ph en om en on 78, 86 m an agem en t of 166 region al flaps for 43 recon struction , free 110111
Bern ard-Burrow -Webster procedure, ch em ical 166 tissue expan sion for 43 Deep ven ous th rom bosis 135
for lip recon struction 27 circum feren tial 163 Ch em ical peels, in facial ch em oprophylaxis 157
Bilam in ate n eoderm is, see In tegra con tract ure ban ds w ith , rejuven ation 67 prophylaxis 138
Biobran e 167 m an agem en t of 168 Ch em oden er vation , in facial Derm abrasion , in facial
Bleph aroplast y depth of 163 paralysis 8687 rejuven ation 67
low er lid 71 elect rical 162163, 166 Ch est, burn con tract ure in 176 Derm agraft, for burn injur y 168
upper lid 71 esch ar excision 167 Ch est w all defect 147, 147 Derm ofasciectom y, for Dupuytren
Body con tourin g, see Liposuct ion exten t of 162, 162 dead space obliteration for 148 con tract ure 190
after m assive w eigh t loss 133 flam e 162, 165 etiology of 148 Dist ract ion osteogen esis 97
Body m ass in dex 110, 134 fluid resuscitation w ith 163 skeletal defect recon struction Dressin g(s)
Bon e gap hypertroph ic scarrin g w ith , for 148 for burn injur y 163
in low er leg, m an agem en t of 100 m an agem en t of 168 soft-tissue coverage for 148 for pressure ulcers 130

205
Index

Dr y eye h orizon tal laxit y, surgical correct ion Fasciotom y Gluteus m axim us rotation flap, for
evaluation for 70, 70, 74 of 78 en zym atic, for Dupuyt ren sacral pressure sore 131, 131
See a lso Schirm er test low er, see Ect ropion con tract ure 190 Golden h ar syn drom e 60
risk factors for 70 adjun ct support m easures for 75 for burn injur y 163, 166, 167 Gracilis m yocutan eous flap, for
Dupuytren con tract ure 189, 189 lateral can th al laxit y test 78 in leg 100 perin eal recon struction 152
surgical m an agem en t of 190, 191 m edial can th al laxit y test 78 n eedle, for Dupuytren Graft coverage
Dyskin esis, after facial n er ve repair 87 pin ch test 74, 78 con tract ure 190 for burn injur y 176
sn ap -back test 74, 78 of forearm 166, 167 for soft-t issue defect of h an d 184
platin um w eigh ts for 87 of h an d 167, 168 Great auricular n er ve, injur y to 68
E Fibrillation s, w ith n er ve injur y 186 Grow th factors, for pressure ulcers 130
Ear Filler(s), in facial rejuven ation 67 Gun n in g splin ts 20
can cer of 37, 37
F Fin ger(s) Gust ilo classification , of open tibial
com plete avulsion , treatm en t of 38 Face exten sion , ten don tran sfer for 203 fract ures 92
defects of aging 65 flexion, ten don tran sfer for 203 Gyn ecom astia 125, 125
h elical rim 38, 38 an alysis of Fit zpat rick scale, for skin t ype 66 an d breast ten dern ess 126
in low er on e-th ird 39 for rejuven ation (facelift) 66 Five Ps, of com partm en t syn drom e 166 an d fem in ization 126
in m iddle on e-th ird 38 for rh in oplast y 82 Flail segm en t 148 an d testicular m ass 126
in upper on e-th ird 38 in facial paralysis 86 Flap coverage an d thyroid m ass 126
large 38 burn injur y of 163 for abdom in al w all defect 141 drugs an d 126
m edium 38 subun its of 42, 42 for burn injur y im aging w ith 126
sm all 38 upper, aging 69, 69 of h an d 168 treatm en t of 126
prosth etic 60 Facelift 66 of n eck 176
recon struction of 37 adjun ct treatm en ts w ith 67 of scalp 172
An tia-Buch flap for 38, 38 after m assive w eigh t loss 135 for first w eb space of h an d 168 H
ban n er flap for 38 com posite 67 for foot an d an kle 104
for low er leg 100 Hair tran splant 172
by location of defect 38 dissatisfied patien t after 68
for scalp defects 172173, 173 Ham strin g m usculocutan eous V-Y
by size of defect 38 facial an alysis for 66
for soft-t issue defect of h an d 184 advan cem ent flap, for isch ial
Ect ropion 5, 35, 44 MACS (m in im al access cran ial
for stern al w oun d repair 144 pressure sore 131, 131
after bleph aroplast y 71, 73, 73 suspension ) 67
free, for upper leg 93 Han d, see Dupuytren con tracture,
ch aracteristics of 74 SMAS (superficial m usculo-
local, for m iddle leg 96 Metacarpal fract ures, Syn dact yly
cicatricial 73, 73 apon eurotic system ) 66, 67
Math es-Nah ai classification of 104 burn injur y 165, 165
causes of 74 SMASectom y procedure 67, 67
pedicled, for upper leg 92 first w eb space con tract ure release
surgical m an agem en t of 74 stan dard in cision for 66, 66
Flexor digitorum lon gus m uscle flap, for 168, 169
classification of 74, 78 sh ort scar tech n ique 66
for m iddle leg 96 cascade of 180
paralytic 77 subcutan eous 66
Flexor digitorum profun dus fun ct ion , fascial com partm en ts of 167
sen ile (involution al) 77, 77 subperiosteal 67
assessm en t of 180 fasciotom y of 167, 168
Elbow Facial n er ve
Flexor digitorum superficialis fun ction , flexor ten don
exten sion , ten don tran sfer for 203 buccal bran ch
assessm en t of 180 laceration 179, 179
flexion, ten don tran sfer for 203 exam in ation of 86
Flexor h allucis lon gus m uscle flap, for postoperative th erapy for 181
Elect rodiagn ostic tests injur y to 68
m iddle leg 97 recon struction of 181
for carpal tun n el syn drom e 200 cervical bran ch , exam in ation of 86
Flexor pollicis lon gus fun ction , repair 180, 180, 181
for n er ve injur y 186 fron tal bran ch 71
assessm en t of 180 lum brical plus fin ger 182
En tropion 5 injur y
Fluid m an agem en t, for large-volum e Quadriga e ect in 182
Epiph ora, w ith ectropion 74 acute repair of 87
liposuct ion 138 soft-tissue defect of 183, 183
Erich arch bars, for m axillar y cross-facial n er ve graftin g for 87
Fluid resuscitation in fection -related 184
fixation 21 delayed surgical recon struction
Parklan d form ula 163 traum a-related 184
Esch arotom y, for burn injur y 163, 166, for 87
w ith burn injur y 163 tum or-related 184
167 direct repair for 87
Foot an d an kle ten don tran sfers in 201, 201
Estlan der flap 27, 28 in terposition al n er ve graft in g
am putation of 105 ten odesis e ect in 180, 190
Extensor digitorum lon gus m uscle flap, for 87
gun sh ot w oun d of 103 Hearin g assessm en t, w ith m icrotia 60
for m iddle leg 96 m argin al m an dibular bran ch ,
recon struction of 103 Hem atom a, retrobulbar 5, 71, 78
Extensor h allucis lon gus m uscle flap, exam in ation of 86
Foreh ead, an alysis of, for Hem ifacial m icrosm ia 60
for m iddle leg 97 tem poral (fron tal) bran ch ,
rejuven ation 70 Hem orrh age, retrobulbar 71
Extern al oblique m uscle flap, pedicled, exam in ation of 86
Free tissue tran sfer Hern ia, abdom in al w all 139, 139
for abdom in al w all defect 141 zygom atic bran ch , exam in ation
for low er leg 100 Hugh es tarsoconjun ct ival flap 75, 75
Extrem it y(ies), see Arm (s), Leg(s) of 86
for m iddle leg 97 Hum eral fract ures, an d n er ve
burn injur y of 163 Facial paralysis 85, 85
Fron tal sin us injur y 186
Eyebrow (s), see Brow lift delayed surgical recon struction
an terior w all, fract ures of 13 Hypom ast ia 115, 116
an alysis of, for rejuven ation 70 for 87
location of, an alysis of 70 free m uscle tran sfers for 87 cran ialization of 12, 13
peak of, an alysis of 70 n on surgical m an agem en t of 86 fract ures of 11, 11
ptosis 70 region al m uscle t ran sfers for 87 m an agem en t algorith m 13 I
after bleph aroplast y 71 static slin gs for 87 obliteration of, in dication s for 12, 13
In h alation injur y 162
sh ape of, an alysis of 70 Facial rejuven ation 65, 69 posterior w all, fract ures of 13 In tegra
Eyelid Fasciectom y Fron ton asal an gle 82 coverage w ith
can cer of 33, 33 local, for Dupuyt ren con tract ure 190 for low er leg 100
layers of 34 region al, for Dupuyt ren
low er, recon struction of 35, 42, 42 con tract ure 190
G for m iddle leg 97
for burn injur y 168, 176
recon struction of 33 Fasciocutan eous flap(s) Garrod n odes 190 for scalp defect 172
upper, recon st ruction of 34, 35 for foot an d an kle 104 Gastrocn em ius m uscle flap In term axillar y fixation , in ch ildren 21
zon es of 34, 34 for low er leg 100 for m iddle leg 96 In terph alangeal (IP) join t, con tract ure,
Eyelid(s), see Bleph aroplast y posterior th igh , for isch ial pressure pedicled, for upper leg 92 see Dupuytren con tract ure
an alysis of, for rejuven ation 70 sore 131, 131 Girdleston e procedure 132 Inverted-V deform it y, of n ose 83

206
Index

J w ett in g solution s for 138


Lum brical plus fin ger 182
Mouth , com m issure defects,
recon struction of 27, 28
region al flaps for 31
subun it prin ciple 30
Jah ss m an euver 198 Musculocutan eous flap, for low er tran sposition (ban n er) flap for 30
leg 100 saddle n ose deform it y of 82
M Mustard ch eek rotation flap 42, 42 septal deform it y 48
K Macrom astia 123, 124 Mustard lid sw itch , for upper lid septal h em atom a 82
Man dible recon struction 34 septal resect ion 82
Karapan dzic flap 27, 27
(para)sym physeal fract ures Myom ectom y, in facial paralysis 87 spreader grafts for 82
Kn uckle pads 190
displaced 9 tip sh aping 82
n on displaced 8
N
L pediatric 21
body/an gle fractures Naso-orbito-ethm oid fractures, t ype O
Lagoph th alm os, after displaced 9 IA 16 Obesit y, classification of 134
bleph aroplast y 71 n on displaced 8 Nasoalveolar m olding 48, 52 Om en tal flap
Laser resurfacing, in facial pediatric 2021 Nasofron tal duct, injur y to, w ith fron tal for ch est w all defect 148
rejuven ation 67 con dylar fractures of, pediatric 21 sin us fract ure 12, 13 for stern al w oun d repair 144
Lath am applian ce 48, 52 eden tulous, fract ure t reatm en t in 9 Nasolabial an gle 82 Orbital fractures 4
Latissim us dorsi flap fract ures of 7, 7 Neck Ort icoch ea flaps, for scalp
for breast recon st ruction 110111 displaced 8 aging 65 recon struction 172, 173
for ch est w all defect 148 n on displaced 8 rejuven ation 67, 68 Osseous tran sfer, for m iddle leg 97
for stern al w oun d repair 144 pediatric 19, 19 an alysis of, for rejuven ation 66 Osteocutaneous flap, for lower
free, for abdom in al w all defect 142 grow th of 20 burn con tracture in 175, 175 leg 100
pedicled, for abdom in al w all subcon dylar/ram us fract ures Negative-pressure w oun d th erapy Osteocutaneous flap tran sfer, for
defect 142 bilateral 2021 for pressure ulcers 130 m iddle leg 97
Le Fort fract ures 15, 15 displaced 8 in low er leg 100 Osteom yelitis 148
t ype I 16, 16, 17 n on displaced 8 Nerve injur y bon e biopsy for 130
t ype II 16, 16, 17 pediatric 2021 classification of 186 ch ron ic 93
t ype III 16, 16, 17 sym physis, green st ick fractures closed 186 m agn etic resonan ce im aging of 130
Ledderh ose disease 190 of 20 elect rodiagn ostic tests for 186 treatm en t of 131
Leg zon es of 8, 9 open 186
am putation of 93, 100 Mastectom y, breast recon st ru ct ion progn osis for 187
low er th ird, open w oun d of 99, 99 after 109, 109 Nerve repair, prin ciples of 187
m iddle th ird Mastopexy, for breast Neurapraxia 186
P
bony recon struction of 97 ptosis 120, 120 progn osis for 187 Palate, see Cleft palate
early defin itive recon struction Maxilla, fixation , Erich arch bars Neurom uscular retrain in g, in facial postoperative fistula of 58
of 96 for 21 paralysis 86 prim ar y 56
open w oun d of 95, 95 Maxillom an dibular fixation 8 Neurotm esis 186 secon dar y 56
soft-tissue recon struction of 96 in dicat ion s for 16 Nipple(s) Palatoplasty
w oun d progression in 96 Melan om a depression (crater deform it y) 126 t w o-flap (Bardach ) 56, 57
recon struction , prin ciples of 92 Breslow th ickn ess of 26 free graft in g, w ith breast V-Y push back (Veau-Wardill-
upper th ird of lip, excision m argin s for 26 reduct ion 124 Kiln er) 56
bony recon struction 93 of n ose, excision of 30 sen sation 124 Von Lan gen beck 56
open w oun d of 91, 91 Mesh , for ch est w all size of 124 Pectoralis m ajor flap
soft-tissue recon struction 92 recon struction 148 Nose, see Cleft n asal deform it y, for ch est w all defect 148
vascular injur y, m an agem en t in fection 148 Rh in oplast y for stern al w oun d repair 144
of 100101 Metacarpal fract ures 197, 197 aesth etic subun its of 30 Perin eal recon struction 151, 151
Lip, see Cleft lip Metacarpoph alangeal join t, an alysis of, for rh in oplast y 82 Periocular region
adh esion, w ith cleft lip 48, 52 con tract ure, see Dupuytren can cer of 29 recon struction of 34
can cer of 25, 25 con tract ure dorsum /radix guidelin es for 35
full-th ickn ess defects of, Microstom ia, w ith lip augm en tation of 82 zon e I (upper lid), recon st ruction
recon struction of 26 recon struction 27 reduct ion of 82 of 34, 35
low er, full-th ickn ess defects of 27 Microtia 59, 59 fram ew ork replacem en t for, don or zon e II (lower lid), recon struction
m ucosal/verm ilion defects of, classification of 60 sites for 31 of 34, 35
recon struction of 26 recon struction of full-th ickn ess defects of, zon e III (m edial can th us),
recon struction of 25, 26 alloplastic 60, 62 recon struction of 31 recon struction of 35, 35
m ucosal advan cem en t for 26 autogen ous 60 in ferior turbin ates, m an agem en t in zon e IV (lateral can th us),
tongue flap for 26 Bren t tech n ique 60, 61 rh in oplast y 82 recon struction of 35, 35
total 27 Nagata tech n ique 60, 61 lin in g of, recon struction option s zon e V (periorbital), recon struction
verm ilion advan cem en t for 26 prosth etic 60 for 31 of 35
verm ilion lip sw itch for 26 Microvascular flap(s), for foot an d low er lateral cart ilages, ceph alic trim zon es of 34, 34
tapin g, w ith cleft lip 48, 52 an kle 105 for 82 Peyron ie disease 190
upper, full-th ickn ess defects Middle ear, atretic, recon struction open roof deform it y of 82 Ph alangeal fractures 197
of 26 of 60, 61 osteotom ies for 82 Ph alen m an euver 200
Liposuct ion Midface, in stabilit y of, assessm en t pollybeak deform it y of 82 Pierre Robin sequen ce 56
for gyn ecom ast ia 126 for 16 recon struction of 29 Plat ysm aplast y 67, 68
large-volum e Millard rotationadvan cem ent flap, for bilobed flap for 30, 31 Pollybeak deform it y 82
fluid m an agem en t for 138 cleft lip repair 48, 49 com posite ch on drocutan eous graft Pressure sore(s)
procedure for 138 Moh s surger y for 30 isch ial 129, 129
laser-assisted 138 for can cer of ear 38 dorsal n asal (m iter) flap for 31 flaps for 131, 131
m ajor 137 for can cer of lip 26 full-th ickn ess skin graft for 30 recurren ce of 132
pow er-assisted 138 for n asal can cer 30 local flaps for 30 risk factors for 130
suction -assisted 138 Motor un it poten tials, w ith n er ve n asolabial flap for 31 sacral, flaps for 131, 131
ultrasoun d-assisted 138 injur y 186 option s for 30 staging of 130

207
Index

troch anteric, flaps for 132


Proxim al in terph alangeal (PIP) join t,
S com plex 194
com plicated 194
Tibialis an terior m uscle flap
for m iddle leg 97
con tract ure, see Dupuytren Saddle n ose deform it y 82 in com plete 194 pedicled, for upper leg 92
con tract ure Scalp sim ple 194 Tin el sign 200
Ptosis an terior defects, recon struction Syn kin esis Tisseel 176
breast, see Breast (s) of 172 after facial n er ve repair 87 Tissue expan sion , for scalp
brow, see Eyebrow (s) burn injur y 171, 171 of facial m uscles 86 recon struction 172, 173
Puden dal th igh flap, for perin eal n early com plete defects, Syn polydact yly 194 Topical th erapy, for burn injur y 163
recon struction 152, 152 recon struction of 172 TRAM flap, for breast recon st ruction
Pulm on ar y em bolism 135 occipital defects, recon st ruction free 110111
ch em oprophylaxis 157 of 172
parietal defects, recon struction
T pedicled 110111
Tran sCyte 167
of 172 Tabletop test 190 Tran sm etatarsal am putation 105
Q recon struction Tarsal sh orten ing 78 Treach er Collin s syn drom e 60
flap coverage for 172 Tarsoconjun ct ival (Hugh es) flap, for Trip ier flap 74, 74
Quadriga e ect , in h an d 182 Ort icoch ea flaps for 172, 173 low er lid recon struction 35
pinw h eel flaps for 172, 173 Tarsoconjun ct ival graft , for upper lid
tissue expan sion for 172, 173 recon struction 34 V
R vertex defects, recon st ruction of 172 Tem porom an dibular join t , an kylosis of,
Vacuum -assisted closure
Radial n er ve Sch irm er test 74, 78 w ith m an dibular fract ures 21
for burn graft 176
injur y 185, 185 Sch uch art techn ique, for lip Ten don tran sfer(s)
of low er-extrem it y w oun d 92
acute closed injuries an d 186 recon struction 27 don or m uscles for 203
Van der Woude syn drom e 56
acute open injuries an d 186 SEACOAST m n em on ic 202 for radial n er ve palsy 187, 202
Vastus lateralis m uscle flap, distally
m ech anism of injur y in 186 Septorh inoplast y 48 fun ction s restored by 202
based, for upper leg 93
progn osis for 187 Serratus an terior m uscle flap, for ch est in h an d 201, 201
Veloplast y, in t ravelar 56
tim in g of presen tation 186 w all defect 148 recipien ts in 203
Vision loss, after upper face
palsy, ten don tran sfers for 187, Skin ten don s com m on ly used in 202
rejuven ation 71
202 replacem en t , for burn injur y 167 Ten sor fasciae latae flap
Vulvar can cer, perin eal recon struct ion
Recon structive ladder, for soft-tissue resurfacin g, for burn injur y 167 free, for abdom in al w all defect 142
for 151, 151
w oun ds 100 Skin graft pedicled, for abdom in al w all
Rectus abdom in is flap for low er leg 100 defect 142
for ch est w all defect 148 for m iddle leg 96 Ten zel sem icircular rotation al flap W
for stern al w oun d repair 144 for upper leg 92 for low er lid recon st ruction 35
Weigh t loss
pedicled, for abdom in al w all Skin t ype, Fitzpatrick scale for 66 for upper lid recon struction 34
bariatr ic procedures for 134
defect 141 Soleus m uscle flap Testicular m ass, gyn ecom astia an d 126
m assive, body con tourin g after 133,
Rectus abdom in is m yocutan eous flap, for m iddle leg 96 Th igh flap, for perin eal
133
ver tical, for perin eal proxim ally based, for upper leg 92 recon struction 153, 153
Wrist
recon struction 152 Squam ous cell carcinom a Th igh (s)
exten sion , ten don tran sfer for 203
Rectus fem oris flap, pedicled, for of ch eek 41 lateral
flexion, ten don tran sfer for 203
abdom in al w all defect 142 of lip, excision m argin s for 26 lift , after m assive w eigh t loss 135
Reflex sym path etic dystrophy, see of n ose, excision of 30 saddlebag lipodystrophy 137, 137
Com plex region al pain syn drom e Stern al w oun d in fection 143, 143 m edial, lift , after m assive w eigh t
Z
Rh in oplast y 81, 81 presen tation of loss 135
closed approach for 82 acute 144 Th um b Z-plast y, double-opposin g (Furlow ) 56,
open approach for 82 ch ron ic 144 exten sion , ten don tran sfer for 203 57
postoperative splin ting subacute 144 flexion, ten don tran sfer for 203 Zygom a
for 82 Sym e am putation 105 opposition , ten don tran sfer for 202 articulation s of 4
Rhyt idectom y Syn dact yly 193, 193 Thyroid m ass, gyn ecom astia an d 126 fract ures of 3, 3
after m assive w eigh t loss 135 border digit, release of 194 Tibia, open fract ures of, Gust ilo Zygom aticom axillar y com plex,
in facial paralysis 87 com plete 194 classification of 92 fract ures of 4

208