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Plastic Surgery Review

A Study Guide for the

Written Board, In-Service,
and Maintenance of
Certification Exams

Gregory E. Lakin, MD
Diplomate, American Board of Plastic Surgery
Chief, Division of Pediatric Plastic Surgery
Director, Craniofacial Center
Director, Vascular Anomalies Center
University Hospitals Rainbow Babies &
Children's Hospital
Assistant Professor, Departments of Plastic
Surgery, Neurosurgery, and Pediatrics
Case Western Reserve University School of
Cleveland, Ohio

73 illustrations

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Library of Congress Cataloging-in-
Publication Data

Lakin, Gregory E., author.

Plastic surgery review: a study guide for the
in-service, written board, and maintenance of
certification exams/Gregory E. Lakin.
p.; cm.
Summary: “Plastic Surgery Review meets the
need for a high-yield, compact review book for
the plastic surgery in-service, written board,
and maintenance of certification examinations.
Its 50 chapters are organized into four sections
tested by the plastic surgery in-service
examination: comprehensive plastic surgery
craniomaxillofacial surgery breast and
cosmetic surgery hand and lower extremity An
outline format with bullet points, tables,
figures, mnemonics, and references facilitates
review and memorization. Invited expert
reviewers ensure the material is accurate and
up-to-date”--Provided by publisher.
ISBN 978-1-60406-836-8 (paperback) --
ISBN 978-1-60406-835-1 (e-book)
I. Title.
[DNLM: 1. Reconstructive Surgical
Procedures--methods. 2. Certification. WO
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Important note: Medicine is an ever-changing

science undergoing continual development.
Research and clinical experience are
continually expanding our knowledge, in
particular our knowledge of proper treatment
and drug therapy. Insofar as this book mentions
any dosage or application, readers may rest
assured that the authors, editors, and publishers
have made every effort to ensure that such
references are in accordance with the state of
knowledge at the time of production of the
Nevertheless, this does not involve, imply, or
express any guarantee or responsibility on the
part of the publishers in respect to any dosage
instructions and forms of applications stated in
the book. Every user is requested to examine
carefully the manufacturers’ leaflets
accompanying each drug and to check, if
necessary in consultation with a physician or
specialist, whether the dosage schedules
mentioned therein or the contraindications
stated by the manufacturers differ from the
statements made in the present book. Such
examination is particularly important with
drugs that are either rarely used or have been
newly released on the market. Every dosage
schedule or every form of application used is
entirely at the user's own risk and
responsibility. The authors and publishers
request every user to report to the publishers
any discrepancies or inaccuracies noticed. If
errors in this work are found after publication,
errata will be posted at on the
product description page.
Some of the product names, patents, and
registered designs referred to in this book are
in fact registered trademarks or proprietary
names even though specific reference to this
fact is not always made in the text. Therefore,
the appearance of a name without designation
as proprietary is not to be construed as a
representation by the publisher that it is in the
public domain.
This book, including all parts thereof, is legally
protected by copyright. Any use, exploitation,
or commercialization outside the narrow limits
set by copyright legislation without the
publisher's consent is illegal and liable to
prosecution. This applies in particular to
photostat reproduction, copying,
mimeographing or duplication of any kind,
translating, preparation of microfilms, and
electronic data processing and storage.
This book is dedicated to Clifford and
Arlene Lakin, who have been the best
parents anyone could ever ask for.
Gregory E. Lakin, MD
Henry K. Kawamoto Jr.
Section I Comprehensive Plastic
Chapter 1 Wound Healing
Reviewed by Jeffrey E. Janis
Chapter 2 Local Tissue Rearrangement
Reviewed by William Y. Hoffman
Chapter 3 Skin, Bone, and Cartilage
Reviewed by Justine C. Lee
Chapter 4 Flaps and Microsurgery
Reviewed by Suhail Khuzema
Chapter 5 Implants and Biomaterials
Reviewed by Michael J. Yaremchuk
Chapter 6 Burns
Reviewed by Ludwik K. Branski
Chapter 7 Trunk Reconstruction
Reviewed by Derek E. Bell
Chapter 8 Tissue Expansion
Reviewed by Sara R. Dickie
Chapter 9 Lymphedema and Pressure
Reviewed by Reid A. Maclellan
Chapter 10 Skin Lesions and Soft Tissue
Reviewed by Jeffrey H. Kozlow
Chapter 11 Soft Tissue Infection
Reviewed by Andre Yuan Levesque
Chapter 12 Immunology and
Reviewed by Eduardo D. Rodriguez
Chapter 13 Coding, Medicolegal, and
Psychiatric Aspects
Reviewed by Kent K. “Kye” Higdon
Section II Craniomaxillofacial Surgery
Chapter 14 Head and Neck Anatomy
Reviewed by Andrew Wexler
Chapter 15 Cleft Lip and Palate
Reviewed by Jesse A. Taylor
Chapter 16 Tessier Clefts
Reviewed by Henry K. Kawamoto Jr.
Chapter 17 Orthognathic,
Temporomandibular Joint, and Chin
Reviewed by Anand R. Kumar
Chapter 18 Craniosynostosis and
Craniofacial Syndromes
Reviewed by Jeffrey A. Fearon
Chapter 19 Hemangiomas and Vascular
Reviewed by Arin K. Greene
Chapter 20 Facial Paralysis
Reviewed by Andre Panossian
Chapter 21 Head and Neck Tumors,
Salivary Gland Tumors, Lip, and Scalp
Reviewed by Brian T. Andrews
Chapter 22 Maxillofacial Trauma
Reviewed by Richard Hopper
Chapter 23 Ear Reconstruction
Reviewed by Reza Jarrahy
Chapter 24 Mandible Reconstruction
Reviewed by Nidal Farhan ALDeek
and Fu-Chan Wei
Chapter 25 Nasal Reconstruction
Reviewed by Robert L. Walton
Chapter 26 Eyelid and Lacrimal System
Reviewed by S. Anthony Wolfe
Section III Breast and Cosmetic
Chapter 27 Anesthesia
Reviewed by Derek M. Steinbacher
Chapter 28 Breast Augmentation,
Mastopexy, and Reduction
Reviewed by Luis O. Vasconez
Chapter 29 Breast Reconstruction
Reviewed by Stephen Vega
Chapter 30 Body Contouring,
Abdominoplasty, and Liposuction
Reviewed by Jeffrey A. Gusenoff
Chapter 31 Facelift and Neck
Reviewed by Val Lambros
Chapter 32 Rhinoplasty
Reviewed by Ali Totonchi
Chapter 33 Blepharoplasty and Brow
Reviewed by Oren Tepper
Chapter 34 Otoplasty
Reviewed by Gaby Doumit
Chapter 35 Chemical Peels
Reviewed by David J. Rowe
Chapter 36 Fillers and Injectables
Reviewed by Ivona Percec
Chapter 37 Hair Transplantation
Reviewed by Alfonso Barrera
Chapter 38 Lasers
Reviewed by David W. Low
Section IV Hand and Lower Extremity
Chapter 39 Congenital Hand
Reviewed by Phuong D. Nguyen
Chapter 40 Fingertip Amputations
Reviewed by Fernando A. Herrera Jr.
Chapter 41 Mutilating Hand Injuries
Reviewed by Ryan Katz
Chapter 42 Dupuytren and Vascular
Reviewed by Alexander M. Spiess
Chapter 43 Fractures and Dislocations
Reviewed by Brent M. Egeland
Chapter 44 Nerves and Compartment
Reviewed by Ida K. Fox
Chapter 45 Tendons
Reviewed by Warren C. Hammert
Chapter 46 Hand Tumors
Reviewed by Andrew Chen
Chapter 47 Hand Infections
Reviewed by Devra Becker
Chapter 48 Wrist
Reviewed by Anthony Perrone
Chapter 49 Rheumatology
Reviewed by Jennifer F. Waljee
Chapter 50 Lower Extremity
Reviewed by Hani Sbitany
When I completed my residency in
general surgery at Columbia-
Presbyterian Medical Center in New
York, a naïve thought flashed through my
brain: “Frustration would be less now
that my attention could be concentrated
on a subspecialty with a smaller
knowledge base.” Just a few months in
to the new residency at the New York
University Institute of Reconstructive
Plastic Surgery thoroughly exposed my
fallacy of thought.
Although training in general surgery
focuses mainly on the trunk, plastic
surgery truly encompasses surgery in
general of the entire body. In addition, it
commands far greater attention to
Heaped upon the needs of trainees to
capture basic core knowledge is the
explosive nature of the specialty.
Practitioners as well need to heed
attention because the field has moved
beyond the “filling a hole and erasing a
defect” phase (restorative surgery) to the
incorporation of transplantation
(replacement surgery). And right around
the corner lies regenerative surgery.
The process of acquiring new
information, applying it properly, and
achieving a successful outcome is the fun
part. But recalling information needed to
prepare for an examination is another
thing. Testing cannot be avoided. It
defines the formal educational process,
and public and governmental agencies
demand it beyond formal training.
Plastic Surgery Review seeks to
assist the student who is preparing for
testing. Its streamlined format facilitates
the recall process. Residents preparing
for the In-service Examination, new
graduates preparing for the American
Board of Plastic Surgery's Written
Examination, and veteran practitioners
for the Maintenance of Certification
Examination will all find great value in
this compact book.
Henry K. Kawamoto Jr., MD, DDS
Clinical Professor Emeritus
Department of Surgery
Division of Plastic Surgery
University of California at Los Angeles
Los Angeles, California

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

• Plastic surgeons studying for their
American Board of Plastic Surgeons
Written Examination and
Maintenance of Certification
• Plastic surgery residents preparing
for their annual In-Service
• Medical students on plastic surgery

• 50 chapters organized into four
sections tested by the plastic surgery
In-Service Examination
Comprehensive Plastic Surgery
Craniomaxillofacial Surgery
Breast and Cosmetic Surgery
Hand and Lower Extremity Surgery
• Based on the Content Outline of the
American Board of Plastic Surgery
Written Examination and
Maintenance of Certification
• Outline format with bullet points,
tables, figures, mnemonics, and
references facilitate review and
• Invited expert reviewers ensured the
material is accurate and up-to-date

• Expert reviewers for their leadership
in the field and contributions to this
• Thieme Publishers Timothy Hiscock,
Elizabeth Palumbo, Natascha Morris,
Kenny Chumbley, Chris Malone,
Cornelia Schulze, and Emily Ekle for
sheparding this project to publication
• Peggy Firth and Thompson Digital
for the beautiful illustrations
• Dr. James Bradley for encouraging
me to publish this work
• Dr. Joseph Serletti for always
believing in me
• Dr. Henry Kawamoto and Dr.
Bahman Guyuron for their
• Margaret, my beloved wife, for her
love and support
Gregory E. Lakin, MD
Nidal Farhan ALDeek, MSc, MD
Chang Gung Memorial Hospital
Chang Gung University Medical College
Taipai, Taiwan

Brian T. Andrews, MD, MA

Director of Cleft and Craniofacial
Assistant Professor
Department of Plastic Surgery
Department of Otolaryngology–Head
and Neck Surgery
University of Kansas Medical Center
Kansas City, Kansas

Alfonso Barrera, MD, FACS

Clinical Assistant Professor of Plastic
Baylor College of Medicine
Houston, Texas

Ludwik K. Branski, MD, MMS

Assistant Professor
Division of Plastic Surgery
Department of Surgery
The University of Texas Medical Branch
Staff Surgeon
Shriners Hospital for Children
Galveston, Texas

Devra Becker, MD, FACS

Assistant Professor
Department of Plastic Surgery
University Hospitals Case Medical
Louis Stokes VA Medical Center
Cleveland, Ohio

Derek E. Bell, MD
Assistant Professor of Plastic and
Reconstructive Surgery
Burn Program Director
The University of Rochester Medical
Rochester, New York

Ludwik K. Branski, MD, MMS

Assistant Professor
Department of Surgery
The University of Texas Medical Branch
Staff Surgeon
Shriners Hospital for Children
Galveston, Texas

Andrew Chen, MD, FACS

Associate Professor
Department of Surgery
Division of Plastic Surgery
University of Connecticut Health Center
Farmington, Connecticut

Sara R. Dickie, MD
Clinical Educator
Section of Plastic and Reconstructive
Department of Surgery
University of Chicago Hospitals
NorthShore University Health System
Chicago, Illinois
Gaby Doumit, MD, MSc, FRCSC,
Director of Pediatric Plastic and
Craniofacial Surgery
Dermatology and Plastic Surgery
Cleveland Clinic
Cleveland, Ohio

Brent M. Egeland, MD
Plastic Surgeon
Institute of Reconstructive Plastic
Surgery of Central Texas
Round Rock, Texas

Jeffrey A. Fearon, MD, FACS, FAAP

The Craniofacial Center
Medical City Children's Hospital
Dallas, Texas

Ida K. Fox, MD
Assistant Professor, Surgery
Division of Plastic and Reconstructive
Washington University School of
St. Louis, Missouri

Arin K. Greene, MD, MMSc

Associate Professor of Surgery
Harvard Medical School
Department of Plastic and Oral Surgery
Boston Children's Hospital
Boston, Massachusetts
Jeffrey A. Gusenoff, MD
Associate Professor of Plastic Surgery
Co-Director, Life after Weight Loss
Director, Post-Bariatric Body
Contouring Fellowship
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania

Warren C. Hammert, MD, DDS

Professor of Orthopaedic Surgery and
Plastic Surgery
Chief, Division of Hand Surgery
Department of Orthopaedic Surgery and
University of Rochester Medical Center
Rochester, New York
Fernando A. Herrera Jr., MD
Assistant Professor of Surgery
Division of Plastic Surgery
Medical University of South Carolina
Charleston, South Carolina

Kent K. “Kye” Higdon, MD, FACS

Associate Program Director
Assistant Professor
Department of Plastic Surgery
Vanderbilt University Medical Center
Nashville, Tennessee

William Y. Hoffman, MD, FAAP

Professor and Chief
UCSF Plastic Surgery
Stephen J. Mathes Endowed Chair
Vice Chair, Department of Surgery
University of California–San Francisco
San Francisco, California

Richard Hopper, MD
Surgical Director, Craniofacial Center
Chief, Division of Craniofacial and
Plastic Surgery
Seattle Children's Hospital
University of Washington
Seattle Washington

Jeffrey E. Janis, MD, FACS

Professor and Executive Vice Chairman
Chief of Plastic Surgery, University
Department of Plastic Surgery
Ohio State University Wexner Medical
Columbus, Ohio

Reza Jarrahy, MD, FACS, FAAP

Associate Clinical Professor
Division of Plastic and Reconstructive
Department of Pediatrics
David Geffen School of Medicine at
Co-Director, UCLA Craniofacial Clinic
Assistant Chief of Plastic Surgery
Olive View-UCLA Medical Center
Los Angeles, California

Suhail Khuzema Kanchwala, MD

Assistant Professor
Department of Surgery
University of Pennsylvania Hospital
Philadelphia, Pennsylvania

Ryan Katz, MD
Attending Hand Surgeon
Department of Orthopedics
The Curtis National Hand Center
Medstar Union Memorial Hospital
Baltimore, Maryland

Henry K. Kawamoto Jr., MD, DDS

Clinical Professor Emeritus
Department of Surgery
Division of Plastic Surgery
University of California at Los Angeles
Los Angeles, California

Jeffrey H. Kozlow, MD, MS

Clinical Assistant Professor Section of
Plastic Surgery
University of Michigan Health System
Ann Arbor, Michigan

Anand R. Kumar, MD, FACS, FAAP

Director, Center for Pediatric
Craniofacial Surgery
Associate Professor of Plastic Surgery
and Pediatrics
Department of Plastic and
Reconstructive Surgery
The Johns Hopkins University School of
Baltimore, Maryland

Val Lambros, MD
Clinical Professor of Plastic Surgery
University of California–Irvine
Irvine, California

Justine C. Lee, MD, PhD

Assistant Professor of Surgery
Craniofacial Surgery
Division of Plastic and Reconstructive
UCLA Medical Center
Los Angeles, California

Andre Yuan Levesque, MD

Assistant Professor
Division of Plastic Surgery
University of Alabama at Birmingham
Birmingham, Alabama

David W. Low, MD
Professor of Surgery
Division of Plastic Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

Reid A. Maclellan, MD, MMSc

Department of Plastic and Oral Surgery
Boston Children's Hospital
Harvard Medical School
Boston, Massachusetts

Phuong D. Nguyen, MD
Division of Plastic and Reconstructive
The Hospital for Sick Children
Toronto, Canada
Andre Panossian, MD
Director, Facial Paralysis Center
Department of Plastic and Maxillofacial
Children's Hospital Los Angeles
Keck School of Medicine
University of Southern California
Los Angeles, California

Ivona Percec, MD, PhD

Assistant Professor
Division of Plastic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania

Anthony Perrone, MD, MBA, RPh

Chief, Plastic Surgery
Department of Surgery
Maine General Medical Center
Augusta, Maine

Eduardo D. Rodriguez, MD, DDS

Helen L. Kimmel Professor of
Reconstructive Plastic Surgery
Chair, Department of Plastic Surgery
Director, Institute of Reconstructive
Plastic Surgery
Department of Plastic Surgery
New York University Langone Medical
New York, New York

David J. Rowe, MD, FACS

Assistant Professor
Department of Plastic Surgery
University Hospitals Case Medical
Cleveland, Ohio

Hani Sbitany, MD, FACS

Assistant Professor of Surgery
Division of Plastic and Reconstructive
University of California–San Francisco
San Francisco, California

Alexander M. Spiess, MD
Assistant Professor of Plastic Surgery
Assistant Professor of Orthopaedic
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Derek M. Steinbacher, DMD, MD,
Associate Professor of Plastic Surgery
Director, Craniomaxillofacial Surgery
Yale School of Medicine
Yale New Haven Hospital
New Haven, Connecticut

Jesse A. Taylor, MD
Mary Downs Endowed Chair of
Pediatric Craniofacial Treatment and
Director, Penn Craniofacial Fellowship
Co-Director, CHOP Cleft Team
Department of Plastic, Reconstructive,
and Craniofacial Surgery
The University of Pennsylvania
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

Oren Tepper, MD
Assistant Professor of Plastic Surgery
Director of Craniofacial Surgery
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, New York

Ali Totonchi, MD
Medical Director of Craniofacial
Deformity Clinic
On-Site Director of Plastic Surgery
Department of Surgery
MetroHealth Medical Center
Case Western Reserve University
Cleveland, Ohio
Luis O. Vasconez, MD, FACS
Plastic Surgeon
The Kirklin Clinic of University of
Alabama-Birmingham Hospital
Birmingham, Alabama

Stephan Vega, MD
Plastic Surgeon
Vega Plastic Surgery
Pittsford, New York

Jennifer F. Waljee, MD, MS

Assistant Professor
Department of Surgery
University of Michigan
Ann Arbor, Michigan

Robert L. Walton, MD, FACS

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

Fu-Chan Wei, MD, FACS

Distinguished Chair Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital
Chang Gung University Medical College
Taipei, Taiwan

Andrew Wexler, MD, MA

Chief, Plastic Surgery
Regional Director of Craniofacial
Southern California Kaiser Permanente
Clinical Professor Plastic Surgery
University of Southern California
Los Angeles, California

S. Anthony Wolfe, MD, FACS, FAAP

Chief, Division of Plastic Surgery
Miami Children's Hospital
Miami, Florida

Michael J. Yaremchuk, MD
Professor of Surgery
Department of Surgery
Harvard Medical School
Boston, Massachusetts
Section I
Comprehensive Plastic
1 Wound Healing
Reviewed by Jeffrey E. Janis

Phases of Wound Healing

(Table 1.1)
• Peak tensile strength: 80% at 60 days
• Epithelial cell migration in healing
Occurs in first 48 to 72 hours
Initiates by loss of contact
Mitosis occurs at wound margin to
replace migrated cells
Contact inhibition reestablished
• Ratios type I:III (Table 1.2)
Normal skin: 4:1
Early scar: 2:1
Fetal scar: 1:3
Table 1.2 Types of collagen

Type Characteristics

Skin, bone, tendon,

I arteries, uterus,
dentin, fascia
II Eye, cartilage

Skin, arteries, bowel

wall, uterus

IV Basement membrane

Similar to type IV,


• Amino acid composition

Hydroxyproline: vitamin C
hydroxylates proline to form
Hydroxylysine: vitamin C
hydroxylates lysine to form
• Tropocollagen
• Filament
• Fibril
• Fiber
• Bundle: crosslinked–strongest
• Procollagen: secreted from cell
• Collagen: formed when amino and
carboxy ends cleaved off

Impaired Wound Healing

• Smoking
Increases microvascular
Increases carboxyhemoglobin
Carbon monoxide by-product
competitively inhibits carbon
dioxide and hemoglobin hypoxia
erythropoiesis blood viscosity
platelet aggregation, collagen
deposition, and thrombogenesis
• Steroids: decreases inflammatory
• Organ transplantation
antilymphocytes do not impair
wound healing
• Radiation therapy
Increases blood vessel thrombosis
Decreases acute inflammatory
response, neutrophil function,
cytokines, growth factors, wound
healing, and tissue oxygenation
• Infection: culture of 1 × 105
bacteria/g of tissue diagnoses

Excessive Wound Healing

• Keloids
Characterized by: excess scarring
beyond borders of original wound,
common among patients with dark
skin color, seen in face, neck,
chest, deltoid region
Histology: no myofibroblasts,
decreased blood vessels, collagen
in large disorganized bundles
Treatment excision alone: 45 to
100% recurrence
Treatment excision combined with
something else is more successful
than excision alone: excision with
steroid injections (20 to 40%
recurrence), excision with
pressure (induces local tissue
hypoxia), excision with radiation
therapy (25% recurrence), silicone
Do not cause contractures, do not
Ear keloid: treat with excision,
steroid, pressure therapy, and
radiation therapy (if recurrent),
electronegative charge, increase in
skin surface temperature to
decrease recurrence rates
• Hypertrophic scars
Characterized by: elevated scar
within borders of original wound,
seen in flexor regions
Usually caused by tension
Histology: myofibroblasts,
collagen in organized bundles
Cause contractures, can regress

Wound Care
• Negative pressure wound therapy:
avoid putting on open blood vessels
• Alginate: absorbent, for exudative
• Silver ion impregnated:
• Hydrogels: waterproof, prevent
bacterial contamination
• Films/transparent dressings:
waterproof, impermeable to
bacterial contamination
• Silicone sheeting: occlusive, acts
through hydration, electronegative
charge, increase in skin surface
• Zinc: cofactor for metalloproteinases
• Folate and Vitamin B6 (pyridoxine):
for DNA synthesis, cell proliferation
• Vitamin E: antioxidant, immune
• Vitamin A: restores steroid effects
• Isotretinoin (Accutane): related to
vitamin A, for cystic acne, impairs
epithelialization, decreases activity
of sebaceous glands
• Tretinoin (Retin-A, Ortho-McNeil-
Janssen Pharmaceuticals, Titusville,
NJ): promotes epithelialization, skin
• Mechanical debridement: scrub brush
to remove embedded dirt prevents
• Scar revision surgery: wait for > 12
months postop, do routine scar
management therapy until then
(massage, sunscreen)

Suggested Reading
Broughton G, Rohrich RJ. Wounds and
Scars. Dallas TX: Selected
Readings in Plastic Surgery, Inc.;
2005:5–7. Selected Readings in
Plastic Surgery; vol 10, issue 7
Gurtner GC. Wound healing: normal and
abnormal. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2006:15–22
Janis JE, Kwon RK, Lalonde DH. A
practical guide to wound healing.
Plast Reconstr Surg
Levenson SM, Geever EF, Crowley LV,
Oates JF III, Berard CW, Rosen H.
The healing of rat skin wounds. Ann
Surg 1965;161(2):293–308
2 Local Tissue
Reviewed by William Y. Hoffman

• Elliptical
Most common type of excision
Avoid dog ears by excising in a 4:1
length/width ratio
• Serial
Staged excision of wide or large
Skin expands between stages
Shorter scar than single-stage
elliptical excision
Random Cutaneous Flap
• Length/width ratio
3:1 length/width ratio should be
maintained for optimal circulation
Length/width ratio not important if
making axial flap (no longer
random flap because contains
vascular pedicle)
• Delayed incisions: improves survival
of distal tip
• Tissue expansion
Similar effect to surgical delay
Takes time, cannot do
intraoperative expansion

Rotation Flap (Fig. 2.1)

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

Advancement Flap
• Principles
Slide forward to adjacent defect
No lateral or rotational movement
Examples: rectangular
advancement flap, V-Y flap
Fig. 2.1 Rotation flap. (From Chen W.
Oculoplastic Surgery: The Essentials. New
York Thieme; 2001. Used with permission.)

• Rectangular advancement flap (Fig.

Rectangular tissue is moved
forward to close adjacent defect
Burow triangles are excised to
remove excess skin
• V-Y flap (Fig. 2.3)
Tissue to be moved forward is
incised in a V shape
After donor site is closed directly,
the suture line has a Y shape

Transposition Flap
• Characteristics
Rectangular or triangulated flap,
may have rounded edges
Rotates laterally about a pivot
point to close adjacent defect
• Examples: rhomboid, Z-plasty, and
bilobed flaps
Fig. 2.2 Rectangular advancement flap.
Fig. 2.3 V-Y flap. (From Chen W. Oculoplastic
Surgery: The Essentials. New York Thieme;
2001. Used with permission.)

• Rhomboid (Limberg) flap (Fig. 2.4)

Angles: 120 and 60 degrees
Four flaps can be designed, each
off the 120-degree point
Choose flap based on skin laxity to
ensure donor site will close
Flaps are not designed off the 60-
degree point
• Z-plasty (Table 2.1) (Fig. 2.5)
Lengthens scars by adding tissue
Reverses direction of scar
15-degree incremental increases in
Z-plasty angle lead to,
theoretically, a 25% increase in
scar length
Ideal angle is 60 degrees, leading
to a theoretical 75% increase in
scar length

Fig. 2.4 Rhomboid flap. (From Chen W.

Oculoplastic Surgery: The Essentials. New
York Thieme; 2001. Used with permission.)

Table 2.1 Z-plasty angles and theoretical

increases in length (percentage)
Angle (degree) increase in length

30 25

45 50

60 75

75 100

90 120
Fig. 2.5 Z-plasty.

Fig. 2.6 Bilobed flap. (From Park SS. Facial

Plastic Surgery. New York Thieme; 2005.
Used with permission.)

• Bilobed flap (Fig. 2.6)

Each lobe rotates 45 to 50 degrees
Use: defects 1 to 1.5 cm in lower
third of nose (tip, ala)

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

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

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

Suggested Reading
Broughton G, Rohrich RJ. Wounds and
Scars. Dallas TX: Selected
Readings in Plastic Surgery, Inc.;
2005:5–7. Selected Readings in
Plastic Surgery; vol 10, issue 7
Jackson IT. Local Flaps in Head and
Neck Reconstruction. 2nd ed. St.
Louis, MO: Quality Medical
Publishing; 2007
Thorne CH. Techniques and principles
in plastic surgery. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2007:3–14
Thornton JF, Gosman AA. Skin Grafts
and Skin Substitutes and Principles
of Flaps. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2004:1–78. Selected Readings in
Plastic Surgery; vol 10, issue 1
3 Skin, Bone, and Cartilage
Reviewed by Justine C. Lee

Skin Grafts (Table 3.1)

• Types
Split-thickness skin graft (STSG):
epidermis and part of dermis
Full-thickness skin graft (FTSG):
epidermis and entire dermis
• Donor site
Replace like with like: choose
based on match of color, texture,
thickness, hair
Retroauricular or supraclavicular
FTSG: for facial defects
Eyelid FTSG: for thin eyelid
• Graft failure causes
Fluid collection beneath graft:
prevent with hemostasis (best
method), pressure (bolsters),
meshing (not cosmetic)
Poor bed vascularity
• Reharvesting STSG
Can reharvest from same donor site
Number of reharvests depends on
amount of dermis harvested
Dermis does not regenerate as well
as epidermis
Back best source for reharvesting
• Contraction
Normal process of wound healing
Primary contraction: initial
shrinkage of skin graft upon
harvest secondary to amount of
elastin in dermis. FTSG > STSG
because more dermis in FTSG.
Secondary contraction: shrinkage
of skin graft over time in recipient
site. STSG > FTSG because
rigidity of dermis in FTSG
prevents wound bed contraction
• Contracture
Negative sequelae of wound
healing over flexor surfaces
Causes: skin graft contraction,
burns, Dupuytren disease
• Stages of skin graft sensation return
Begins 4 weeks, lasts 2 years
Table 3.1 Stages of skin graft healing

Stage Description

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

Next 48
Inosculation hours of

Begins after Capillary

Revascularization inosculation anastomosis

Order of return: (1) pain, (2) light

touch, (3) temperature, (4)
Recovers faster in FTSG: FTSGs
have more neurilemmal sheaths
than STSGs for nerve ingrowth
from recipient site

Bone Grafts
• Bone graft properties
Osteoconduction: scaffold matrix
to accommodate new bone in-
Osteoinduction: stimulates
Osteogenesis: bone formation with
no indication of cellular origin
• Cancellous bone grafts
More osteoconductive and
osteoinductive than cortical bone
Osteoblasts brought with graft
Example: iliac crest
• Cortical bone grafts
Stronger than cancellous bone
Example: split calvarial bone graft,
most commonly taken from parietal
• Membranous bone formation
Bone derived from mesenchymal
Examples: cranial vault, facial
• Enchondral bone formation
Cartilage replaced by bone
Example: long bones
• Creeping substitution
Process where new vascularity
carries osteoblasts to form new
Occurs faster in cancellous than in
cortical bone grafts
• Bone morphogenetic protein (BMP)
Stimulates osteogenesis
Example: recombinant human BMP
• Pediatric cranioplasty
Calvarial bone graft: cannot split
until diploic space forms after 4
years old (some may argue earlier
is possible)
Particulate bone: harvested with
low-speed bur, usable at any age
Bone dust: powder harvested with
high-speed bur, may be nonviable
due to heat during harvest

Cartilage Grafts
• Uses
Craniofacial skeleton
• Compared to bone grafts, cartilage
Resorb less
Have less healing potential
Have fewer donor sites
Are carved easily
Do not need vascular supply
• Warping
Scoring cartilage leads to curving
toward contralateral side

Suggested Reading
Greene AK, Mulliken JB, Proctor MR,
Rogers GF. Pediatric cranioplasty
using particulate calvarial bone
graft. Plast Reconstr Surg
Hallock GG, Morris SF. Skin grafts and
local flaps. Plast Reconstr Surg
Lee WP, Feili-Hariri M, Butler P.
Transplant biology and applications
to plastic surgery. In:
Thorne CH, Beasley RW, Aston SJ, et
al, eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Lipschitz AH, Kenkel JM. Implantation:
Bone, Cartilage, and Alloplasts.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2004;1–34.
Selected Readings in Plastic
Surgery vol 10, issue 2
Motoki DS, Mulliken JB. The healing of
bone and cartilage. Clin Plast Surg
Thornton JF, Gosman AA. Skin Grafts
and Skin Substitutes and Principles
of Flaps. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2004;1–78. Selected Readings in
Plastic Surgery; vol 10, issue 1
Vercler CJ, Sugg KB, Buchman SR.
Split cranial bone grafting in
children younger than 3 years old:
debunking a surgical myth. Plast
Reconstr Surg 2014 133: 822e-827e
4 Flaps and Microsurgery
Reviewed by Suhail Khuzema Kanchwala

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

One dominant

Tensor fascia lata branch of lateral
femoral artery

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

branch of lateral
Vastus lateralis
femoral artery

Deep circumflex
iliac artery (off
external iliac
artery) courses
along inner
border of iliac
Iliac lateral femoral
osseomusculocutaneous cutaneous nerve
of thigh on
iliacus muscle,
runs medial to
anterior superior
iliac spine,
passes downward
under inguinal
ligament to thigh

Table 4.3 Type II muscle/musculocutaneous

Dominant Minor
Flap pedicle(s) pedicle(s)

Gracilis femoral
brevis and
gracilis 8–
10 cm
inferior to
branch of
lateral Superficial
Rectus femoris
circumflex femoral
femoral artery

posterior Posterior
tibial artery, tibial artery
and peroneal

Occipital superior
artery thyroid
artery, bran

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

Table 4.4 Type III muscle/musculocutaneous


Two dominant

Superior and
inferior gluteal
Gluteus maximus
arteries (off internal
iliac artery)

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

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

Lateral thoracic and

Serratus thoracodorsal

Table 4.5 Type IV muscle/musculocutaneous


Flap Segmental pedicles

Superficial femoral
Sartorius artery

Tibialis anterior Anterior tibial artery

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

Table 4.6 Type V muscle/musculocutaneous

Flap One dominant Secondary
pedicle segmental

Lumbar and
Latissimus Thoracodorsal posterior
dorsi artery intercostal

Pectoralis Thoracoacromial
major artery

and lumbar
Internal Deep circumflex
oblique iliac artery
Nutrient Periosteal
endosteal artery and
(off peroneal muscular
Fibula artery) branches

Table 4.7 Innervation of thigh flaps

Motor Sensory
nerve nerve

Gracilis Obturator
Rectus femoris Anterior
(harvest results in femoral
15-degree Femoral cutaneous
extensor lag of (L2–L3)

Vastus lateralis Femoral

Superior (T12–L3),
Tensor fascia lata
gluteal lumbar
V-Y hamstring femoral
(biceps femoris, cutaneous
semitendinous, (S1–S3)
semimembranous) below level
of most
Fig. 4.1 Vascular supply to the iliac
osteocutaneous flap, cutaneous groin flap, TFL,
vastus lateralis muscle, rectus femoris muscle,
and gracilis muscle. DCIA, deep circumflex
iliac artery; DIEA, deep inferior epigastric
artery; LCFA, lateral circumflex femoral
artery; MCFA, medial circumflex femoral
artery; SCIA, superficial circumflex iliac
artery; SIEA, superficial inferior epigastric
artery; TFL, tensor fascia lata.
Fig. 4.2 External oblique muscles.
Fasciocutaneous Flaps
(Table 4.8) (Fig. 4.3)
• Anterior lateral thigh flap
Type B septocutaneous pedicle:
perforates between rectus femoris
and vastus lateralis muscles
Type C musculocutaneous pedicle:
perforates on medial aspect of
vastus lateralis muscle, can
harvest a cuff of vastus lateralis
• Peroneal artery flap
Type B fasciocutaneous flap based
on peroneal artery
Coverage: middle and lower thirds
of leg
• Lateral calcaneal flap (Fig. 4.4)
Variation of peroneal artery flap
Pedicle: terminal branch of
peroneal artery
Coverage: lateral ankle
Preoperative Doppler: check for
• Posterior interosseous flap
Fasciocutaneous flap: type B
Pedicle: posterior interosseous
artery (off ulnar artery) travels
between extensor carpi ulnaris and
extensor digiti minimi
Retrograde pedicle: based on
anterior interosseous artery
Coverage: elbow, wrist, dorsum of
hand, thumb web space, proximal
phalanx thumb
Fig. 4.3 Mathes–Nahai fasciocutaneous flap
Fig. 4.4 Lateral calcaneal artery flap.

• Lateral arm flap

Fasciocutaneous flap: type B
Pedicle: posterior radial collateral
artery (off profunda brachii artery)
arises between brachialis and
Reverse flap pedicle: radial
recurrent artery (off radial artery)
Free flap: covers dorsum of hand
• Scapular and parascapular flaps (Fig.
Fasciocutaneous flaps: type B
septocutaneous flaps
Scapular flap: based on transverse
branch of circumflex scapular
Parascapular flap: based on
vertical branch of circumflex
scapular artery
Triangular space: space between
teres minor, teres major, and long
head of triceps transmits the
circumflex scapular artery (branch
of subscapular artery, which is
branch of axillary artery;
subscapular artery also later gives
off thoracodorsal artery)
Fig. 4.5 Scapular and parascapular flaps.

Quadrangular space: space

between teres minor, teres major,
long head of triceps, and humeral
neck transmits the posterior
humeral circumflex artery (not
circumflex scapular artery)
Coverage: head and neck, upper
and lower extremity
Osseocutaneous flap: can harvest
bone from lateral scapula
• Radial forearm fasciocutaneous free
Fasciocutaneous flap: type B
Reconstructive uses: lower lip,
tongue, penis, nose (prelaminated),
marginal mandibulectomy defects
(osseocutaneous flap), lower
Allen test: preoperative evaluation
confirms ulnar artery dominant
supply to hand, but if hand gets
cold after flap harvest, do vein
At level of elbow, radial artery
arises between: brachioradialis
and pronator teres
At level of midforearm, radial
artery arises between:
brachioradialis and flexor carpi
At the level of the wrist, radial
artery arises between: abductor
pollicis longus and flexor carpi
Leave paratenon on flap donor site
for skin graft
Radial bone harvested between:
brachioradialis and pronator teres
(can take up to 10 cm and 40%
diameter of radius); bone harvest
risks distal radius fracture and so
must plate radius if taking bone

Fig. 4.6 Radial artery anatomical landmarks.

APL, abductor pollicis longus; FCR, flexor
carpi radialis.

• Distally based radial forearm

pedicled flap venous outflow
bypasses valves through (Fig. 4.6)
Collateral branches of each same
Communicating branches crossing
over between two venae

• Free flap monitoring
Clinical observation (most
accurate): check skin color,
temperature, capillary refill,
muscle flap turgor, needle stick
Exteriorize free jejunal flap to
esophagus, because
esophagoscopy is not practical for
frequent monitoring
Doppler ultrasound
Implantable Doppler: for buried
Pulse oximetry: useful with
replants and toe to thumb transfer
Quantitative fluoroscopy: uses
fluorescein dye, which can cause
Temperature monitoring
• Free flap failure
Most common time: first 24 hours
Most common cause: technical
(surgical skill)
Venous thrombosis more common
than arterial thrombosis
Treatment: immediately return to
operating room to explore
Radiation, smoking, and obesity:
lead to worse peripheral flap
perfusion (microcirculation),
• Multiple free flap failures from
Check platelets if on heparin: rule
out heparin-induced
Sickle cell: causes sludging
Look for local options if multiple
free flap failures have occurred;
can always perform delayed
pedicled flaps in multiple stages
Pediatric microsurgery: higher
sympathetic tone and vasospasms,
but not a risk factor for thrombosis
• Flap perfusion may be improved by
the following:
Heparin and dextran:
anticoagulants inhibit platelet
aggregation, decrease platelet
Heparin mechanism of action:
activates antithrombin III,
inactivates thrombin
Nifedipine: calcium channel
blocker, smooth muscle cell
relaxant causes vasodilation
Topical nitroglycerin: affects
venous circulation on axial and
random flaps
Anti-inflammatory agents and
corticosteroids (prednisolone):
cause vasodilation and anti-
inflammatory properties
plasminogen activator (TPA):
thrombolytics administered via
intravascular infusion. These
agents are utilized to salvage a
free-flap thrombosis. Mechanism:
convert plasminogen to plasmin,
breaking down fibrinogen and
fibrin found in proximal
thrombosis, can cause bleeding
(TPA causes least bleeding
because acts locally, enhanced by
fibrin presence in clot)
• Dextran
Volume expander and anticoagulant
improves flap perfusion
Decreases clotting factor VIII and
von Willebrand factor, causing
decreased platelet function
Increases alpha-2 antiplasmin,
leads to increased plasminogen
Increases electronegativity of
platelets, preventing aggregation
Modifies fibrin structure, leads to
fibrin degradation
Give test dose to prevent
anaphylaxis reaction (adult
respiratory distress)
• Mechanisms of delay
Open choke vessels
Vascular reorganization
Reactive hyperemia
Nonspecific inflammatory reaction
Acclimatization to hypoxemia
• Anastomotic coupler devices
Anastomosis of veins and arteries
Saves time versus hand suturing
Can use with size mismatch
Cannot use with rigid vessels
(radiation, plaques)
• Medicinal leeches (Hiruda
Use: relieve venous congestion
Aeromonas hydrophila: gram-
negative bacteria found in gut of
Antibiotic prophylaxis: Bactrim
(AR Scientific, Philadelphia, PA)
(trimethoprim sulfamethoxazole
[TMP-SMX]), ciprofloxacin, and
• Venous flow through flap
Thin flap with inflow and outflow
Coverage: small wounds on hand
or finger
Arterialized through microsurgical
Epidermolysis and congestion for
approximately 1 week

Perineal and Penile

• Perineal and vaginal reconstruction
VRAM: gold standard, leaves
abdominal scar, has skin paddle,
good blood flow
Pudendal flap: sensate with
pudendal nerve (S2–S4)
Posterior thigh flap: sensate with
posterior femoral cutaneous nerve
• Penile reconstruction: single stage
with radial forearm free flap
• Penis replantation: reanastomose
dorsal vein, dorsal nerve, deep
dorsal artery, and urethra

Suggested Reading
Angrigiani C, Grilli D, Dominikow D,
Zancolli EA. Posterior interosseous
reverse forearm flap: experience
with 80 consecutive cases. Plast
Reconstr Surg 1993;92(2):285–293
Ariyan S. One-stage reconstruction for
defects of the mouth using a
sternomastoid myocutaneous flap.
Plast Reconstr Surg
Bakamjian VY, Long M, Rigg B.
Experience with the medially based
deltopectoral flap in reconstructive
surgery of the head and neck. Br J
Plast Surg 1971;24(2):174
Das SK. The size of the human omentum
and methods of lengthening it for
transplantation. Br J Plast Surg
Forrest C, Boyd B, Manktelow R, Zuker
R, Bowen V. The free vascularised
iliac crest tissue transfer: donor site
complications associated with
eighty-two cases. Br J Plast Surg
Freeman JL, Walker EP, Wilson JSP,
Shaw HJ. The vascular anatomy of
the pectoralis major myocutaneous
flap. Br J Plast Surg 1981;34(1):3–
Giordano PA, Abbes M, Pequignot JP.
Gracilis blood supply: anatomical
and clinical re-evaluation. Br J
Plast Surg 1990;43(3):266–272
Griffin JR, Thornton JF. Microsurgery:
Free Tissue Transfer and
Replantation. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005;1–39. Selected Readings in
Plastic Surgery; vol 10, issue 5
Gu YD, Wu MM, Li HR. Lateral lower
leg skin flap. Ann Plast Surg
Hallock GG, Morris SF. Skin grafts and
local flaps. Plast Reconstr Surg
Lin SD, Lai CS, Chiu CC. Venous
drainage in the reverse forearm flap.
Plast Reconstr Surg
Mathes SJ, Nahai F. Classification of the
vascular anatomy of muscles:
experimental and clinical
correlation. Plast Reconstr Surg
Mathes SJ, Vasconez LO. The
cervicohumeral flap. Plast Reconstr
Surg 1978;61(1):7–12
Monstrey S, Blondeel P, Van Landuyt K,
Verpaele A, Tonnard P, Matton G.
The versatility of the pudendal thigh
fasciocutaneous flap used as an
island flap. Plast Reconstr Surg
Ramasastry SS, Tucker JB, Swartz WM,
Hurwitz DJ. The internal oblique
muscle flap: an anatomic and
clinical study. Plast Reconstr Surg
Rowsell AR, Davies DM, Eisenberg N,
Taylor GI. The anatomy of the
subscapular-thoracodorsal arterial
system: study of 100 cadaver
dissections. Br J Plast Surg
Snower DP, Ruef C, Kuritza AP, Edberg
SC. Aeromonas hydrophila infection
associated with the use of medicinal
leeches. J Clin Microbiol
Spear SL, Walker RK. The external
oblique flap for reconstruction of
the rectus sheath. Plast Reconstr
Surg 1992;90(4):608–613
Stan M, Blondeel P, Van Landuyt K, et
al. The versatility of the pudendal
thigh fasciocutaneous flap Used as
an island flap. Plast Reconstr Surg
Thornton JF, Gosman AA. Skin Grafts
and Skin Substitutes and Principles
of Flaps. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2004;1–78. Selected Readings in
Plastic Surgery; vol 10, issue 1
Timmons MJ. The vascular basis of the
radial forearm flap. Plast Reconstr
Surg 1986;77(1):80–92
Watson JS, Craig RD, Orton CI. The
free latissimus dorsi myocutaneous
flap. Plast Reconstr Surg
Zhou G, Qiao Q, Chen GY, Ling YC,
Swift R. Clinical experience and
surgical anatomy of 32 free
anterolateral thigh flap
transplantations. Br J Plast Surg
5 Implants and Biomaterials
Reviewed by Michael J. Yaremchuk

• Purpose: reconstruct soft tissue and
osseous defects, cosmetic surgery,
reconstructive surgery
• Ideal implant
Inert, causes no foreign body
Resistant to infection
No donor site morbidity
• Autologous tissue preferred in some
Poor quality of surrounding tissue
Lack of soft tissue coverage
Compromised vascularity
• Alloplastic implants to augment
facial skeleton
Smooth contour
No donor site morbidity
No resorption
Simplifies procedure (time,
Placement technique: antibiotic
prophylaxis, sterile handling, wide
subperiosteal undermining to
develop pocket
• Solid silicone
Resists compression
Resorption of underlying bone
Forms fibrous capsule
Easy to remove with revisional
• Porous polyethylene (Medpor)
Allows for tissue ingrowth because
Difficult to remove with revisional
• Metal
Used in craniofacial, hand,
orthopedic, dental surgery
• Calcium bone substitutes
Hydroxyapatite: calcium substitute
Tricalcium phosphate (TCP)
Calcium phosphate cement
(Norian, Synthes, West Chester,
• Polymethyl methacrylate (PMMA)
Exothermic reaction
Used for cranioplasty
• Resorbable plating
Poly-L-lactic acid and poly-
glycolic acid
Useful for pediatric craniofacial

• AlloDerm (LifeCell Corp.,
Bridgewater, NJ)
Acellular human cadaveric dermis
• Apligraf (Organogenesis, Inc.,
Canton, MA)
Neonatal foreskin epidermal
keratinocytes, dermal fibroblasts,
matrix bovine collagen
Venous stasis ulcer and diabetic
foot ulcer dressing
Requires multiple applications
• Biobrane (Smith & Nephew,
Andover, MA)
Nylon and silicone fabric coated
with porcine collagen
Temporary burn dressing
• Integra Dermal Regeneration
Template (Integra LifeSciences
Corp., Plainsboro, NJ)
Bilayer skin substitute composed
of dermal matrix bovine collagen
and shark-derived chondroitan-6-
sulfate, covered with a layer of
Remove silicone layer after 21
days and cover with split-
thickness skin graft
Used for full-thickness and partial-
thickness wounds, burn
reconstruction, tendon without
paratenon, cartilage without
perichondrium, and bone without
• TransCyte (Advanced Tissue
Sciences, La Jolla, CA)
Temporary human skin substitute
with dermal fibroblasts cultured
on a nylon mesh coated with
porcine dermal collagen, bonded
to silicone membrane
• Surgisis (Cook Biotech, West
Lafayette, IN)
Porcine small intestine submucosa
(SIS) with collagen

Suggested Reading
Breitbart AS, Ablaza VJ. Implant
materials. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2006:58–65
Lipschitz AH, Kenkel JM. Implantation:
Bone, Cartilage, and Alloplasts.
Dallas TX: Selected Readings in
Plastic Surgery, Inc.; 2004:1–34.
Selected Readings in Plastic
Surgery; vol 10, issue 2
Yaremchuk MJ. Facial skeletal
reconstruction using porous
polyethylene implants. Plast
Reconstr Surg 2003;111(6):1818–
Yaremchuk MJ. Improving aesthetic
outcomes after alloplastic chin
augmentation. Plast Reconstr Surg
2003;112(5):1422–1432, discussion
Yaremchuk MJ. Mandibular
augmentation. Plast Reconstr Surg
6 Burns
Reviewed by Ludwik K. Branski

Thermal Burns
• Degrees of burns (Table 6.1)
• Zones of injury
Coagulation: necrotic center
Stasis: could become necrotic or
live (watch for demarcation, could
improve with fluids and wound
Hyperemia: outer margin will live
Table 6.1 Degrees of burns
1st Sunburn, heals

Partial thickness,
blisters, superficial
second-degree burn
is sensate, deep
second-degree burn
2nd is insensate,
spontaneously, treat
with cleaning,
debridement, topical

Full thickness,
insensate, charred,
require excision and
skin grafting
Burn Center Transfer
Second- and third-degree burns >
20% total body surface area
(TBSA) in patients 10 to 50 years
Third-degree burns > 5% TBSA in
any age group
Second- and third-degree burns
involving the face, hands, feet,
genitalia, perineum, or major
Electric burns, including lightning
Chemical burns with serious threat
of functional or cosmetic
Inhalation injuries
Lesser burns in patients with
preexisting medical conditions
Problems that could complicate
Combined mechanical and thermal
injury in which the burn wound
poses the greater risk
• Immunology
⇩ Leukocyte function
⇧ Complement activation
⇧ Suppressor T lymphocytes
⇩ Help T cell lymphocytes
⇩ Production immunoglobulins
⇧ Erythroblasts (predicts mortality)
• Rule of nines to estimate TBSA (Fig.
6.1): the rule of nines differs
between adult and pediatric patients
based on differences in body
proportions (i.e., pediatric head size
is larger relative to body size
compared to the adult head size)
Fig. 6.1 Rule of nines for (a) adult and (b)
pediatric patients.

• Parkland rule for fluid management

4 × TBSA kg = 24 h intravenous
fluid (IVF)
Give half in first 8 hours, half in
next 16 hours
Calculate hourly rate based on
hours after injury
For burns > 20% TBSA
Parkland Rule should only be used
as a general guideline because
severe over-resuscitation with
lung and tissue edema can occur if
too much fluid is administered.
• Fluid management
Practice calculation: a 70 kg
patient presents 4 hours after
sustaining a 30% TBSA: 4 × 70 ×
30 = 8400/2 = 4,200 mL in first 8
hours, give 4,200/4 hours
remaining in first 8 hours = 1,050
mL/h for first 4 hours. Then give
4,200/16 = 262.5 mL/h for next 16
Add 5% albumin after 24 hours to
maintain intravascular volume
Sensitive markers of fluid
resuscitation course: urine output
(most common), mean arterial
pressure, pH and base deficit
• Nutrition for burn patients
Protein requirements: 1.5 to > 2.0
g/kg/d for adults, up to 3.0 g/kg/d
for children
Fat requirements: up to 1 g/kg/day
Arginine, Vitamins A, C, Zn, and
Cu supplements
Modulators of hypermetabolic
response: propranolol, growth
hormone, insulin, and oxandrolone
• Mechanism of action of silver (used
in Silvadene and numerous burn
wound dressings widely used such as
Mepilex AG)
Antimicrobial: poisons microbe
cell respiration (Table 6.2)
Wound healing: inhibits excessive
activity of matrix
metalloproteinase (MMP), a
collagenase, by decreasing zinc
(essential for MMP activity)
Silver nitrate: has silver, like
Silvadene, but unlike Silvadene
can rarely cause
methemoglobinemia (silver nitrate
is used wisely without
• Contractures
Areas of contracture: neck, hands,
wrist, elbows, shoulders
Prevention: use full-thickness, not
split-thickness, grafts, maintain
position opposite direction of
contraction while graft is healing
and use compression garments
Treatment: excision/grafting, local
tissue rearrangement (Z-plasty),
distant flaps (parascapular flap),
Integra Dermal Regeneration
Template (Integra LifeSciences
Corp., Plainsboro, NJ)
Integra: useful for patients with
mentosternal contractures and high
TBSA with no viable distant tissue
to harvest (Integra is collagen,
glycosaminoglycan covered by
silicone; at postoperative day 21
the silicone is removed and STSG
is placed)
• Inhalational injury
Mechanism of injury: burned in
closed space, asphyxiation, direct
mechanical injury of particles to
airway, upper airway thermal
Carboxyhemoglobin (COHb) may
be elevated > 15% (10% seen in
Bronchoscopy: used to rule out
airway disease if there is singed
nasal hair and carbonaceous
sputum, find erythema and sooty
deposits in airway
Table 6.2 Topical antimicrobials


No Yes

Antipseudomonal No Yes

Can use with

No Yes
sulfa allergy

Painful No No

acetate (
Side effects Granulocytopenia acidosis
(MA) be

Treatment: supportive, possibly

prophylactic intubation, aggressive
suctioning, bronchodilators,
inhalative heparin, fluid
resuscitation, aggressive diuresis
often necessary at later timepoint
• Complications from burn
Pneumonia: most common cause of
Burn shock: can try to prevent with
IVF resuscitation but unfortunately
still common
Over-resuscitation with severe
lung and tissue edema
Infection: depends largely on the
size of the burn; almost all large
burns get infected; give
prophylactic topical antibiotics,
give Zosyn for antipseudomonal
prophylaxis, vancomycin for
Staphylococcus aureus (MRSA)
Arrhythmias: succinylcholine use
in burn patients can lead to
hyperkalemia-induced arrhythmias

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

Electric Burns
• Electric burns
Injury may be worse than appears
on surface
Electrocardiography to confirm
heart in normal rhythm
Heat injury along bone and deeper
compartments where increased
Check for compartment syndrome
(e.g., by measuring compartment
If needed release compartments
and debride deeper tissues
• Myoglobinuria
Electric burns can injure muscles,
leading to rhabdomyolysis
Symptoms: red urine from
myoglobin released into the urine,
renal failure
Treatment: check for compartment
syndrome—if present, fasciotomy
is mandatory; fasciotomy of volar
forearm includes decompression
of the carpal tunnel and pronator
quadratus in the deep compartment
Supportive treatment includes IV
fluids, diuresis with Lasix,
Diamox and mannitol, and sodium
Chemical Burns (Table 6.3)
Table 6.3 Chemical burns

Chemical Antidote

Water irrigation,
White phosphorus Wood's lamp,

Calcium gluconate
Hydrofluoric acid
gel or injection

Cool tar, then fat

emulsifier such as
Neosporin (Johnson
Tar & Johnson, New
Brunswick, NJ)
(Tween 80, Sigma-
(Tween 80, Sigma-
Aldrich, St. Louis,
MO), or mineral oil

Dermatologic Conditions
Requiring Burn Care
• Toxic epidermal necrolysis (TEN)
Life-threatening epidermal
sloughing and blisters, mucosal
inflammation and ulceration
Involves 30 to 100% TBSA
Etiology: infection, drug-related
(phenobarbital, diphenylhydantoin,
sulfonamides, antibiotics,
nonsteroidal anti-inflammatory
Treatment: transfer to burn center,
stop offending drug, prevent
• Stevens–Johnson syndrome (SJS)
TEN and SJS are part of same
spectrum of disease
SJS involves < 30% TBSA
Treatment: same as for TEN
• Erythema multiforme (EM)
Does not require burn care
Confused with TEN and SJS
Self-limited maculopapular target
Minor form cutaneous, major form
involves mucous membranes
• Purpura fulminans
Etiology: hereditary deficiency of
anticoagulants (protein S, protein
C, antithrombin III), infection
(Neisseria meningitidis)
Diagnosis: rapidly progressive
hemorrhagic bullae, septic shock,
disseminated intravascular
coagulation, low assay levels of
Treatment: antibiotics, supportive
care, activated protein C,
debridement and digit amputation
once dermatologic condition

Suggested Reading
Bezuhly M, Fish JS. Acute burn care.
Plast Reconstr Surg
Broughton G, Zbar RI. Burns and
Postburn Reconstruction. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2005:1–27. Selected
Readings in Plastic Surgery; vol
10, issue 7
Donelan MB. Principles of burn
reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:150–161
Klein MB. Thermal, chemical, and
electrical injuries. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:132–149
7 Trunk Reconstruction
Reviewed by Derek E. Bell

Abdominal Wall Anatomy

• Arcuate line: lower limit of posterior
rectus sheath
• Anatomy above the arcuate line (Fig.
Rectus is covered by posterior and
anterior rectus sheaths
External oblique and anterior half
of internal oblique aponeurotic
fibers form the anterior rectus
Posterior half of the internal
oblique sheath, and the transversus
abdominis aponeurosis, form the
posterior rectus sheath
Transversalis fascia is the most
posterior layer
• Anatomy below the arcuate line
Rectus is covered ventrally by only
anterior rectus sheath
External oblique, internal oblique,
and transversus abdominis
aponeuroses form the anterior
rectus sheath
• Blood supply
Upper abdomen supplied by
superior epigastric artery
Lower abdomen supplied by
inferior epigastric (deep and
superficial) arteries
Lateral abdomen supplied by
intercostals and lumbar vessels

Abdominal Wall
• Flap reconstruction
Component separation: rectus
advancement covers midline
abdominal defects
Tensor fascia lata (TFL): covers
lower abdominal defects
Gracilis: covers lower abdominal
Vastus lateralis: covers lower
abdominal defects
Fig. 7.1 Structure of the rectus sheath. (From
Schuenke M, Schulte E, Schumacher U.
General Anatomy and Musculoskeletal
System. Stuttgart, Germany: Thieme; 2010.
Used with permission.)

Free flaps (latissimus dorsi, TFL):

if no local options exist
Abdominal wall transplant: if no
local and free flap options
• Mutton chop flap
Named after extravagant 19th
century sideburns
Rectus femoris flaps (unilateral or
bilateral) with or without TFL
Can include distal posterior lateral
iliotibial tract into the fascial unit
• Component separation
Described by Dr. Oscar Ramirez in
1990 to medialize the rectus
abdominis muscles with attached
internal oblique muscle and trans-
versus abdominis muscle to the
Can close 10 cm, 20 cm, and 5 cm
in epigastric, midabdominal, and
low abdominal regions,
Includes extra 2 cm for incising
posterior rectus fascia
If > 20 cm defect, add mesh to
Do not need tissue expansion
unless missing skin
Incise external oblique aponeurosis
2 cm lateral to the rectus
abdominis muscle
Separate plane between the
external and internal oblique
Violation of the plane between the
internal oblique and transversus
abdominis could damage the
innervation to the rectus abdominis
muscles (regional block for
abdominoplasty is administered in
this plane)
Open book technique: modification
of component separation includes
single fascial incision releasing
external oblique and concurrently
creates an anterior rectus sheath
turnover flap
• Prosthetic mesh
Polytetrafluoroethylene: Gortex
Polypropylene (Marlex or Prolene)
Used in clean fields because needs
to be removed if infected
Increased risk of adhesions, bowel
obstruction, and fistula formation
compared to biologic mesh
• Biologic mesh
AlloDerm (LifeCell Corp.,
Bridgewater, NJ): human
cadaveric acellular dermal
Strattice (LifeCell): porcine
acellular dermal matrix
Permacol (Covidien, Mansfield,
MA): porcine dermal collagen
Surgisis (Cook Biotech, West
Lafayette, IN): porcine small
intestine submucosa
Contaminated field
Immunocompromised patients
If concerned about wound
breakdown and exposure of
prosthetic mesh

Chest Reconstruction (Table

• Flap options
Pectoralis major muscle
advancement flap
Based on the thoracoacromial
Most commonly used flap to
cover the anterior central chest,
especially superior chest
Pectoralis major muscle turnover
flap: based on the internal
mammary artery (IMA)
Rectus abdominis muscle flap:
based on superior epigastric artery
(if IMA patent)
Omental flap
Based on gastroepiploic artery
Covers large chest wounds
Used if pectoralis flap or rectus
abdominus muscle not options
Latissimus dorsi muscle
Based on thoracodorsal artery
Covers ipsilateral hemithorax
and sternum
Sternal debridement and immediate
reconstruction for early wound
infections, versus staged
reconstruction after multiple
debridements for chronic infected

Congenital Chest Anomalies

• Marfan syndrome
Connective tissue disorder
Patients are tall with a concave
chest (pectus excavatum)
Usually asymptomatic unless
compression of heart from a
severe deformity
• Anterior thoracic hypoplasia
Syndrome of anterior chest wall
depression, posteriorly displaced
ribs, hypoplasia of ipsilateral
breast, superiorly displaced nipple
areola complex

Sternum and pectoralis are normal

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

Lower Back Reconstruction

• Spina bifida
Congenital neural tube defect
Vertebrae not fully formed
Skin covering present
• Myelomeningocele
Most severe form of spina bifida
Neural sac exposed without skin
Treatment: local paraspinous
musculofascial flaps followed by
coverage with skin advancement
• Lower back wound
Reverse latissimus dorsi flap:
coverage over inferior posterior
Skin graft: if no exposed vertebrae
No recipient vessels for free flap

Suggested Reading
Arnold PG, Pairolero PC. Chest-Wall
reconstruction: an account of 500
consecutive patients. Plast Reconstr
Surg 98(5): 804-810, 1996
Butler CE, Langstein HN, Kronowitz SJ.
Pelvic, abdominal, and chest wall
reconstruction with AlloDerm in
patients at increased risk for mesh-
related complications. Plast
Reconstr Surg 2005;116(5):1263–
1275, discussion 1276–1277
Chang RR. Thoracic reconstruction. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:665–669
Dibbell DG Jr, Mixter RC, Dibbell DG
Sr. Abdominal wall reconstruction
(the “mutton chop” flap). Plast
Reconstr Surg 1991;87(1):60–65
Dumanian GA. Abdominal wall
reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:670–675
Fiala TG, Buchman SR, Muraszko KM.
Use of lumbar periosteal turnover
flaps in myelomeningocele closure.
Neurosurgery 1996;39(3):522–525,
discussion 525–526
Hoxworth RE. Trunk Reconstruction.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2009:1–60.
Selected Readings in Plastic
Surgery; vol 10, issue 24
Izaddoost S, Withers EH. Sternal
reconstruction with omental and
pectoralis flaps: a review of 415
consecutive cases. Ann Plast Surg
Mathes SJ, Steinwald PM. Foster RD, et
al. Complex Abdominal Wall
Reconstruction: a Comparison of
Flap and Mesh Closure. Ann Surg
2000 Oct; 232(4): 586–596
Mericli AF, Bell D, DeGeorge BR Jr, et
al. The single fascial incision
modification of the “0pen-book”
component separation repair: a 15-
Year experience. Ann Plast Surg
2013;71(20): 203–20
Netscher DT, Baumholtz MA. Chest
reconstruction: I. Anterior and
anterolateral chest wall and wounds
affecting respiratory function. Plast
Reconstr Surg 2009;124(5):240e–
Netscher DT, Baumholtz MA, Bullocks
J. Chest reconstruction: II. Regional
reconstruction of chest wall wounds
that do not affect respiratory
function (axilla, posterolateral
chest, and posterior trunk). Plast
Reconstr Surg 2009;124(6):427e–
Ramirez OM, Ruas E, Dellon AL.
“Components separation” method
for closure of abdominal-wall
defects: an anatomic and clinical
study. Plast Reconstr Surg
Rubayi S, Chandrasekhar BS. Trunk,
abdomen, and pressure sore
reconstruction. Plast Reconstr Surg
Shestak KC, Edington HJ, Johnson RR.
The separation of anatomic
components technique for the
reconstruction of massive midline
abdominal wall defects: anatomy,
surgical technique, applications, and
limitations revisited. Plast Reconstr
Surg 2000;105(2):731–738, quiz
van Aalst JA, Phillips JD, Sadove AM;
van AJ. Pediatric chest wall and
breast deformities. Plast Reconstr
Surg 2009;124(1, Suppl):38e–49e
8 Tissue Expansion
Reviewed by Sara R. Dickie

• Effects of tissue expansion

Epidermis thickens
Dermis thins
Dermal elastic fibers
Dermal interstitial fluid displaced
Collagen fibers realign
Rete ridges flatten
Underlying bones thin
Skeletal muscles atrophy
Vascular endothelial growth factors
(VEGFs) upregulated during
Circulation increased in delayed
Surface area increases as cells
creep (stretch then proliferate)
• Delay procedure
Immediate tissue expansion is
suboptimal for acute wounds
Need healed skin with no evidence
of infection
• If erythema, mottling, severe pain
without fever or purulent drainage
Withdraw fluid or deflate
Do not remove expander
• Calculate tissue expansion design to
fill defect (Fig. 8.1)
Amount of advancement achieved
by tissue expansion to fill the
defect can be calculated
Subtract the diameter of the tissue
expander base (A) from the
distance of the arc of skin
overlying the tissue expander (C)
This calculation refers to direct
advancement only. Flaps expanded
many times can be rotated or
transposed and therefore this
calculation does not apply
• Scalp expansion
Place between galea and
Used for large wounds > 6 cm (>
15%) and alopecia
• Forehead expansion: place between
frontalis muscle and periosteum
• Breast expansion and radiation

Fig. 8.1 Tissue expander.

Autologous reconstruction after

radiation has improved aesthetic
outcomes and reduced
complications compared with
implant reconstruction
If an implant-based reconstruction
has to be radiated, for best
outcomes remove the tissue
expander, radiate, and convert to
autologous reconstruction
Can also deflate, radiate, reinflate,
then do implant or autologous-
based reconstruction
• Failures in tissue expansion
Complications: infection,
extrusion, pain, failure of device
Lower extremity: highest
complication rates 37 to 50%
Scalp: complication rates < 20%
Areas of greater skin elasticity:
lowest complication rates
• Giant congenital melanocytic nevi
Treat with tissue expansion and
staged excision
Do not do punch biopsy because
risk of false-negative results
Estimated 5% risk of malignant
transformation (newer data
suggests 2 to 3% risk)
In comparison, for small nevi,
melanoma risk is < 1%: may
observe or excise
• Osmotic tissue expander
Composed of: hydrogel (vinyl
pyrrolidine and
Second generation has silicone
membrane with pores
Self-filling, no injections required,
decreased infection rate compared
with conventional tissue expansion
with external fillings
Drawbacks: cannot slow or stop
expansion, cannot overfill

Suggested Reading
Anwander T, Schneider M, Gloger W, et
al. Investigation of the expansion
properties of osmotic expanders
with and without silicone shell in
animals. Plast Reconstr Surg
Arneja JS, Gosain AK. Giant congenital
melanocytic nevi. Plast Reconstr
Surg 2009;124(1, Suppl):1e–13e
Bauer BS. Tissue expansion. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Gosain AK, Santoro TD, Larson DL,
Gingrass RP. Giant congenital nevi:
a 20-year experience and an
algorithm for their management.
Plast Reconstr Surg
Hudson DA, Grob M. Optimising results
with tissue expansion: 10 simple
rules for successful tissue expander
insertion. Burns 2005;31(1):1–4
Krengel S, Hauschild A, Schafer T.
Melanoma Risk in Congenital
Melanocytic Naevi: a Systematic
Review. Br. J. Dermatol. 155(1):1–
8, 2006
9 Lymphedema and Pressure
Reviewed by Reid A. Maclellan

• Definitions
Primary lymphedema: abnormal
collection of interstitial fluid due
to embryological lymphatic
Secondary lymphedema: acquired
lymphatic obstruction
• Causes (Table 9.1)
• Symptoms
Thick, peau d'orange skin due to
congested dermal lymphatics
Pits, fissures, and open wounds
accommodate debris and bacteria
Lymphorrhea: leakage of lymph out
of the skin
• Nonsurgical treatment
Start with conservative therapy:
compression, elevation, physical
therapy, weight loss
Do not compress with Unna boots
(for venous stasis not for
Diuretics are not a useful treatment
• Surgical treatment
Liposuction only for mild/moderate
cases, still need compression
Table 9.1 Causes of lymphedema


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

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

Presenting in
Lymphedema tarda


Most common cause

worldwide, 90% of
all cases, infestation
of lymph nodes by
parasite Wuchereria

Most common cause

in the United States,
Breast cancer mastectomy, axillary
and radiation therapy

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

Staged excision of skin and

subcutaneous tissue: best surgical
procedure (popularized by Miller)
Physiological procedures
(lymphovenous and
lympholymphatic anastomoses) are
not shown to have great long-term
Charles procedure: extreme
operation where skin,
subcutaneous tissue, and fascia are
completely excised; skin from
resected specimen used for
immediate skin grafting
• Stewart–Treves syndrome
Lymphangiosarcoma from long-
standing arm lymphedema after
Best treated by wide local excision
or amputation
• Massive localized lymphedema
(MLL) and morbid obesity
Undergo resection of MLL, then
gastric bypass
Pressure Sores
• Etiology
Prolonged pressure above end
capillary pressure (32 mm Hg)
> 70 mm Hg for > 2 hours causes
irreversible tissue necrosis
Ischial sores from sitting
Sacral ulcers from supine position
Trochanter sores from lateral
decubitus position
Secondary causes: diabetes
mellitus (DM), incontinence,
• Stages (Table 9.2)
• Prevention
Avoid pressure by changing
position every 2 hours
Improve nutrition, control diabetes,
manage comorbidities
Antispasmodics: intrathecal
baclofen via implantable pump
Diverting colostomy to prevent
fecal soilage
Negative pressure wound therapy
does not work over fibrotic
pressure sore
Dry eschars should be directly
excised; do not use Accuzyme
(enzymatic debridement)
• Osteomyelitis
Diagnosis: bone culture
Treatment: resect bone
Do partial ischiectomy if bone
Table 9.2 Staging of pressure sores

Stage Description


II Through dermis

subcutaneous tissue,
III not fascia or muscle

Through fascia or
muscle to bone
Do not do complete ischiectomy,
because will increase pressure on
opposite side
Do not do bilateral ischiectomy,
because will increase pressure on
perineum, leading to
urethrocutaneous fistula
Juncture S2–S3: highest-level bone
debridement without entering dural
Cauda equina L2: end of spinal
cord where bundlelike structures
of nerves exit
• Most common cause of death in
chronic pressure sore patients: renal
• Marjolin ulcers: squamous cell
carcinoma in chronic wound, seen in
0.5% of pressure sores
• Reconstruction (Table 9.3)
If ambulatory, use fasciocutaneous
flap instead of muscle flap to
decrease morbidity (harvesting
gluteus maximus muscle flap
affects ability to rise from a seated
Rehabilitation: patient should
avoid sitting for 3 weeks after
reconstruction, then sitting
protocol is initiated
Table 9.3 Reconstruction of pressure sores

Pressure sore Management

Superior gluteal
Sacrum artery flap,
transverse back flap

flap: use if
ambulatory TFL: use
if paraplegic below
T12, a sensory flap
based on lateral
femoral cutaneous
nerve from T12–L3
spinal roots
Ischium Posterior thigh
(hamstring) V-Y flap
(biceps femoris,
use if paraplegic
above T12; detach
origin of insertion
for additional length;
do not use V-Y if

TFL, vastus lateralis

flap, girdlestone
(remove proximal
femur, stops
contraction and

Suggested Reading
Bauer JD, Mancoll JS, Phillips LG.
Pressure sores. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:722–729
Bauer J, Phillips LG. MOC-PSSM CME
article: Pressure sores. Plast
Reconstr Surg 2008;121(1,
Brorson H, Svensson H. Liposuction
combined with controlled
compression therapy reduces arm
lymphedema more effectively than
controlled compression therapy
alone. Plast Reconstr Surg
1998;102(4): 1058-1067
Chang DW. Lymphaticovenular bypass
for lymphedema management in
breast cancer patients: a prospective
study. Plast Reconstr Surg
Chim H, Drolet B, Duffy K, Koshima I,
Gosain AK. Vascular anomalies and
lymphedema. Plast Reconstr Surg
Rubayi S, Chandrasekhar BS. Trunk,
abdomen, and pressure sore
reconstruction. Plast Reconstr Surg
Rudkin GH, Miller TA. Lymphedema.
In: Thorne CH, Beasley RW, Aston
SJ, et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:717–721
Schook CC, Mulliken JB, Fishman SJ, et
al. Primary lymphedema: clinical
features and management in 138
pediatric patients. Plast Reconstr
Surg 2011;127(6): 2419–2431
Tchanque-Fossuo CN, Kuzon WM Jr. An
evidence-based approach to
pressure sores. Plast Reconstr Surg
10 Skin Lesions and Soft
Tissue Tumors
Reviewed by Jeffrey H. Kozlow

Skin Cancer
• Classification
Squamous cell carcinoma (SCC)
Basal cell carcinoma (BCC)
• Risk factors
Sun exposure: UVB > UVA
Family history
Fair skin complexion (Fitzpatrick
Xeroderma pigmentosum
Autosomal recessive inheritance
Altered DNA repair mechanisms
in response to UV damage
Increased risk for melanoma,
SCC, and BCC
Management: minimize sun
• Prevention
Components: para-amino
benzoic acid (PABA), padimate,
oxybenzone, and zinc oxide

• Melanoma: skin cancer originating
from melanocyte cells
• Layers of epidermis (from superficial
to deep)
Stratum (S) corneum: superficial
S. lucidum
S. granulosum
S. spinosum
S. basale: deep layer containing
• Diagnosis
Mnemonic ABCDE
Asymmetry: shape not
Borders: irregular borders
Color variegation: different
colors within lesion
Diameter: > 6 mm
Evolving: change in size, shape,
color, or new symptom (bleeds,
Punch biopsy: often preferred over
shave biopsy; provides depth of
• Types
Lentigo maligna: least aggressive,
“Hutchinson freckles”
Acral lentiginous: seen in African
Americans, soles and palms
Nodular: aggressive
Superficial spreading: most
• Tumor depth
Breslow: most common
classification of tumor depth
T1 < 1 mm (T1a without
ulceration, T1b with ulceration
and/or mitrotic rate < 1
T2 1 to 2 mm (T2a without
ulceration, T2b with ulceration)
T3 2 to 4 mm (T3a without
ulceration, T3b with ulceration)
T4 > 4 mm (T4a without
ulceration, T4b with ulceration)
Clark's classification of tumor
Mnemonic: Every Pigmented
Junction Requires Formalin
Papillary dermis
Junction of papillary and
reticular dermis
Reticular dermis
Fat (subcutaneous) layer
• Nodal involvement
N0: no nodes
N1: 1 regional lymph node
N2: 2 to 3 nodes or in-transit
N3: ≥ 4 nodes or in-transit disease
N1-3a: microscopic disease; N1-
3b: macroscopic disease; N1-3c:
satellitosis or in-transit
• Metastasis
M0: no metastasis
M1a: skin and distant lymph nodes
M1b: lung
M1c: other organs, elevated serum
lactate dehydrogenase (LDH)
• Staging
0: melanoma in situ
IA: T1a, N0, M0
90% 5-year survival
IB: T1b, N0, M0 or T2a, N0, M0
II: T2b-T4b, N0, M0
45 to 80% 5-year survival
III: any T, N1-3, M0
25 to 65% 5-year survival
Nodal involvement, only, no
distant disease
Candidate for postsurgical
chemotherapy or immunotherapy
IV: any T, any N, M1
5 to 20% 5-year survival
• Surgical margins based on depth
In situ: 0.5 cm margin
< 1 mm deep: 1 cm margin;
sentinel lymph node biopsy
(SLNBx) if between 0.75 to 1.0
mm with increased mitotic rate
1 to 4 mm deep: 2 cm margin and
SLNBx (if 1 to 2 mm deep on face
can do 1 cm margin)
> 4 mm deep: 2 cm margin
• Nail bed melanoma
Melanoma of germinal matrix
Hutchinson sign: paronychial
Shave biopsy
Amputation proximal to most
distal joint with SLNBx based
on depth
Nailbed resection only if
atypical junctional melanocytic
hyperplasia (AJMH) or
melanoma in situ

Sentinel Lymph Node

• Indications
Melanoma 1 to 4 mm deep (T2,
T3) or if between 0.75 to 1.0 mm
with increased mitotic rate
Marjolin SCC
SCC > 2 cm diameter
Merkel cell carcinoma
• Contraindications
Node positive melanoma: do
lymph node dissection, not SLNB

Giant Congenital
Melanocytic Nevi (CMN)
• Definitions
Nevi > 20 cm in diameter in adults
Expected to become 20 cm in
adulthood (translated to 9 cm on an
infant's head)
2% body surface area, or 1% of
body surface area in head and neck
Requires staged excision, often
with tissue expansion and skin
• Melanoma association
Estimated 5% risk of malignant
transformation (newer data
suggests 2 to 3% risk)
• Neurocutaneous melanosis (NCM)
Melanocytes in leptomeninges
Risk factors
Large or multiple axial nevi
Calvarial and posterior midline
Multiple satellite nevi (> 20)
Central nervous system (CNS)
manifestations usually present
by 2 years of age:
hydrocephalus, seizures, focal
deficits, paresis
Magnetic resonance imaging:
meningeal, cerebral, cerebellar,
or spinal cord involvement
Life-threatening symptom
Need ventriculoperitoneal (VP)
shunt, which disseminates tumor
Treatment: if NCM is
asymptomatic, do not treat CMN
until 2 years old to see whether
neurological symptoms present,
because may not survive long
enough to benefit from resection of
Melanocytic Nevi
• Definition: benign melanocyte
lesions with low malignant potential
• Junctional nevus
Located in the border between
epidermis and dermis
• Intradermal nevus
Found within the dermal layer
• Compound nevus
Present in both the epidermis and
the dermis
• Halo (Sutton) nevus
Central nevus surrounded by
hypopigmented skin (less pigment
corresponds to regression of
central nevus and occurs
secondary to immune response)
• Nevus spilus
Café au lait spots
• Spitz nevus
Benign pink lesion in head and
neck region
Called “juvenile melanoma”
because occurs in 5- to 10-year-
olds and histologically is similar
to melanoma
Treatment: excision alone, although
pathologically high risk lesions
should be treated like melanoma
• Nevus of Ota
Blue gray lesion in cranial nerve
V1 and V2 distribution
Treatment: Q-switch ruby laser
• Nevus of Ito
Similar to nevus of Ota but in
lateral brachial cutaneous and
supraclavicular nerve distribution
• Blue nevus
Small intradermal nevus rarely
Do not confuse with blue rubber
bleb nevi (venous malformation)
• Mongolian spot
Benign blue-gray-brown lesion on
sacrum, which spontaneously
resolves by age 5

Squamous Cell Carcinoma

• Squamous cell carcinoma (SCC)
Nonmelanoma skin cancer
originating from squamous cell in
Low metastatic rate (compared to
mucosal SCC, which has 10%
meta-static rate) except when large
or with aggressive pathologic
Excision with 4 to 10 mm
margins; can perform Mohs in
critical areas
Radiation therapy
Topical chemotherapy
• Actinic (solar) keratosis
Precursor to SCC (10%
transformation risk)
Most common premalignant lesion
in elderly fair-skinned patients
Dry, scaly, rough patches, itch,
5-Fluorouracil (5-FU)
Best treatment
Good cosmetic treatment, no
Side effects: irritation,
burning, erythema
Imiquimod (Aldara, 3M
Pharmaceuticals, St. Paul, MN)
Stimulates immune response by
increasing interferon levels
and inducing apoptosis
Also treatment for viral warts
Retinoids: derived from vitamin
• Bowen disease
SCC in situ
Red-brown scaly patches
Erythroplasia of Queyrat: SCC in
situ arising on the penis
• Keratoacanthoma
Benign round, smooth nodule
around a keratinous plug
Rapidly grows over weeks
Potential for spontaneous
regression over months
5.7% develop into SCC
• Cutaneous horn
Hard, keratinized skin protrusions
secondary to excessive epidermal
20% premalignant, 15% associated
with SCC
Treatment: excision or shave

Basal Cell Carcinoma

• Basal cell carcinoma (BCC)
Most common type of cancer
Originate from basal layer of
epidermis (deepest layer)
Small, dome-shaped, pearly white
Rarely metastasize
Excision with 3 to 10 mm
Mohs in sensitive areas or
aggressive growth patterns
Electrodesiccation and curettage
Photodynamic therapy
Topical fluorouracil (5-FU)
Topical imiquimod
• Gorlin syndrome
Nevoid BCC syndrome
Autosomal dominant
Multiple BCC: dome-shaped tan
papules on face, neck, and trunk
Keratocystic odontogenic tumor:
swelling, pain in molar and
premolar area
Palmar and plantar erythematous
skin pits
• Bazex syndrome
Autosomal dominant
Multiple BCCs on the face
Similar to Gorlin syndrome, but no
skin pits or odontogenic tumor
• Nevus sebaceous of Jadassohn
Potential to transform to BCC
(15% risk)
Yellow-orange, elevated plaque on
face or scalp since birth
Treatment: excision

• Indications
Tumors without distinct margins
Morpheaform BCC: fingerlike
extensions can be missed with
standard excision
Recurrent tumors
Cosmetic and functionally sensitive
Sclerosing BCCSCC with
perineural invasion
Microcystic adnexal carcinoma
Dermatofibrosarcoma protuberans
Desmoplastic melanoma
• Recurrence rate: low compared to
standard excision, cryotherapy,
ED&C, 5-FU, and radiation therapy
Miscellaneous Skin Lesions
and Soft Tissue Tumors
• Seborrheic keratosis
Benign, stuck-on lesion
Waxy, sharply circumscribed
• Dermatosis papulosa nigra
Variant seborrheic keratosis in
Seen in cheeks
• Xanthelasma palpebrarum
Yellow periorbital plaques
50% familial dyslipidemia
• Pseudofolliculitis barbae
Seen in African American men
Papules over chin, cheeks, back of
neck can develop into keloids
• Acrochordon
Benign skin tag
• Tricholemmoma
Benign tumor arising from outer
root sheath of hair follicle
Found on face, neck, scalp, chest,
• Epidermal inclusion cyst
Dermal cyst containing epidermal
• Becker nevus
Benign hamartoma (normal tissue
Nevus misnomer because no
Brown patch with hair in upper
Males 20 to 30 years old
• Neurofibromatosis
Type 1 (von Recklinghausen
Inheritance: autosomal dominant
Café au lait spots: macules
Benign tumor of superficial
peripheral nerve sheath
Treatment: excision if
symptomatic or for cosmesis
Lisch nodules: iris hamartomas,
do not affect vision
Malignant peripheral nerve
sheath tumor (MPNST): 7 to
13% lifetime risk
Type 2
More severe CNS involvement
Acoustic neuroma
(schwannoma): tumor of eighth
cranial nerve
• Simple lentigo
Benign proliferation of
melanocytes in children
Not sun-related
• Solar (senile) lentigo
Benign proliferation of
• Ephelis
Benign common freckle
Normal number of melanocytes
Increased melanin production
• Syringoma
Benign lower eyelid papule in
• Cylindroma
Benign round, firm scalp nodule
• Melasma
Hyperpigmented macules in face
and neck
Secondary to pregnancy or
Treatment: bleaching
• Pyogenic granuloma
Common in children and young
Pedunculated mass rapidly
develops and can bleed
Treatment: excision and cautery of
• Pilomatricoma
Benign hard, solitary, calcifying
nodule of hair origin in children
• Molluscum contagiosum
Virally induced papules in children
and young adults
• von Hippel-Lindau disease
Inheritance: autosomal dominant
Hemangioblastomas in cerebellum,
spinal cord, kidney, retina
Renal cell carcinoma
Café au lait spots
• Dermatofibroma
Benign dermal fibrous
histiocytoma of anterior lower leg
Neoplasm, nodule, or reaction to
Asymptomatic, firm, raised 3 to 10
mm diameter
Treatment: excisional biopsy
• Dermatofibrosarcoma protuberans
Sarcoma of the dermal skin layer
Locally invasive, rarely
metastasizes, high recurrence rate
Treatment: surgical margin of 2.5
cm or Mohs excision
• Lymphangioma circumscriptum
Cutaneous lymphatic malformation
Small multiple clusters clear-to-
white appearance vesicular
Obliterate with pressure, then
reappear and refill
Treatment: excision of skin with
deeper lymphatics
• Merkel cell carcinoma
Aggressive, malignant
neuroendocrine skin cancer
Smooth, painless, solitary
dermal nodule
Patients > 65 years old
50% in head and neck, 40% in
Wide local resection
Radiation therapy and
chemotherapy postoperatively
Eyelid involvement: treat with
wide excision with subtotal and
total eyelid reconstruction
Low 5-year survival: 66%

Suggested Reading
Anderson RG. Skin Tumors II:
Melanoma. Dallas TX: Selected
Readings in Plastic Surgery, Inc.;
2004:1–50. Selected Readings in
Plastic Surgery; vol 10, issue 3
Arneja JS, Gosain AK. Giant congenital
melanocytic nevi. Plast Reconstr
Surg 2009;124(1, Suppl):1e–13e
Culliford A, Hazen A. Dermatology for
plastic surgeons. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:105–114
Gosain AK, Santoro TD, Larson DL,
Gingrass RP. Giant congenital nevi:
a 20-year experience and an
algorithm for their management.
Plast Reconstr Surg
Gulleth Y, Goldberg N, Silverman RP,
Gastman BR. What is the best
surgical margin for a Basal cell
carcinoma: a meta-analysis of the
literature. Plast Reconstr Surg
Krengel S, Hauschild A, Schafer T.
Melanoma risk in congenital
melanocytic naevi: a systematic
feview. Br. J. Dermatol
2006;155(1): 1-8
Lee EH, Nehal KS, Disa JJ. Benign and
premalignant skin lesions. Plast
Reconstr Surg 2010;125(5):188e–
Netscher DT, Leong M, Orengo I, Yang
D, Berg C, Krishnan B. Cutaneous
malignancies: melanoma and
nonmelanoma types. Plast Reconstr
Surg 2011;127(3):37e–56e
O'Connor WJ. Roenigk RK, Brodland
DG. Merkel cell carcinoma:
comparison of Mohs micrographic
surgery and wide excision in eighty-
six patients. Dermatol Surg
Rogers CR, Bentz ML. An evidence-
based approach to the treatment of
nonmelanoma facial skin
malignancies. Plast Reconstr Surg
Weedon DD, Malo J, Brooks D,
Williamson R. Squamous cell
carcinoma arising in
keratoacanthoma: a neglected
phenomenon in the elderly. Am J
Dermatopathol 2010;32(5):423–426
Zbar RI. Skin Tumors I: Basal Cell and
Squamous Cell Carcinoma. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2004:1–34. Selected
Readings in Plastic Surgery; vol
10, issue 3
Zbar RI, Canady JW. MOC-PSSM CME
article: Nonmelanoma facial skin
malignancy. Plast Reconstr Surg
2008;121(1, Suppl):1–9
11 Soft Tissue Infection
Reviewed by Andre Yuan Levesque

Snake Bites (Table 11.1)

• Pit viper family
Cause 99% of bites in United
Pit vipers: rattlesnakes,
copperheads, cottonmouths
Rattlesnakes have most potent
• Dry bites (no envenomation)
10 to 50% of bites are dry
Treatment: observe, give tetanus,
intravenous fluid (IVF), broad
spectrum antibiotics
Mark with pen for progression and
monitor for signs of envenomation
(no antivenom required unless
• Envenomation
Presentation: pain, swelling,
ecchymosis, coagulopathy,
hypotension, mental status changes,
Transfer: if being transferred to
medical center, transfer
immediately without intervention
Equine antivenom: can cause serum
sickness, do skin testing with horse
serum to rule out hypersensitivity
Incision and suction: do shallow
linear incision around fangs and
snakebite suction cup therapy to
remove venom if within 15 to 30
minutes of bite and snake was
Resuscitation: use lactated Ringer
solution, not normal saline,
because chloride exacerbates
metabolic acidosis
Fasciotomy: can be done if
symptoms of compartment
syndrome (early symptoms are
pain on passive stretching,
pressures > 30 mm Hg; late finding
is loss of pulse)
Not necessary: ice packs,
debridement, suction therapy if
does not meet above criteria,
cryotherapy, tourniquet (causes
more ischemia)
Table 11.1 Snake bite grades

Grade Presentation

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

Pain and
5–20 vials, after
Moderate extending
serum testing
beyond fang
> 20 vials, do
Severe not delay for
serum testing

Spider Bites
• Black widow (Lactrodectus
Venom is neurotoxic
Presentation: within 15 minutes
have muscle pain and cramps, can
lead to tremors, vomiting,
increased salivation, paresthesias,
and shock
Treatment: muscle relaxants
(calcium gluconate intravenous
[IV] and methocarbamol),
• Brown recluse (Loxosceles reclusa)
Venom causes tissue necrosis
Presentation: edema, erythema,
tissue necrosis, demarcates over
weeks, systemic reactions lead to
hemolysis and disseminated
intravascular coagulation
Treatment: dapsone 100 mg orally
twice a day for 14 days (leukocyte
inhibitory properties)
Dapsone: side effects of hemolysis,
therefore do not give if patient has
dehydrogenase (G6PD) deficiency
Hydradenitis Suppurativa
• Apocrine gland disease, which
secretes malodorous viscous milky
fluid with bacterial colonization
• Does not involve
Eccrine glands in skin that secrete
thin clear sweat
Sebaceous glands in face/scalp that
secrete sebum
• Location: axilla, groin, mons,
buttock, inframammary fold, and
• Categorized according to system
proposed by Hurley (Table 11.2)
• Treatment
Long-term antibiotics (2 to 3
Commonly tetracycline,
(Clindamycin/Rifampin) among
TNF-alpha inhibitors
Topical clindamycin and
Radical excision
Healing by secondary intention
Reconstruction via skin grafts or
Table 11.2 Hurley staging of hidradenitis

Stage Characteristics
Single or multiple
abscesses without
sinus or scar

abscesses, single or
2 multiple abscesses
with sinus tract

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

Necrotizing Fasciitis
• Definition: soft tissue infection
spreads along fascial planes in
subcutaneous tissue
• Etiology
Infection: most commonly
polymicrobial, but group A
streptococcus is also common
Immunocompromised patients:
diabetes is most common
• Presentation
Pain out of proportion to exam,
crepitus, dishwater pus (gray
watery discharge), edema,
erythema, fever
Progresses to blisters, necrotic
skin, sepsis, death
• Workup
Labs:↑white blood cells,
↓platelets, ↑potassium
Radiography: clostridium
associated with subcutaneous air
• Treatment
Immediate debridement followed
by serial debridements until
infection control achieved
IV antibiotics for gram-negative,
gram-positive, and anaerobic
Hyperbaric oxygen can be adjunct
• Streptococcus toxic shock syndrome
Coagulopathy (↑international
normalized ratio)

Suggested Reading
Anz AW, Schweppe M, Halvorson J,
Bushnell B, Sternberg M, Andrew
Koman L. Management of venomous
snakebite injury to the extremities. J
Am Acad Orthop Surg
Broughton G, Rohrich RJ. Wounds and
Scars. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005:1–56. Selected Readings in
Plastic Surgery; vol 10, issue 7
Culliford A, Hazen A. Dermatology for
plastic surgeons. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:105–114
Elliott DC, Kufera JA, Myers RAM.
Necrotizing soft tissue infections:
risk factors for mortality and
strategies for management. Ann Surg
Hurley HJ. Axillary Hyperhidrosis,
Apocrine Bromhidrosis,
Hidradenitis Suppurativa, and
Familial Benign Pemphigus:
Surgical Approach. In: Roenigk RK,
Roenigk HH, eds. Dermatologic
Surgery. New York: Marcel Dekker;
1989: 729–739
Jallali N, Withey S, Butler PE.
Hyperbaric oxygen as adjuvant
therapy in the management of
necrotizing fasciitis. Am J Surg
2005 189(4): 462-466
Rees RS, Altenbern DP, Lynch JB, King
LE Jr. Brown recluse spider bites: a
comparison of early surgical
excision versus dapsone and
delayed surgical excision. Ann Surg
12 Immunology and
Reviewed by Eduardo D. Rodriquez

History of Transplantation
• 1954 Kidney (Murray)
• 1959 Azathioprine
• 1963 Lung (Hardy)
• 1966 Pancreas (Lillehei)
• 1967 Intestine (Lillehei)
• 1967 Heart (Barnard)
• 1967 Liver (Starzl)
• 1970 Cyclosporine
• 1981 Heart and lung (Reitz)
• 1988 Peripheral nerve (MacKinnon)
• 1988 Flexor tendon (Guimberteau)
• 1996 Knee (Hofmann)
• 1998 Hand (Dubernard)
• 1998 Laryngeal (Strome)
• 2000 Double hand (Dubernard)
• 2003 Abdominal wall (Levi)
• 2003 Tongue (Kermer)
• 2004 External ear (Jiang)
• 2005 Face (Dubernard)
• 2006 Penis (Hu)
• 2008 Double arm (Biemer)

Transplant Immunology
• Transplantation grafts
Autograft: transplantation on the
same individual
Allograft: transplantation between
different individuals of the same
Xenograft: transplantation between
different species
Isograft: transplantation between
identical twins
• Solid organ transplantation:
transplantation of mainly one tissue
• Composite tissue allotransplantation
Transplantation of an allograft
composed of heterogeneous tissues
Most antigenic tissue in body: skin
Most commonly used tissue for
biopsy to monitor rejection: skin
(visible, accessible, most
• Epitope
Molecular unit of specific immune
Can be bound to TCR of T cells or
the antibody of B cells
• Antigen
Epitope containing molecule
Each antigen may contain many
• Histocompatibility
Degree to which the donor and
recipient share regulatory
molecules of immune system
Major histocompatibility complex
(MHC): in vertebrates
Human leukocyte antigens (HLAs):
in humans
MHC and HLA genes can differ
among individuals serving as
• Innate versus adaptive immunity
Innate: nonspecific response
Adaptive: specific response by
cellular (T cells) and humoral
(anti-body-producing B cells)
• Immunosuppressive agents (Table
• Common side effects of transplant
Increased risk of forming
• Dynamics of rejection (Table 12.2)
Table 12.2 Dynamics of rejection

Rejection Timing Mechanism

Hyperacute Minutes

First 3–6
Acute T cells

Months to Mechanism
years unclear

• Chimerism
Coexistence of donor and recipient
cell lines
Holy grail of transplant
immunology is to induce tolerance
and prevent the need for lifelong
Suggested Reading
Gordon CR, Hewitt CW, Lee WP.
Transplantation of Composite
Tissue Allografts. New York:
Springer; 2007
Hettiaratchy S, Randolph MA, Petit F,
Lee WP, Butler PE. Composite
tissue allotransplantation—a new
era in plastic surgery? Br J Plast
Surg 2004;57(5):381–391
Lee WP, Feili-Hariri M, Butler P.
Transplant biology and applications
to plastic surgery. In:
Thorne CH, Beasley RW, Aston SJ, et
al, eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Siemionow M, Klimczak A. Basics of
immune responses in transplantation
in preparation for application of
composite tissue allografts in plastic
and reconstructive surgery: part I.
Plast Reconstr Surg
Siemionow M, Klimczak A. Tolerance
and future directions for composite
tissue allograft transplants: part II.
Plast Reconstr Surg
Siemionow MZ, Kulahci Y, Bozkurt M.
Composite tissue
allotransplantation. Plast Reconstr
Surg 2009;124(6, Suppl):e327–
13 Coding, Medicolegal, and
Psychiatric Aspects
Reviewed by Kent K. “Kye” Higdon

• Wound closure coding (Table 13.1)
Skin lesion excisions are reported
based on the total excised
diameter, including margins, not
just the size of the lesion; simple
closures are included in the
Skin lesion excision with adjacent
tissue transfer: cannot bill for
excision if doing closure with
adjacent tissue transfer; report
excised diameter including
margins and dimensions of
secondary defect of flap created
Benign skin lesion: benign skin
lesion excision reimbursement
requires an ICD-9 code for benign
lesion and a code for a
complicating pathology (e.g.,
bleeding, itching, pain)
Wound closure global to another
procedure: if performing another
procedure (e.g., nerve repair,
parotid tumor resection), cannot
report wound closure in addition
to primary procedure
• Breast reconstruction coding
Implant removal: included with
capsulectomy and replacement
procedures; capsulotomy is
included with these procedures
Tissue expander insertion: includes
expansion during a 90 day global
Free flaps (TRAM, DIEP, SIEA,
GAP, etc.) have the same code and
are bundled with microsurgical
anastomosis, use of operating
room microscope, harvest and
insetting of the flap, closure of the
abdominal site, and rib excision to
expose the internal mammary
• Free flap coding
Includes: the use of a microscope,
harvesting and insetting the flap,
closure of the donor site defect,
microsurgical anastomosis
Does not include: procedures
additional to those listed above,
split-thickness skin grafts, closures
more complex than primary
closure of donor defect, use of
vein or nerve grafts
Table 13.1 Wound closure classification

Type Definition

One layer (skin


More than one layer

Intermediate (skin or fascia, no
Requires revision,
Complex extensive
undermining, and
creation of a defect

Local tissue
Adjacent tissue rearrangement based
transfer on random blood

Axial blood supply

• Abdominoplasty coding
Billed as two codes:
abdominoplasty and resection of
abdominal skin (panniculectomy)
Includes: closure of abdominal
wall, translocation of umbilicus,
musculofascial plication of the
rectus sheath, resection of skin and
fat, undermining of abdominal flap
• Facial trauma coding
Includes: exploration of nerves,
exploration of fracture site,
reduction of fracture, debridement
of tissue
Does not include: separate codes
for bone grafting or implants used,
separate codes for approach to
orbital floor, separate codes for
each fracture site repaired (e.g.,
orbital vs. malar fracture repair)
• Global period
Definition: time after an operation
when physician cannot bill for
follow-up appointments
Duration: 3 months for most
operations, 10 days for lesion
excision, and simple, intermediate,
and complex repairs
• Aesthetic versus insurance cases
Aesthetic cases: patient pays out of
pocket for entire fee
Insurance cases: insurance covers
majority of case, depending on
policy descriptions, deductibles,
and maximum out-of-pocket limits
Combined aesthetic and insurance
cases: insurance part of case
billed to insurance company,
aesthetic part billed directly to
patient (typically prepaid)
Aesthetic case bill based on:
surgeon, anesthesia, and operating
room fees

• Injectables and fillers
American Society of Plastic
Surgeons (ASPS) Code of Ethics
states that procedures requiring an
incision may not be donated
Injectables and fillers can be
donated, because no incision is
Food and Drug Administration
(FDA)-approved filler or
injectable brought from another
country may be used even if it is
no longer manufactured in the
United States
Physicians may advertise approved
uses for FDA-approved
injectables and fillers in specific
Physicians must obtain consent and
disclose any nonapproved use
• Most common lawsuit in plastic
surgery: breast surgery
• Doctor–patient relationship: begins
the moment you have a professional
discussion regardless of whether or
not you are in the office, hospital, or
exam room
• Complications: see patients
frequently (every day to every other
week) if there is a complication until
the patient gets better or does not
want to see you
• Job hiring: do not ask about age,
religion, race, childcare
responsibilities, disabilities, arrests
• Health Insurance Portability and
Accountability Act (HIPAA)
Protects privacy of medical
Personal identifiable information,
which cannot be released unless
written consent from patient is
obtained: identifiable photographs
(face, tattoos), name, date of birth,
contact information (i.e., telephone
number, address)
• Wrong site surgery
Surgery on the wrong extremity,
person, or organ
Joint commission recommendations
for prevention include: site
marking, time-out, informed
consent, specifying laterality
• Informed consent discusses:
indications, procedures, alternatives,
risks, benefits

Psychiatric Aspects
• Patients to potentially avoid
Unrealistic expectations
Unstable male
Minimum deformity
Incompatible with you
Dissatisfaction with previous
Pushed to surgery by someone else
Excessively demanding
• Body dysmorphic disorder (BDD)
Overly concerned about minor
1 to 3% of general population
7 to 15% of plastic surgery
Refer to a psychiatrist before
50% associated with suicidal
70% never marry
Acronym for warning signs of
problem patients
• Malingering for anosmia
Test with irritants (bleach,
ammonia) that stimulate trigeminal
If patient claims they cannot smell
irritant, they are malingering
• Gender reassignment
Send for psychiatric evaluation
Medical treatment for 1 year after
initial contact
Surgical treatment 2 years after
initial contact
Suggested Reading
American Society of Plastic Surgeons;
American Society for Aesthetic
Plastic Surgery. Injectables and
fillers: legal and regulatory risk
management issues. Plast Reconstr
Surg 2006;118(3, Suppl):129S–
CPT. Professional ed. Chicago, IL:
American Medical Association;
Crerand CE, Franklin ME, Sarwer DB.
C-PS (SM) CME Article: Patient
safety: body dysmorphic disorder
and cosmetic surgery. Plast Reconstr
Surg 2008;122(4S):1–15
Standards for privacy of individually
identifiable health information.
Office of the Assistant Secretary for
Planning and Evaluation, DHHS.
Final rule. Fed Regist
Rohrich RJ. The who, what, when, and
why of cosmetic surgery: do our
patients need a preoperative
psychiatric evaluation? Plast
Reconstr Surg 2000;106(7):1605–
Section II
14 Head and Neck Anatomy
Reviewed by Andrew Wexler

Orbital Anatomy (Fig. 14.1)

• Seven bones compose the orbit:
frontal, lacrimal, ethmoid, palatine,
maxilla, zygoma, and sphenoid
• Optic canal
In lesser wing of sphenoid
Transmits optic nerve and
ophthalmic artery
• Superior orbital fissure
In greater wing of sphenoid
Transmits cranial nerves (CN) III,
IV, VI, and V1
• Medial wall: ethmoid makes up most
of wall, also composed of lacrimal,
palatine, and lesser wing of sphenoid
• Floor: composed of maxilla
medially, zygoma anteriorly
• Inferior orbital fissure
Between maxilla, sphenoid,
palatine, and zygoma
Transmits CN V2 and infraorbital
• Extraocular muscles (Table 14.1)
Fig. 14.1 Orbital anatomy.
Sinus Anatomy
• Sinus drainage patterns
Middle meatus: nasofrontal,
frontal, maxillary, and anterior
ethmoid sinuses
Inferior meatus: nasolacrimal duct
Superior meatus: posterior ethmoid
Supreme meatus: sphenoid sinus
Inferior concha: eustachian tube

• SCALP acronym
Connective tissue: subcutaneous
tissue contains blood vessels and
Aponeurosis (galea): strength layer
Loose areolar tissue: avulsions
occur in this plane
Periosteum: receives blood from
diploic circulation via perforators
Skull Base (Table 14.2) (Fig.
• Cranial fossa
Anterior: frontal bone, ethmoid
bone, lesser sphenoid wing
Medial: temporal bone, greater
sphenoid wing
Posterior: temporal bone, occipital

• Muscles of mastication (Table 14.3)
• Depressors of mandible: platysma,
geniohyoid, genioglossus,
mylohyoid, digastrics (anterior head
depresses mandible, posterior head
elevates hyoid)
• Maximal mouth opening
Vertical interincisal opening: 41 to
50 mm
Horizontal: 10 mm
• Inferior alveolar nerve
Inferior alveolar nerve enters the
mandibular foramen 10 mm below
the sigmoid notch at the level of
the occlusal plane
Nerve course: along buccal side
(1.8 mm from edge) in
ramus/angle, runs toward lingual
side (4.1 mm from buccal surface)
around the first and second molars,
then runs along inferior cortex
through the body, exiting the mental
foramen as the mental nerve
• Mental foramen: located below the
second mandibular premolar
Table 14.2 Skull base foramina and contents

Foramina Contents

Anterior ethmoid Anterior ethmoid

foramen vessels

Olfactory nerve (CN


Foramen cecum Encephaloceles

Optic foramen Optic nerve (CN II)

Oculomotor nerve
(CN III), trochlear
Superior orbital nerve (CN IV),
fissure trigeminal nerve
ophthalmic branch
(CN V1), abducens
nerve (CN VI)

Trigeminal nerve
Foramen rotundum maxillary branch
(CN V2)

Inferior orbital CN V2 and its

fissure zygomatic branch

Trigeminal nerve
Foramen ovale mandibular branch
(CN V3)

Internal carotid
artery, pterygoid
Foramen lacerum
canal nerve
Facial nerve (CN
VII) exits
Internal acoustic stylomastoid
meatus foramen,
nerve (CN VIII)

nerve (CN IX), vagus
Jugular foramen nerve (CN X), spinal
accessory nerve (CN

Hypoglossal nerve
Hypoglossal canal

Foramen magnum Medulla oblongata

Fig. 14.2 Skull base. (a) Superior view of
cranial cavity; (b) Inferior view of base of
skull. (From Baker EW, Schuenke M. Head
and Neck Anatomy for Dental Medicine. New
York: Thieme; 2010. Illustration by Karl
Wesker. Used with permission.)
Dental Anatomy
• Dental anatomy basics (Fig. 14.3;
Fig. 14.4)
20 deciduous (baby) teeth: 4
central incisors, 4 lateral incisors,
4 canines, 4 first molars, 4 second
Deciduous first and second molars
are replaced by the adult first and
second premolars (bicuspids)
First permanent molar and central
incisors erupt ages 6 to 7
Mixed dentition: period when
deciduous and permanent teeth
32 permanent (adult) teeth: 4
central incisors, 4 lateral incisors,
4 canines (cuspids), 8 premolars
(bicuspids), 12 molars (have four
cusps each)
Crown: exposed 1/3 of tooth is
capped by enamel. Under the
enamel is dentin and below that the
pulp, which extends into the root.
Injury to the enamel may cause
temperature sensitivity and require
a crown. Infection of the pulp or
fracture through the pulp blood
supply may cause tooth death and
require a root canal.
Root: buried two thirds of tooth
consists of dentin with a central
pulp containing the nerve and
artery of the tooth. A layer of
cementum attaches the tooth to the
socket. Periodontal ligaments
(Sharpey's fibers) attach the tooth
root to alveolar bone.
• Terminology
Palatal: surface of maxillary tooth
facing palate
Lingual: surface of mandibular
tooth facing the tongue
Buccal: surface of mandibular and
maxillary teeth facing the cheek
Fig. 14.3 Dental anatomy. (a) Deciduous
dentition. (b) Adult dentition.
Fig. 14.4 Cross section of tooth. (From Baker
EW, Schuenke M. Head and Neck Anatomy for
Dental Medicine. New York: Thieme; 2010.
Illustration by Marcus Voll. Used with

Mesial: surface of teeth facing the

oral aperture
Distal: surface of teeth toward the
Labial: surface of teeth facing the

Tongue (Fig. 14.5)

• Blood supply: paired lingual arteries
travel laterally along the ventral third
• Innervation for taste
Anterior two-thirds: facial nerve
(CN VII) chorda tympani branch
Posterior one-third:
glossopharyngeal nerve (CN IX)
lingual branch
• Innervation for sensation
Anterior two-thirds: trigeminal
nerve mandibular branch (CN V3)
Posterior one-third:
glossopharyngeal nerve (CN IX)
• Innervation for movement
Hypoglossal nerve (CN XII)
innervates majority of tongue
muscles (hyoglossus, styloglossus,
Vagus nerve (CN X) innervates the
palatoglossus muscle
Fig. 14.5 Tongue innervation.

Branchial Arches (Table

• Head and neck structures are derived
from branchial arches

Suggested Reading
Gosain AK, Nacamuli R. Embryology of
the head and neck. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2007:179–190
Netter FH. Atlas of Human Anatomy.
Rittenhouse Book Distributors Inc.;
Thangavelu K, Kannan R, Kumar NS, et
al. Significance of localization of
mandibular foramen in an inferior
alveolar nerve block. J. Nat. Sc.
Biol. Med 2012;3(2): 156–160
Wexler A. Craniofacial anatomy. In:
Thaller SR, Bradley JP, Garri JI,
eds. Craniofacial Surgery. New
York: Informa Healthcare; 2008:7–
15 Cleft Lip and Palate
Reviewed by Jesse A. Taylor

Classification of Cleft Lip

and Palate (CLP) (Fig. 15.1,
Table 15.1)
• Complete or incomplete
• Kernahan and Stark's Striped Y (Fig.
Visual component of uni- or
Can designate isolated cleft lip
Oriented relative to incisive
Anterior to incisive foramen: 1 lip,
2 alveolus, 3 primary palate
Posterior to incisive foramen:
divided into three segments

• Age of development
Cleft lip: 5 to 6 weeks
Cleft palate: 7 to 8 weeks
Fig. 15.1 (a) Veau and (b) Kernahan and Stark's
Striped Y classifications of cleft lip and palate.

Table 15.1 Veau classification

Class Characteristics

I Soft palate only

II Hard and soft palate

III Unilateral cleft lip
and palate

Bilateral cleft lip

and palate

• Embryological origins
Primary palate: fusion between
medial nasal prominences of the
frontonasal process and the
maxillary prominences
Secondary palate: fusion of the
lateral palatine processes of the
maxillary prominences with the
nasal septum
Premaxilla, nasal tip, philtrum,
columella, Cupid's bow: form
from medial nasal prominences
Forehead and nasal bridge: form
from frontonasal process
Nasal ala: form from lateral nasal
Macrostomia: failure of fusion
between mandibular and maxillary
prominences (Tessier cleft number
Cleft lip: failure of fusion between
medial nasal prominences and
maxillary prominence

• Incidence of CLP
Approximately 1:750
Varies 1:500 to 1:1,000 depending
on race: African-American <
Caucasian < Asian = Hispanics
Incidence of cleft lip with or
without cleft palate increases with
parental (especially paternal) age
> 30 years. Some association with
low socioeconomic class may be
nutrition related.
• Nonsyndromic CLP inheritance: non-
Mendelian (Table 15.2)
• Autosomal dominant syndromes of
Mendelian inheritance
50% risk if one parent affected,
75% risk if both parents affected
• Isolated cleft palate: 50% have
additional anomalies

Syndromes Associated with

• Van der Woude syndrome
Autosomal dominant
Most common syndromic CLP
Lower lip pits (accessory salivary
glands) in 85% of patients,
• Pierre Robin sequence
Not a syndrome, it is a sequence:
micrognathia, glossoptosis, airway
Associated with cleft palate,
possibly because during
palatogenesis the palatal shelves
cannot elevate from a vertical to a
horizontal position due to intraoral
Conservative treatment with prone
positioning, endotracheal
intubation if respiratory distress
despite prone positioning
Nasoendoscopy to rule out other
causes of airway obstruction
Surgical options: tongue–lip
adhesion (TLA), distraction
osteogenesis (DO)
May need tracheostomy tube if
respiratory distress despite TLA
and DO
Cleft palate repair is delayed until
14 to 18 months to make sure
airway is adequate
• Stickler syndrome
Autosomal dominant
Associated with Pierre Robin
sequence, optical conditions (e.g.,
myopia, retinal detachment),
skeletal abnormalities
• Velocardiofacial syndrome
Autosomal dominant
Also called: Shprintzen syndrome,
CATCH-22 syndrome, 22 minus
syndrome, DiGeorge syndrome,
22q11.2 deletion syndrome,
conotruncal anomaly face
Most common syndrome associated
with cleft palate
Characteristics: absent thymus,
cleft palate (submucous cleft, bifid
uvula), velopharyngeal
insufficiency (VPI), anomalous
carotid arteries, broad nasal root,
low-set ears, retrognathia,
elongated face (maxillary excess),
epicanthal folds, hypocalcemia
Diagnosis: clinical exam,
symptoms, fluorescence in situ
hybridization (FISH) analysis for
deletion in chromosome 22q11.2
Treatment: symptomatic; prior to
palate repair, do magnetic
resonance angiography (MRA) or
nasoendoscopy preop to rule out
pulsations in the posterior
pharyngeal wall (anomalous
carotid arteries)
• Waardenburg syndrome: autosomal
dominant, white forelock, deafness,
Cleft Lip
• Prenatal ultrasound diagnosis:
detects cleft lip with 90 to 100%
• Nasoalveolar molding (NAM)
Passive presurgical molding (as
opposed to active molding with
Latham appliance)
Aligns premaxilla with alveolar
segments (bilateral clefts)
Aligns alveolar segments
(unilateral clefts)
Nasal stents lengthen columella
and reposition nasal cartilage
(unilateral/bilateral clefts)
• Unilateral cleft lip rotation
advancement repair (Fig. 15.2)
Timing: 3 to 6 months old
C-flap: lengthens columella
M-flap: medial lip flap
L-flap: lateral lip flap used to fill
nasal lining
• Bilateral cleft lip repair (Fig. 15.3)
Straight line repair: lateral
vermilion joins to form tubercle,
muscle joins along midline
Sulcus: formed from lateral
mucosal flaps and prolabium
Tight upper lip: Abbe flap can
soften and provide fullness to tight
upper lip
Table 15.2 Risk of child affected with
nonsyndromic CLP

Risk factor Cleft lip (%)
palate (%)

1 child has
4 2

1 parent has
CLP 4 6

1 child/1
parent have 17 15

2 children
9 1
have CLP

1 child has
bilateral CLP 5.7–8

Fig. 15.2 Unilateral cleft lip rotation

advancement repair markings.
Fig. 15.3 Bilateral cleft lip repair markings.

• Cleft rhinoplasty
Timing of repair: primary cleft lip
repair, school-age (5 years old),
teenage years
Cleft ala position: slumps in a
lateral, inferior, and posterior
direction can correct by
repositioning the medial and
middle crus and possible cartilage
Flaring alar base: can correct with
alar cinch stitch or alar base
Deviated septum: caudal septum
deviated away from cleft, may
need septoplasty
Nasal dorsum: broad in bilateral
cleft patients, may need

Cleft Palate
• Terminology
Primary cleft palate: anterior to the
incisive foramen
Secondary cleft palate: posterior to
the incisive foramen (hard and soft
Premaxilla: bone anterior to the
incisive foramen, includes central
and lateral incisors
Prolabium: lip overlying
premaxilla in bilateral CLP
Velum: soft palate
• Muscles of the palate (Fig. 15.4)
Uvula: thickens, moves superior
and anterior
Palatopharyngeus: pulls soft palate
posterior, passes along posterior
tonsillar pillars, used in sphincter
pharyngoplasty to correct
deficiency in lateral wall
Levator veli palatini: arises from
eustachian tube and sphenoid bone,
inserts and decussates in the
middle third of the velum, elevates
and posteriorly displaces velum
against the posterior pharynx,
opens eustachian tube
Palatoglossus: passes along
anterior pillars, pulls soft palate
down, elevates tongue base to soft
Tensor veli palatini: arises from
medial pterygoid plate and
eustachian tube, passes around
hamulus (inferior extension of
medial pterygoid plate), inserts on
junction of soft and hard palates,
tenses during swallowing, not
needed for velopharyngeal closure
Superior pharyngeal constrictors:
moves lateral and posterior walls,
forms Passavant ridge (bulge in
posterior pharynx above arch of
Fig. 15.4 Palate anatomy. LVP, levator veli
palatini; TVP, tensor veli palatini.

• Surgical repair
Timing: 9 to 14 months (before
learns to speak)
Two-flap palatoplasty (closes hard
palate) and intravelar veloplasty
(closes soft palate)
Furlow palatoplasty: for isolated
soft palate repair, or with two-flap
palatoplasty for hard and soft
palate closure, posterior flaps
contain muscle, anterior flaps
contain mucosa
Vomer flap: used to help close
wide unilateral cleft palates, and
bilateral cleft palates
Otitis media is more common with
cleft palate, and bilateral
myringotomy tubes can be inserted
at the time of cleft repair.
• Submucous cleft palate
May have bifid uvula, absent
posterior nasal spine, notching of
posterior hard palate, and zona
pellucida (thin mucosa between
abnormally placed muscle)
Soft palate may have normal length
Most do not require treatment;
however, 10 to 15% will develop
velopharyngeal insufficiency (VPI)
based on speech evaluation and
objective tests and require
operative repair

Alveolar Cleft
• Gingivoperiosteoplasty and NAM
Presurgical molding followed by
local periosteal flap closure
Timing: at time of cleft lip repair
• Alveolar bone grafting
Most common alveolar cleft repair
Provides bone for eruption of
permanent cleft lateral incisor or
Builds up nasal base by increasing
sagittal projection of pyriform
Iliac crest cancellous bone is most
common graft used
Collapse of maxilla and subsequent
crossbite can result if alveolar
bone graft not done
Timing: during mixed dentition (6
to 9 years old), after maxilla
growth nearly complete
• Definition: soft palate cannot contact
posterior pharynx, resulting in
• Diagnosis
Speech evaluation
Nasoendoscopy and/or
videofluoroscopy done at 3 to 4
years old
Nasometry (measurement of nasal
airway resistance with speech)
• Treatments: speech therapy,
appliance, or surgery
• Surgical options
Furlow palatoplasty: double
opposing Z-plasty lengthens soft
Sphincter pharyngoplasty: useful if
coronal closure seen on
nasoendoscopy where there is no
lateral wall movement
Posterior pharyngeal flap: useful if
anterior-posterior (sagittal) gap
seen on nasoendoscopy; to
determine posterior pharyngeal
wall flap width for VPI, evaluate
movement of lateral pharyngeal

Orthognathic Surgery
• Between 25 to 50% of affected
individuals will develop midfacial
retrusion that would benefit from
orthognathic surgery at the
culmination of growth
• The goals of orthognathic surgery are
restoration of Angle Class I maxilla-
mandibular relationships and
improvement in facial
proportions/facial convexity

Suggested Reading
Bardach J. Two-flap palatoplasty:
Bardach's technique. Operative
Techniques in Plastic and
Reconstructive Surgery
Fisher DM, Sommerlad BC. Cleft lip,
cleft palate, and velopharyngeal
insufficiency. Plast Reconstr Surg
Fraser FC. Etiology of cleft lip and
palate. In: Grabb WC, Rosenstein
SW, Bzoch KR, eds. Cleft Lip and
Palate. Surgical Dental, and
Speech Aspects. Boston, MA: Little,
Brown; 1971
Furlow LT. Cleft palate repair by double
opposing Z-plasty. Operative
Techniques in Plastic and
Reconstructive Surgery
Good PM, Mulliken JB, Padwa BL.
Frequency of Le Fort I osteotomy
after repaired cleft lip and palate or
cleft palate. Cleft Palate Craniofac.
J 2007;44(4): 396-401
Gosman AA. Cleft Lip and Palate I:
Embryology, Anatomy,
Epidemiology, and Clinical
Outcomes. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2007:1–52. Selected Readings in
Plastic Surgery; vol 10, issue 16
Gosman AA. Cleft Lip and Palate II:
Surgical Management. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2007:1–93. Selected
Readings in Plastic Surgery; vol
10, issue 16
Guyuron B. MOC-PS (SM) CME
article: late cleft lip nasal deformity.
Plast Reconstr Surg 2008;121(4,
Hopper RA, Cutting C, Grayson B. Cleft
lip and palate. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:201–225
Kernahan DA. The striped Y—a
symbolic classification for cleft lip
and palate. Plast Reconstr Surg
Koshy JC, Ellsworth WA, Sharabi SE,
Hatef DA, Hollier LH Jr, Stal S.
Bilateral cleft lip revisions: the
Abbe flap. Plast Reconstr Surg
Liau JY, Sadove AM, van Aalst JA. An
evidence-based approach to cleft
palate repair. Plast Reconstr Surg
Losee JE, Kirschner RE, eds.
Comprehensive Cleft Care. New
York: McGraw-Hill Professional;
Marcus JR, Fisher DM, Lenz GJ, Magee
WP, Zuker RM. Inadequate
gingivolabial sulcus remains an
avoidable problem after bilateral
cleft lip repair. Plast Reconstr Surg
Marsh JL. The evaluation and
management of velopharyngeal
dysfunction. Clin Plast Surg
Mohler LR. Unilateral cleft lip repair.
Plast Reconstr Surg
Moore KL, ed. The Developing Human.
4th ed. Philadelphia, PA: Saunders;
Santiago PE, Grayson BH, Cutting CB,
Gianoutsos MP, Brecht LE, Kwon
SM. Reduced need for alveolar
bone grafting by presurgical
orthopedics and primary
gingivoperiosteoplasty. Cleft Palate
Craniofac J 1998;35(1):77–80
Sitzman TJ, Girotto JA, Marcus JR.
Current surgical practices in cleft
care: unilateral cleft lip repair. Plast
Reconstr Surg 2008;121(5):261e–
van Aalst JA, Kolappa KK, Sadove M.
MOC-PSSM CME article:
Nonsyndromic cleft palate. Plast
Reconstr Surg 2008;121(1,
16 Tessier Clefts
Reviewed by Henry K. Kawamoto Jr.

Tessier Clefts
• Classification
Dr. Paul Tessier (1917–2008)
classified rare orofacial soft tissue
and bony clefts
Infraorbital facial clefts are
numbered 0 through 7
Supraorbital cranial clefts are
numbered 9 through 14
Numbered like a sundial
Facial clefts and cranial extensions
usually total 14 if added together
• Bony clefts (Fig. 16.1)
0: Midline
1: Central and lateral incisors to
2: Lateral incisor to nose
3: Naso-ocular
4: Medial to infraorbital foramen
5: Lateral to infraorbital foramen
6: Hypoplastic zygoma body
7: Hypoplastic mandible; zygomatic
arch hypoplastic or absent
8: Frontozygomatic suture
9–11: Supraorbital rim
12–13: Paramedian
14: Midline
• Soft tissue clefts (Fig. 16.1)
0: Midline cleft with Cupid's bow
and philtral columns divided
1–3: Common clefts through Cupid's
bow and philtrum then nose
1: Notches alar cartilage dome
2. Mid-alar rim
3: Displaces nasal alar base and
medial canthus
4: Begins lateral to Cupid's bow,
does not touch nose
5: Lateral lip to mid-lower eyelid
6–8: Treacher Collins if bilateral
6: Notching lower lateral eyelid
7: Most common Tessier cleft
(1/3,000), associated with
unilateral hemifacial microsomia
and macrostomia
8: Cleft of lateral canthus, epibulbar
dermoids, seen in Goldenhar
9: Rarest, tail of eyebrow
10–14: Associated with
encephaloceles and
• Treatment
3 to 12 months: soft tissue repair
6 to 9 months: midface
reconstruction with autogenous
bone graft
Orthognathic surgery at skeletal

• Definition
Increased interorbital distance
(IOD) between medial orbital
walls measured at dacryon
Dacryon: junction of frontal,
lacrimal, and maxillary bones
• Etiology
Rare Tessier clefts
Frontonasal dysplasia
Craniofrontonasal dysplasia
Apert syndrome
Crouzon syndrome
Pfeiffer syndrome
• Diagnosis
Clinical exam
X-ray or computed tomographic
(CT) scan
Radiographic measurement of IOD:
average IOD in men is 28 mm, in
women is 25 mm
• Tessier Classification
Type 1: 30 to 34 mm
Type 2: 35 to 39 mm
Type 3: > 40 mm
Fig. 16.1 Tessier clefts.
• Munro Classification (Fig. 16.2)
Type A: parallel medial orbital
Type B: anterior medial wall
Type C: middle medial wall
Type D: posterior medial wall
Fig. 16.2 Munro classification of
hypertelorbitism. (From Munro IR, Das SK.
Improving results in orbital hypertelorism
correction. Ann Plast Surg 1979;2(6):499–
507. Used with permission,)

• Treatment
Correction after 8 years of age
reduces relapse
Facial bipartition: during or after
mixed dentition
Four-wall box osteotomy: only
after mixed dentition, otherwise
can injure undescended permanent
• Pseudohypertelorbitism
Increased intercanthal distance, but
normal interdacryon distance on
Posttraumatic telecanthus from soft
tissue swelling or medial canthal
tendon displacement

Congenital Midline Nasal

• Encephalocele
Neural tissue herniates through
foramen cecum
May be associated with a Tessier
cleft or acquired secondary to
No hypertelorbitism: lateral walls
are normal in position and angle
Telecanthus present
Dural covering is present,
compressible, transilluminates,
bluish, pulsatile
Furstenberg sign: enlarges with
Valsalva or crying
Treatment: HULA technique, hard-
tissue sealant, undermine and
excise encephalocele, lower
supraorbital bar, augment nasal
• Glioma
Neural tissue without skull defect
No dura covering
May originate as encephalocele
with hernia, but defect closes
Reddish, telangiectasias, firm,
noncompressible, does not
• Nasal dermoid cyst
Most common congenital nasal
Arise from dermoid sinus
Skin pit with cutaneous inward
passage lined with squamous
stratified epithelium contains
adnexal structures (hair follicles,
sebaceous glands)
10 to 45% have intracranial sinus
Order CT scan if midline mass to
confirm no intracranial extension
of cyst and to rule out
encephalocele or glioma
Treatment: excision
Other locations of dermoid cysts
Lateral brow cyst
Most common site of dermoid
Usually have distinct margins
and no intracranial extension
If indistinct margins, order CT
scan because may extend to
lateral orbital wall
Orbital cyst has no intracranial
• Lipoma: soft, compressible, no
telangiectasias, nonpulsatile, does
not transilluminate

Suggested Reading
Bradley JP, Kawamoto HK.
Craniofacial clefts and
hypertelorbitism. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:268–280
Bradley JP, Levitt A, Nguyen J, et al.
Roman arch, keystone fixation for
facial bipartition with monobloc
distraction. Plast Reconstr Surg
Kawamoto HK Jr. The kaleidoscopic
world of rare craniofacial clefts:
order out of chaos (Tessier
classification). Clin Plast Surg
Kawamoto HK, Heller JB, Heller MM,
et al. Craniofrontonasal dysplasia: a
surgical treatment algorithm. Plast
Reconstr Surg 2007;120(7):1943–
Kumar A, Helling E, Guenther D,
Crabtree T, Wexler AW, Bradley JP.
Correction of frontonasoethmoidal
encephalocele: the HULA
procedure. Plast Reconstr Surg
Mount DL, Swelstad M. Craniofacial
Anomalies II: Syndromes and
Surgery. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2007:1–65. Selected Readings in
Plastic Surgery; vol 17, issue 2
Munro IR, Das SK. Improving results in
orbital hypertelorism correction.
Ann Plast Surg 1979;2(6):499–507
Ozaki W, Kawamoto HK. Craniofacial
clefts. In: Thaller SR, Bradley JP,
Garri JI, eds. Craniofacial Surgery.
New York: Informa Healthcare;
Raposo-Amaral CE, Raposo-Amaral
CM, Raposo-Amaral CA, Chahal H,
Bradley JP, Jarrahy R. Age at
surgery significantly impacts the
amount of orbital relapse following
hypertelorbitism correction: a 30-
year longitudinal study. Plast
Reconstr Surg 2011;127(4):1620–
Tessier P. Anatomical classification
facial, cranio-facial and latero-
facial clefts. J Maxillofac Surg
17 Orthognathic,
Temporomandibular Joint,
and Chin
Reviewed by Anand R. Kumar

Orthognathic Surgery
• Indications
Malocclusion (Table 17.1)
Cleft lip/palate related
Pierre Robin Sequence
Post traumatic
Prognathism (primary)
Bimaxillary protrusion
Idiopathic condylar resorption
Binder syndrome
Congenital craniofacial anomaly
Craniofacial microsomia
Treacher Collins syndrome
Nager syndrome
Miller syndrome
Craniosynostosis related
Apert syndrome
Crouzon syndrome
Pfeiffer syndrome
Frontonasal dysplasia
Rare facial clefts
Tessier clefts 1-14, 30
Table 17.1 Angle's classification of occlusion

Class Characteristics
Mesiobuccal cusp of
the first maxillary
molar lies in the
I Occlusion buccal groove of the
first mandibular
molar, incisors are

As above, but the

incisors are not
aligned, having poor
I Malocclusion spacing,
under- or

Maxillary molar is
II Malocclusion anterior to the
mandibular molar

Maxillary molar is
III Malocclusion posterior to the
mandibular molar

Dentofacial imbalance
With malocclusion
Without malocclusion
Obstructive sleep apnea
Noncompliance with continuous
positive airway pressure
(CPAP)/bilevel positive airway
pressure (BIPAP)
Failued Level 1 sleep apnea
(UPPP) genioglossal
advancement, lateral
• Orthognathic surgery planning
History/physical exam: facial
analysis, photographs
Cephalometric analysis: lateral
cephalogram with tracing
Bite registration (dental wax):
records taken in centric relation
(mandible condyles seated within
the glenoid fossa)
Bite registration with face-bow:
measures centric occlusion and
relation along Frankfort horizontal
(FH) plane for double jaw surgery
Alginate impressions
Dental stone models: poured from
alginate impressions
Acrylic splints: articulate dental
stone models to create final splint
if doing single jaw surgery; do
model surgery to create
intermediate and final splints for
double jaw surgery
Virtual surgical planning (VSP)
Need dental models set in final
occlusion and maxillofacial CT
scan (DICOM file type)
Digital face-bow registration no
longer needed
• Timing of orthognathic surgery
Perform at completion of skeletal
and facial growth (in general)
Distraction osteogenesis can be
performed at any time but must be
planned in the context of final
growth and definitive orthognathic
Serial cephalograms: monitor for
minimal to no change in growth
(best method)
Hand/wrist X-ray: growth plate
closure of the proximal phalanx or
distal radius symbolizes
completion of mandible growth
(controversial method)
When orthodontics preparation is
complete and patient has been
converted to steel orthodontic wire
with surgical hooks (typically 3 to
4 weeks prior to jaw surgery)
• Facial thirds
Upper: trichion to glabella
Middle: glabella to subnasale
Lower: subnasale to menton
Fig. 17.1 Overjet and overbite.

• Overjet (Fig. 17.1)

Anterior-posterior distance
between upper and lower central
incisor edges
Normal: 2 mm positive overjet
> 2 mm: usually seen with Class II
Negative overjet: mandibular
incisors are anterior to maxillary
incisors, usually seen with Class
III malocclusion
Occlusion is based on anterior-
posterior molar relationship,
overjet based on incisor
relationships: can have
malocclusion with normal overjet
if incisors are corrected
• Overbite (Fig. 17.1)
Vertical distance between upper
and lower central incisor edges
Normal: 2 mm overbite
• Centric occlusion and relation
Centric occlusion: ideal
interdigitation of upper and lower
Centric relation: ideal relationship
of mandibular condyle seated
within the glenoid fossa
• Cephalometric analysis using lateral
cephalogram (Table 17.2) (Fig.
SNA angle: anterior-posterior
relationship of maxilla in relation
to cranial base (normal = 82
degrees ± 4 degrees)
SNB angle: anterior-posterior
relationship of mandible in
relation to cranial base (normal =
80 degrees ± 3 degrees)
Table 17.2 Cephalometric points

Point Description

Innermost point of
A mandibular alveolar

Innermost point of
B maxillary alveolar
Nasion (N) Nasofrontal junction

Inferiormost point
Menton (Me)
of chin

Anteriormost point
Pogonion (Pg)
of chin

Superior point of
Porion (Po) external auditory

Center of sella
Sella (S)

Midpoint between
Gnathion (Gn)
Me and Pg

Gonion (Go) Angle of mandible

Inferiormost point
Orbitale (Or)
of orbit
Fig. 17.2 Lateral cephalogram with
cephalometric points.
ANB angle: anterior-posterior
relationship of maxilla in relation
to mandible (normal = 2 degrees)
FH line: horizontal plane between
porion (Po) and orbitale (Or)
Sella nasion pogonion (SNPg)
angle: anterior-posterior
relationship of chin in relation to
cranial base (normal = 80 degrees
± 3 degrees)
• Vertical maxillary excess (VME)
Ideal upper incisor show in
repose: 2 mm in men, up to 4 mm
in women
Patients have a gummy smile and
“long face” due to increased lower
third of the face
Treatment: Le Fort I and maxillary
• Vertical maxillary deficiency
Patients have absence of incisal
show when smiling
Treatment: Le Fort I and maxillary
• Maxillary hypoplasia
Class III malocclusion, SNA less
than normal, SNB within normal
Le Fort I with immediate internal
fixation: if < 10 mm advancement
Le Fort I with distraction
osteogenesis: if > 10 mm
advancement required, reduces
relapse and velopharyngeal
insufficiency associated with
advancing large distances against
soft tissue and scar from previous
palate repair
• Blood supply to maxilla (Fig. 17.3)
Before Le Fort I osteotomy:
external carotid artery supplies
internal maxillary artery, which
supplies the descending palatine,
infraorbital, and posterior superior
alveolar arteries
Descending palatine artery: at risk
for injury during Le Fort I
osteotomy, runs vertical in
posterior maxilla along medial
maxillary sinus wall
After Le Fort I osteotomy: external
carotid artery supplies the facial
artery (which supplies the
ascending palatine branch) and
ascending pharyngeal artery
(which supplies a palatine branch)
• Mandibular deformities
SNB < 77: retrognathia, class II
malocclusion, requires mandibular
SNB > 83: prognathism, class III
malocclusion, requires mandibular
• Distraction osteogenesis
Latency period: may vary
depending on age and type of
Neonatal to 2 years: 12-hours
2 years to adulthood, 3 to 7 days
latency depending on clinical
Activation period: 1 mm/d
advancement age > 2 years
Consolidation period: 10 to 16
weeks (1 week/mm advanced)
• Medpor mandibular angle implants
Increase bigonial distance and
facial width
Fig. 17.3 Blood supply to maxilla.

Temporomandibular Joint
• Internal derangement
Symptoms: clicking and pain (most
common symptom) caused by
subluxation of articular disk
Diagnosis: magnetic resonance
imaging shows anterior
displacement of meniscus (does
not reduce), posterosuperior
malpositioning of condyle
Initial treatment is conservative:
bite adjustment, nonsteroidal anti-
inflammatory drugs, and physical
• Ankylosis
Most common cause: trauma
Symptoms: pain, joint
stiffness/immobility due to
fibrosis, narrowing joint space,
and bony fusion
Treatment: alloplastic interposition
arthroplasty (remove disk),
condylectomy (leave disk, remove
bone), costochondral graft
arthroplasty (remove disk), gap
arthroplasty (resection of bone,
leave disk)
• Avascular necrosis condyle: rare,
secondary to devascularization from
temporomandibular joint surgery
• Myofascial pain dysfunction:
masticatory muscle spasm secondary
to bruxism and stress
• Dislocation
Anterior extension of condyle
secondary to joint hypermobility
Treatment: spontaneous or manual
• Rheumatoid arthritis: can affect
condyles and cause retrognathia and
apergnathia (open bite)
• Hypertrophy coronoid process
Rare, slow progressive reduction
of mandibular opening
Diagnosis: computed tomographic
Treatment: coronoidectomy

• Ideal position of chin
Women: chin is 2 mm posterior to
lower lip
Men: chin is at the same anterior-
posterior position as lower lip
Lower lip is 2 mm posterior to
upper lip
Reidel line
Assesses chin projection: line
connects most anterior portion
of the upper and lower lips to
the most prominent portion of
the soft-tissue menton
If the chin falls behind this line
(and no malocclusion), the
patient has microgenia and could
benefit from genioplasty
• Check for malocclusion
If no malocclusion: proceed to
If malocclusion: hold on
genioplasty, obtain cephalogram,
may need orthodontics and/or
orthognathic surgery
• Mental nerve
Exits at second mandibular
Nerve is superior to implant
placement and horizontal
osteotomy of mandible
• SNPg
Normal = 80 degrees ± 3 degrees
If SNPg < 77 and SNB normal: do
advancement genioplasty
If SNPg > 83 and SNB normal: do
setback genioplasty
• Osseous genioplasty
Horizontal osteotomy of mandible
• Implant genioplasty
Silicone: smooth, encased in
fibrous capsule, easily removed
Porous polyethylene (Medpor):
less likely to migrate because in-
growth of tissue compared to
silicone implants
Soft tissue response to prosthetic:
0.8 mm soft tissue advancement for
every 1 mm implant
• Lower lip paresthesias
Complication from implant
Trim or reposition implant if
paresthesias do not resolve by 3
Paresthesias lasting more than 8
weeks may lead to permanent loss
of sensation

Suggested Reading
Andrews BT, Lakin GE, Bradley JP,
Kawamoto HK Jr. Orthognathic
surgery for obstructive sleep apnea:
applying the principles to new
horizons in craniofacial surgery. J
Craniofac Surg 2012;23(7, Suppl
Baker SB. Orthognathic surgery. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:256–267
Garri JI, Tuchman M, Urrego AF, et al.
Orthognathic surgery. In: Thaller
SR, Bradley JP, Garri JI, eds.
Craniofacial Surgery. New York:
Informa Healthcare; 2008:197–217
Guyuron B. MOC-PS (SM) CME
article: genioplasty. Plast Reconstr
Surg 2008;121(4, Suppl): 1–7
Jefferson Y. Facial beauty—establishing
a universal standard. Int J Orthod
Milwaukee 2004;15(1):9–22
Li KK, Meara JG, Alexander A Jr.
Location of the descending palatine
artery in relation to the Le Fort I
osteotomy. J Oral Maxillofac Surg
1996;54(7):822–825, discussion
Mount DL, Ambay RS. Craniofacial
Anomalies I: Cephalometrics and
Orthognathic Surgery. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2007:1–50. Selected
Readings in Plastic Surgery; vol
10, issue 17
McCarthy JG, Ruff GL. The chin. Clin
Plast Surg 1988;15(1):125–137
Patel PK, Novia MV. The surgical tools:
the LeFort I, bilateral sagittal split
osteotomy of the mandible, and the
osseous genioplasty. Clin Plast Surg
Phillips JH, Nish I, Daskalogiannakis J.
Orthognathic surgery in cleft
patients. Plast Reconstr Surg
Sati S, Havlik RJ. An evidence-based
approach to genioplasty. Plast
Reconstr Surg 2011; 127(2):898–
18 Craniosynostosis and
Craniofacial Syndromes
Reviewed by Jeffrey A. Fearon

• Cranial bones and sutures in newborn
(Fig. 18.1):
Posterior fontanelle closes 2
Anterior fontanelle closes 4 to 24
Transforming growth factor beta
(TGFB) gene associated with
mechanisms of suture fusion
Fibroblast growth factor receptor
(FGFR) gene associated with
coronal suture fusion
Craniosynostosis: premature fusion
of skull sutures
Virchow's law: direction of skull
growth is parallel to fused suture
Metopic suture: first to close
during normal development
Fig. 18.1 Newborn, superior view.

• Diagnosis
Clinical exam (shape, palpable
ridge) (Tables 18.1 and 18.2)
Table 18.1 Cranial shapes

Cranial shape Characteristics

Most common form

of craniosynostosis,
sagittal suture
Scaphocephaly dolichocephalic
(long, narrow),
projects like the
keel of a boat,
toaster head

Unilateral coronal
(anterior) or
lambdoid (posterior)
sutures fused

Bilateral coronal
(anterior) or
lambdoid (posterior)
sutures fused,
turricephalic (broad,

Acrocephaly Conical skull

Bicoronal and
“sharp” head

Metopic suture
closed prematurely,
normally fuses by 9
Trigonocephaly months,
narrowing, forehead
has triangular shape

Cloverleaf skull
deformity, bilateral
Kleeblattschädel coronal and
lambdoid sutures

Table 18.2 Positional molding and unilambdoid

synostosis differences

Positional Unilambdoi
molding synostosis

posterior Occipital Parietal

Frontal bossing Ipsilateral Contralateral

occipitomastoid Absent Present

Anterior Posterior/inf
ipsilateral ear

Skull base/face No tilt inferior tilt

lambdoid Absent Present

Head shape
vertex view Parallelogram Trapezium

Head shape
Normal Parallelogram
posterior view

Status lambdoid
Patent Fused

Treatment exercises, Surgery
helmet if fails

Unilateral coronal
craniosynostosis: ipsilateral
flattening of forehead, elevation of
the ipsilateral supraorbit nasal
root deviation to ipsilateral side,
nasal tip deviation to contralateral
Harlequin deformity: radiographic
appearance of ipsilateral coronal
craniosynostosis, superior
displacement of lesser wing of
sphenoid causes abnormal orbit
shape with opacity extending from
inferiormedial to superior-lateral
direction (ipsilateral upslanting of
the supraorbital rim)
Computed tomographic (CT) scan,
only when clinical exam uncertain
Genetic testing
• Syndromic craniosynostosis (Table
• Principles for treatment
Timing of operation: between 3
and 12 months (varies with
severity and surgical technique),
bone still pliable, osseous defects
Enlarge skull to avoid elevated
intracranial pressure and avoid
neurological defects (though
neurological defects can be
primary, too)
Early surgical repair for ocular
Normalize appearance
Single-suture craniosynostosis can
be treated with open suturectomy
(with or without springs or
postoperative helmet)
Cranial vault remodeling with
resorbable fixation does not
require postoperative helmet
Cranial vault remodeling and
barrel staving for sagittal
Frontal craniotomy and frontal
orbital advancement (FOA) for
coronal and metopic
Greater surface area expansion
with a posterior vault compared to
an anterior vault according to CT-
based study calculations
Midface advancement
Improves airway obstruction,
class III malocclusion,
proptosis, and facial deformities
Monobloc advances forehead,
orbits, nose, and maxilla
Le Fort III repositions malar
eminences and lengthens the
Orthognathic surgery
Le Fort I advances maxilla to
correct class III malocclusion
Le Fort II advances nose and
maxilla to correct nasomaxillary
• Torticollis
Tight sternocleidomastoid (SCM)
muscle, congenital
Associated with deformational
plagiocephaly, affects growth of
lower half of face
Treatment with physical therapy, if
fails conservative therapy may
need Botox injections (Allergan,
Irvine, CA) or resection of SCM
Craniofacial Syndromes
• Craniofacial (hemifacial)
Most common major craniofacial
Hemifacial microsomia often used
for isolated maxillary/mandibular
involvement and craniofacial
microsomia for additional
orbital/frontal involvement
No genetic transmission, secondary
to intrauterine event such as
stapedial artery occlusion or
developmental hematoma, or from
impaired neural crest migration.
Affects first and second branchial
arch structures
Associated with Tessier no. 7
(lateral facial or oral commissure)
cleft, hypoplastic mandible and
zygoma, microtia, cranial nerve
(CN) VII palsy, soft tissue
deficiency, macrostomia, usually
unilateral, cervical spine and renal
anomalies (need screening
cervical spine X-rays and renal
Hypoplastic mandible may require
sleep study to rule out obstructive
sleep apnea; later may need
orthognathic surgery,
costochondral graft, or distraction
depending on severity
• Goldenhar syndrome
Variant of hemifacial microsomia
Also called oculoauriculovertebral
syndrome (OAVS) (ocular,
auricular, and vertebral anomalies)
Microtia, epibulbar dermoid,
cervical vertebral and scapular
anomalies, renal anomalies
• Treacher Collins syndrome
Also called: mandibulofacial
dysostosis, Franceschetti–Klein
Bilateral Tessier no. 6, 7, and 8
Mapped to chromosome 5q31.1-
q33.3, autosomal dominant
Microtia, hypoplastic or absent
zygomas, orbital clefts,
downslanting palpebral fissures,
micrognathia (malocclusion class
• Nager syndrome
Autosomal recessive
Hypoplastic thumb, radius, facial
anomalies similar to Treacher
Often have absent soft palate
• Möbius syndrome
Congenital paralysis bilateral CN
VI and CN VII causing strabismus
requiring surgery
Also involved: CN III, V, IX, XI,
and XII
Limb abnormalities associated
25% of time (clubfeet, syndactyly)
• Trisomy 21 (Down syndrome):
mental retardation, brachycephaly, no
cleft lip/palate
• Holoprosencephaly: varying degrees
of incomplete separations involving
the halves of the brain, causes
hypotelorism, due to mesoderm
deficiency in the midline
• Parry–Romberg syndrome
Progressive hemifacial atrophy,
sporadic inheritance
Presentation: onset 5 to 15 years of
age, lasts 2 to 10 years, affects soft
tissue and bone, follows CN V
distribution, have coup de sabre
lesion, neurological (migraine,
seizures, trigeminal neuralgia),
brain magnetic resonance imaging
may show intracranial
Treat after disease stops
progressing: fat graft, parascapular
flap, which does not atrophy like
muscle flaps and has fascial
component to aid with fixation
compared to omental flaps, which
can sag
• CHARGE syndrome
Associated with Coloboma, Heart
defects, choanal Atresia, Retarded
growth and development, Genital
hypoplasia, and Ear abnormalities
Choanal atresia: diagnosis with CT
scan, inability to pass red rubber
catheter through nose, and
paradoxical cyanosis (newborn
cyanosis relieved with crying
because obligate nose breathers)
Coloboma: congenital defect
eyelid, iris, retina, choroid, or
optic disc
• Binder syndrome (maxillonasal
Lack anterior nasal spine
Midface hypoplasia
Warfarin induced
• Klippel–Feil syndrome
Low posterior hairline, short neck,
cervical > thoracolumbar spine
fusion, associated craniofacial
Note: do not confuse with Klippel–
Trenaunay syndrome, which
consists of leg overgrowth and
• McCune–Albright syndrome
Autosomal dominant
Defect calcium/phosphate
Triad of polyostotic fibrous
dysplasia (can affect craniofacial
skeleton), precocious puberty, and
café au lait spots with irregular
borders which are compared to the
map of the coast of Maine (as
opposed to café au lait spots with
smooth borders seen in other
disorders which are compared to
the coast of California)
Low nasal bridge and short neck
• Fibrous dysplasia
Benign hamartomatous lesion: bone
replaced by fibrous tissue
Affects one (monostotic) or
multiple (polyostotic) bones
Burns out after adolescence
Imaging: ground-glass appearance
Treatment: primary excision when
possible, otherwise contour
reduction (near tooth-bearing
regions) and selective optic canal

Suggested Reading
Bartlett SP. Craniosynostosis
syndromes. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:237–247
Bradley JP, Kawamoto HK, Taub P,
Wexler A, Cahan L. Antley-Bixler
syndrome: correction of facial
deformities and long-term survival.
Plast Reconstr Surg
Chim H, Gosain AK. An evidence-
based approach to craniosynostosis.
Plast Reconstr Surg
Forrest CR, Hopper RA. Craniofacial
syndromes and surgery. Plast
Reconstr Surg 2013;131(1):86e–
Havlik RJ. Miscellaneous craniofacial
conditions. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:281–296
Jarrahy R, Kawamoto HK, Keagle J,
Dickinson BP, Katchikian HV,
Bradley JP. Three tenets for staged
correction of Kleeblattschädel or
cloverleaf skull deformity. Plast
Reconstr Surg 2009;123(1):310–
McCarthy JG. Craniofacial microsomia.
In: Thorne CH, Beasley RW, Aston
SJ, et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:248–255
McCarthy JG, Warren SM, Bernstein J,
et al; Craniosynostosis Working
Group. Parameters of care for
craniosynostosis. Cleft Palate
Craniofac J 2012;49(1, Suppl):1S–
Mount DL, Swelstad M. Craniofacial
Anomalies II: Syndromes and
Surgery. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2007:1–65. Selected Readings in
Plastic Surgery; vol 17, issue 2
Persing JA. MOC-PS (SM) CME
article: management considerations
in the treatment of craniosynostosis.
Plast Reconstr Surg 2008;121(4,
Shin JH, Persing JA. Nonsyndromic
craniosynostosis and deformational
plagiocephaly. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:226–236
19 Hemangiomas and
Vascular Malformations
Reviewed by Arin K. Greene

• Characteristics
Hyperplasia/proliferation of
endothelial cells after birth: 80%
noted during first month
Lesion rapidly grows during the
first 5 months of life, then begins
to regress at approximately 12
months of age
The lesion stops improving after
3.5 years of age
• Histology
Multilaminate basement membrane
Plump endothelial cells
GLUT 1-immunopositive
• Treatment
Observe for spontaneous resolution
Reasons not to observe: impairs
ulcerates/bleeds, causes
recalcitrant pain
First-line medical therapy: steroids
Previous second-line medical
therapy: interferon (no longer used
with infant hemangioma because
reported spastic diplegia, also
took 1 to 2 months to work, caused
flu, neutropenia, alterations in
liver function tests)
New medical therapy: propranolol
has recently been shown to be an
efficacious and safe treatment
Surgery: if it does not regress after
3 to 4 years of age
Laser: does not penetrate deep
portion of hemangioma
• Side-effects from steroid treatment
Cushingoid facies: temporarily
affects 20% of patients and
resolves following completion of
16% temporarily fall of their
growth curve, but will catch-up by
2 years of age
• Subglottic hemangioma
Initial treatment: steroids
CO2 laser: if unilateral (do not
laser circumferential lesions
because can lead to stenosis
Immediate resection if subglottic
May need tracheostomy tube

Vascular Malformations
• Characteristics
Present at birth, do not involute
Ultrasound: diagnoses subcategory
according to fast or slow flow
Slow flow: venous malformations,
capillary malformations, and
lymphatic malformations
Fast flow: arteriovenous
• Capillary malformations (CMs)
Macular lesion present at birth that
does not spontaneously resolve
Treatment: tunable pulse dye laser
(585 nm) in face, neck, trunk
Laser therapy does not work as
well in central face (nose, lips)
and extremities
Laser therapy requires multiple
treatments every 6 to 8 weeks
• Lymphatic malformations (LMs)
Microcystic or macrocystic (cystic
Enlarge with infection, associated
with bony overgrowth
Treatment: intralesional
sclerotherapy or excision followed
by postop compression (not
compression alone)
Sclerotherapies: OK-432 (killed
streptococcal protein, an
immunologic stimulant),
bleomycin, ethanol, doxycycline,
sodium tetradecyl sulfate
• Venous malformations (VMs)
Increase in size with activity or
when dependent, prone to
Treatment: aspirin to prevent
thrombosis and treat pain from
thrombosis, laser therapy,
sclerotherapy, excision (may be
combined with sclerotherapy),
compression therapy for extremity
• Arteriovenous malformations
Characterized by: palpable thrill,
warm to touch, increase in size
with exercise, associated with
heart failure, grow to become
painful, mass effect on bone with
lytic changes
Diagnosis: ultrasound, MRI,
Treatment: embolization of the
nidus with or without excision 24
to 48 hours later

Vascular Anomaly
• Kasabach–Merritt syndrome:
kaposiform hemangioendothelioma
(not hemangioma)
Thrombocytopenia (causes
Treatment: vincristine
• Osler–Weber–Rendu syndrome:
Hereditary hemorrhagic
telangiectasia (HTT)
Triad of telangiectasias (oral and
mucosal), epistaxis, family history
Associated with melena and
• Blue rubber bleb nevus syndrome:
venous malformations (VMs)
Raised blue-purple rubbery
cutaneous lesions easily
compressible, blood filled
Usually found on hands and feet,
but can occur anywhere
Treatment: excision if tender
Note: do not confuse with blue
nevus, which is a small,
intradermal nevus, rarely
• Sturge–Weber syndrome: capillary
malformation (CM)
Port wine stain with V1, V1–2, or
V1–3 distribution
May be associated with
intracranial vascular anomalies
Symptoms: glaucoma, seizures,
mental retardation
Treatment: symptomatic, laser for
CM, anticonvulsants, monitor for
• Maffucci syndrome: VM
VM and enchondromatosis
20% degenerate to
• Klippel–Trenaunay syndrome:
combined CM, LM, and VM (CLVM)
Unilateral limb overgrowth (leg
most common)
Increased risk of deep vein
thrombosis/pulmonary embolism
Note: do not confuse with Klippel–
Feil, which has low posterior
hairline and cervical spinal fusion
• Parkes Weber syndrome: combined
Similar to Klippel–Trenaunay
syndrome except has AVM
• Cobb syndrome: CM
Underlying spinal cord angioma or
Symptoms include neurological
weakness or paralysis
May be in midline scalp over

Suggested Reading
Burns JL. Vascular Anomalies and
Lymphedema. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2006:1–52. Selected Readings in
Plastic Surgery; vol 10, issue 15
Chim H, Drolet B, Duffy K, Koshima I,
Gosain AK. Vascular anomalies and
lymphedema. Plast Reconstr Surg
Dompmartin A, Vikkula M, Boon LM.
Venous malformation: update on
aetiopathogenesis, diagnosis and
management. Phlebology
Drolet BA, Frommelt PC, Chamlin SL,
et al. Initiation and use of
propranolol for infantile
hemangioma: report of a consensus
conference. Pediatrics
Hara K, Yoshida T, Kajiume T, Ohno N,
Kawaguchi H, Kobayashi M.
Successful treatment of
Kasabach-Merritt syndrome with
vincristine and diagnosis of the
hemangioma using three-
dimensional imaging. Pediatr
Hematol Oncol 2009;26(5):375–
Mulliken JB. Vascular anomalies. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:191–200
Mulliken JB, Fishman SJ, Burrows PE.
Vascular anomalies. Curr Probl Surg
20 Facial Paralysis
Reviewed by Andre Panossian

• History
Acute versus chronic injury
Unilateral versus bilateral
• Physical exam
Comprehensive cranial nerve exam
Focused facial nerve exam: raise
eyebrows, unforced and forced eye
closure, smile, nasolabial fold
production, pursing lips, inflating
• Studies
MRI or CT; can identify
intracerebral pathology such as a
mass or tumor as cause of facial
• Treatment
Symmetry at rest and with
Symptomatic control (oral
competence, eye closure)
Voluntary facial movement with
Static: maintains position
without ability to animate (e.g.,
gold weight, fascial sling)
Dynamic: allows for motion

Facial Paralysis Etiology

• Bell palsy
Most common etiology of facial
Idiopathic dysfunction of the facial
Usually unilateral
May be related to latent herpes
80 to 90% show signs of recovery
during first 3 weeks
• Congenital
Birth trauma
Craniofacial microsomia,
hemifacial microsomia, Goldenhar
Möbius syndrome (sixth and
seventh nerve paralysis)
• Infection
Viral, bacterial
Chronic otitis media
• Intracerebral
• Myogenic
Muscular dystrophy (e.g.,
fascioscapulohumeral muscular
Myasthenia gravis
• Neurogenic
Demyelinating disorders (e.g.,
multiple sclerosis, virally
• Rheumatologic
Kawasaki disease
• Trauma
Temporal bone fracture
• Tumor
Parotid gland
Adenoid cystic tumor with
perineural invasion
Acoustic neuromas
Posterior cerebral fossa tumors
Dynamic Reconstruction
(Facial Reanimation)
• Cross-face nerve graft with delayed
free flap
Two-stage procedure
Useful when muscle atrophied from
> 12 to 24 months of facial
Spontaneous smiling
Most common nerve graft used:
sural nerve graft attached across
the face to a facial nerve branch on
the normal side
Only for unilateral cases
Most common free flap used:
gracilis muscle, staged 6 to 9
months after nerve graft, connected
to facial artery and vein
• Free flap to ipsilateral cranial nerve
Single-stage procedure
Useful when muscle atrophied from
> 12 to 24 months of facial
Nonspontaneous smiling (triggered
by biting)
Good cerebral adaptation for
spontaneity over time
Can use for unilateral or bilateral
Most common nerve donor:
masseter nerve
• Local muscle transposition
Single-stage procedure
Muscles: masseter and temporalis
Useful when muscle atrophied from
> 12 to 24 months of facial
Based on trigeminal nerve
Nonspontaneous smiling
Voluntary contraction required
Good cerebral adaptation
• Cranial nerve transfers
Nerves: ipsilateral masseter and
hypoglossal nerves
Useful when paralysis is < 12 to 14
months from onset
Can use for bilateral facial nerve
paralysis, single-stage connection
to free flap, babysitter procedure
Babysitter procedure: cranial
nerve transfer temporarily
preserves viable muscle while
cross-facial nerve graft axons
regenerates from contralateral side
Nonspontaneous smiling
Hypoglossal nerve graft
hyperkinesis: excess movement
with chewing can be treated with
Botox injection (Allergan, Irvine,

Static Reconstruction
• Upper eyelid paralysis
Symptoms: lagophthalmos, dry eye,
Taping and topical lubrication at
Gold or platinum weight
Lower eyelid tendon/fascia sling
Eyelid spring (Levine)
• Brow paralysis
Brow lift: useful for brow droop
Browpexy: via incision above
eyebrow or through upper eyelid
Botox: paralyze contralateral
unaffected side (temporary)
Myectomy of contralateral frontalis
muscle (permanent)
Neurectomy of contralateral frontal
branch to frontalis muscle
• Lower lip asymmetry
Oral commissure elevation with
tensor fascia lata graft
Botox: paralyze contralateral
lower lip depressors (temporary)
Myectomy of contralateral lower
lip depressors (permanent)
Neurectomy of contralateral
marginal mandibular nerve

Suggested Reading
Anderson RG. Facial Nerve Disorders
and Surgery. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2006:1–43. Selected Readings in
Plastic Surgery; vol 10, issue 14
Fattah A, Borschel GH, Manktelow RT,
Bezuhly M, Zuker RM. Facial palsy
and reconstruction. Plast Reconstr
Surg 2012;129(2):340e–352e
Manktelow RT. Use of the gold weight
for lagophthalmos. Oper Tech Plast
Reconstr Surg 1999;6:157–158
Manktelow RT, Zuker RM, Neligan PC.
Facial paralysis reconstruction. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery, Philadelphia, PA:
Lippincott Williams & Wilkins;
21 Head and Neck Tumors,
Salivary Gland Tumors, Lip,
and Scalp
Reviewed by Brian T. Andrews

Oral Cancer
• Etiologies
Tobacco: most common
Human papillomavirus (HPV)
Alcohol: second most common
Sun exposure
Family history
• Most common sites involved
Tongue: most common
Floor of mouth
Other: palate, retromolar trigone,
buccal cavity
• Squamous cell carcinoma
Most common oral cancer
Also most common maxillary sinus
• Diagnosis
Physical exam of primary site and
lymphatic drainage
Biopsy: fine needle aspirate of
masses, excisional biopsy
Imaging: X-ray, computed
tomography, magnetic resonance
imaging, positron-emission
Triple endoscopy: nasoendoscopy,
laryngoscopy, bronchoscopy
• Unknown primary presents as
metastatic neck disease
PET Scan (variable ability to
detect primary malignancy)
Triple endoscopy to biopsy base of
tongue, tonsils, and nasopharynx
(Waldeyer ring), along with any
other suspicious lesions
Lymphatic drainage can hint to
location of pathology
Levels 1, 2, 3, and 4: oral cavity,
Level 5: nasopharynx
Level 6: thyroid

Head and Neck Tumor

Classification and Staging
(Tables 21.1 and 21.2)
• Stage IV: any bony invasion including
mandible, maxilla, palate, and skull
• Most common site of distant
metastasis: lungs
Table 21.1 Head and neck tumor TNM

T1 < 2 cm

T2 2–4 cm

T3 > 4 cm

Tumor size T4a advanced
local tissue

local tissue

N0 No nodes

Ipsilateral <
3 cm

N2 3–6 cm

N2A Ipsilateral
N2C ipsilateral,

N3 > 6 cm

M1 Metastasis

Table 21.2 Head and neck tumor staging

Stage Description

0 Carcinoma in situ

I Tumor < 2 cm (T1)

II Tumor 2–4 cm (T2)

Tumor > 4 cm (T3),

or Tumor any size
(T1–3), spread to
lymph node < 3 cm
on same side of
neck (N1)

advanced local
tissue involvement
(T4a), or Spread to
lymph node 3–6 cm

Spread to lymph
node > 6 cm (N3),
or Very advanced
IVB local tissue
involvement (T4b)
and any lymph node

Distant metastasis

Neck Dissection
• Principles
Can be therapeutic (known
lymphatic spread) or elective
(staging for lymph node sampling
to detect metastasis)
Early disease (Stage 1): can
observe neck
Intermediate disease (Stages 2 and
3): consider elective neck
dissection if no detectable
lymphatic spread
Late disease (Stages 3 and 4):
consider therapeutic neck
dissection if known disease
• Regions of the Neck (Table 21.3)
(Fig. 21.1)
• External carotid artery branches
(listed from proximal to distal)
Superior thyroid artery
Ascending pharyngeal artery
Lingual artery
Occipital artery
Facial artery
Posterior auricular artery
Maxillary artery and superficial
temporal artery are terminal
• Radical neck dissection
Levels: I through V
Requires sacrifice of spinal
accessory nerve, internal jugular,
sternocleidomastoid muscle
Indications: unsuccessful radiation
therapy, large bulky disease,
extracapsular invasion into
adjacent structures
• Modified radical neck dissection
Levels: I through V
Preserves one or more of the
following structures: spinal
accessory nerve, internal jugular,
sternocleidomastoid muscle
Table 21.3 Regions of the neck

Superior: inferio
I Submental/submandibular border of mandib
Inferior: hyoid

Anterior: posteri
border of
sternohyoid musc
II Upper jugular Posterior: poster
border of

Anterior: posteri
border of
sternohyoid musc
Carotid bifurcation Posterior: poster
(midjugular) border of

Anterior: posteri
border of
sternohyoid musc
IV Lower jugular Posterior: poster
border of

Anterior: posteri
border of
V Posterior triangle muscle Posterior
anterior border o
trapezius muscle
Inferior: clavicle
Superior: hyoid
Inferior: sternum
VI Anterior compartment Lateral: posterior
border of
sternohyoid musc
Fig. 21.1 Neck dissection levels.

Indications: cervical adenopathy,

without extracapsular invasion into
adjacent structures allowing
• Selective neck (supraomohyoid)
Levels: I through III
Indications: oral cavity cancer, no
palpable lymph nodes
Note: 63% of T3N0 tumors have
neck metastasis
• Bilateral neck exploration: indicated
if bilateral tumor or primary tumors
at the midline
• Skin lymphatic drainage patterns
Posterior scalp: posterior cervical
Ear tragus and helical root:
preauricular nodes
Posterior ear (not including tragus
and helical root): postauricular
nodes to posterior cervical nodes
gland: preparotid nodes

Neck Dissection
• Chylous leak
4% radical neck dissections injure
thoracic duct (left) or lymphatic
duct (right)
Thoracic duct drains lymph fluid
into left jugular vein 4 to 5 cm
superior to clavicle
Can be low output (< 500 ml/day)
or high output (> 500 ml/day)
Leak usually noticed in immediate
postoperative period with “milky”
fluid in suction drains
Medium chain triglyceride diet
to decrease chyle flow
Pressure dressing
Closed-drain suction to help seal
Surgical exploration and/or
mediastinoscopy with
endoscopic ligation of the
thoracic duct when conservative
treatment fails or for high ouput
Salivary fistula
Typically delayed in presentation
(> 5 days postop)
Symptoms: neck fullness, erythema,
increased white blood cells, fever
Initial treatment: nothing by mouth,
local wound care
Treatment if persistent or
enlarging: local flaps, T-tube
decompression, pectoralis major
muscle flaps
Rare complication is carotid
blowout which is most commonly
fatal and results from digestion of
a major artery in the head or neck
• Hypoglossal nerve injury
Bilateral injury can cause speech
and swallowing problems
requiring gastrostomy-tube
Nerve runs lateral to carotid artery,
medial to internal jugular vein
Passes deep to investing fascia as
it enters posterior triangle of neck
• Sternocleidomastoid muscle and/or
accessory nerve injury/resection
Bilateral muscle/nerve injury:
affects neck flexion
Unilateral muscle/nerve injury:
affects lateral neck flexion
• Marginal mandibular nerve injury
Can be injured during dissection
along mandibular border
Temporary or permanent lower lip
• Carotid artery blowout
Progression of disease
Inadequate soft tissue coverage
after neck dissection
Salivary fistula
Hold pressure
Interventional radiology
Mortality rate: 40%

Head and Neck

• Principles
Primary closure using relaxed skin
tension line for small defects
Local flaps provide better color
and skin match than skin graft
Tissue expansion, regional flaps,
distant flaps, and/or free flaps if
local flaps not an option
Postoperative radiation therapy for
aggressive tumors (T3–4, N1–3),
multiple nodes, one lymph node >
3 cm, extracapsular disease
Postoperative chemotherapy for
metastasis and recurrence
• Microvascular free flap indications
Radiated floor of mouth defect
Resection of half the tongue or
Tubed free flap for total
laryngopharyngectomy defects
• Lingual nerve: sensory recipient
nerve used for free flap
reconstruction of floor of mouth and
glossectomy defects
• Laryngectomy
Social interaction dramatically
affected by loss of voice box
Speech and voice can be restored
Mechanical voice prosthesis
(handheld vs palatal obturator)
Tracheoesophageal puncture
Reconstruction of total
laryngopharyngectomy defects
with nonbulky flaps: tubed radial
forearm free flap, jejunal free flap,
and tubed anterior lateral thigh
• Midface reconstruction after
total/subtotal maxillectomy
Goals: fill soft tissue defect,
provide support to orbit, close
space to oral and nasal cavities,
provide bone for dental
rehabilitation (denture versus
dental implants)
Small defects: radial forearm free
Large defects: rectus abdominis
free flap for large defects
Bone reconstruction: bone graft for
small defects versus
osteocutaneous free flap for large
• Stage I lip cancer
Treatment: wedge resection
Does not need a neck dissection
because risk of lymph node spread
is < 10%
Radiation therapy often reserved
for poor surgical candidates but
has similar long-term outcomes
Chemotherapy is not required for
early disease
• Actinic cheilitis
Similar to actinic keratosis
Precursor to squamous cell
Treatment: vermilionectomy or
CO2 laser resurfacing

Salivary Gland Tumors

(Tables 21.4 and 21.5)
• Parotidectomy
Lateral (superficial) parotidectomy
For benign lesions and
noninvasive malignant lesions in
the lateral lobe
Facial nerve is preserved and
gland removed lateral to it
Total parotidectomy
For lessions that involve the
facial nerve, aggressive
malignant tumors, and tumors
that involve both the deep and
lateral lobes of the parotid
Facial nerve is often sacrificed
with this procedure
• Stensen duct injury
Papilla located opposite maxillary
second molar
Diagnosis: inject methylene blue
into papilla to identify laceration
Treatment: repair over stent
If postop sialocele: treat with
compression and aspiration,
pressure duressing and anti-
cholinergics, such as Robinul
• Frey syndrome
Auriculotemporal nerve syndrome
causes gustatory sweating
Mechanism: complication after
parotid surgery where cranial
nerve V3 auriculotemporal branch
parasympathetic salivatory fibers
cross over and regenerate to
sympathetic sweat fibers
Prevent: superficial
musculoaponeurotic system
(SMAS) flap, alloderm
Table 21.4 Salivary gland tumors


75% benign,
25% malignant
salivary Submandibular


Thousands of Malignant >
glands benign

Table 21.5 Parotid tumors

Tumors Characteristics

Pleomorphic Most common

adenoma benign tumor
Men > women,

Mucoepidermoid Most common

carcinoma malignant tumor

Adenoid cystic
Malignant carcinoma

Acinic cell
parotidectomy if

Treatment: roll-on (topical)

anticholinergics, botox, secondary
alloderm placement under skin
• Adenoid cystic carcinoma
Most common minor salivary gland
Aggressive, distant metastasis
common within 10 years of
disease (lung), perineural invasion
• Excessive salivary gland secretion
Parotid: major contributor to
salivary secretions when
stimulated (eating)
Submandibular gland: major
contributor to salivary secretions
during unstimulated state (rest)
Excision of submandibular gland
Wilkie procedure: excision of
bilateral submandibular glands,
and bilateral rerouting of the
parotid ducts posteriorly into the
tonsillar fossae
Xerostomia: lack of secretions, can
be caused by radiation
• Sjögren syndrome (sicca syndrome)
Inflammatory autoimmune disorder
Symptoms: xerostomia (dry
mouth), keratoconjunctivitis (no
tears), and rheumatoid arthritis
Diagnosis: lip salivary gland
Treatment: symptomatic medical

Lip Reconstruction (Table

21.6) (Figs. 21.2, 21.3, 21.4,
21.5, 21.6)
Table 21.6 Lip defects and reconstruction

Defect Reconstruction

Replace with avulsed

Avulsion segment like skin
(superficial) graft

< 1/4 upper lip, <

Primary closure
1/3 lower lip

Central philtral Cross lip Abbe flap

column (two stage)

Lateral lip with

Estlander flap

(preserves nerve),
Central lower lip Gillies flap, and
defects Webster–Bernard
cheek advancement
Total lower lip Radial forearm free
defects flap with palmaris
longus sling
Fig. 21.2 Estlander flap. (From Sherris DA,
Larrabee WF. Principles of Facial
Reconstruction: A Subunit Approach to
Cutaneous Repair. New York, NY: Thieme;
2009. Used with permission.)
Fig. 21.3 Karapandzic repair of lower lip.
(From Sherris DA, Larrabee WF. Principles of
Facial Reconstruction: A Subunit Approach
to Cutaneous Repair. New York, NY: Thieme;
2009. Used with permission.)
Fig. 21.4 Bernard–Burow flap (Webster
modification). (From Sherris DA, Larrabee
WF. Principles of Facial Reconstruction: A
Subunit Approach to Cutaneous Repair. New
York, NY: Thieme; 2009. Used with
Fig. 21.5 Unilateral Gillies fan flap. (From
Sherris DA, Larrabee WF. Principles of Facial
Reconstruction: A Subunit Approach to
Cutaneous Repair. New York, NY: Thieme;
2009. Used with permission.)
Fig. 21.6 Bilateral perialar crescenteric
advancement flaps and Abbe flap for lip
reconstruction. (From Sherris DA, Larrabee
WF. Principles of Facial Reconstruction: A
Subunit Approach to Cutaneous Repair. New
York, NY: Thieme; 2009. Used with

Table 21.7 Scalp defects and reconstruction

Defect Characteristics Management

Small < 3 cm diameter closure

flap (three-
3–9 cm technique)
diameter split-
skin graft
scoring galea,

Free flap (see

below) ±
or burred
Large > 9 cm diameter outer table
coverage not

Splits loose
Avulsion areolar tissue Replant

Scalp Reconstruction (Table

• Free flaps for scalp reconstruction
Indication: large scalp loss with
exposed calvarium
Flaps: latissimus dorsi, radial
forearm free flap, anterior lateral
thigh flap, omemtum, or
parascapular flap

Pediatric Head and Neck

• Aplasia cutis congenita
Scalp (vertex) defect with
congenital absence of the skin
May have underlying skull defect
with exposed dura or brain
25% have two areas affected
Treatment: moist dressings if < 2
cm, acellular dermal matrix and
split-thickness skin graft if > 2 cm
Delayed tissue expansion and local
scalp flaps for hair restoration
• Pediatric parotid tumors
Hemangioma (benign): most
common pediatric parotid tumor
Must rule out rhabdomyosarcoma
• Pediatric orbital tumors
Most common benign tumor:
Most common malignant tumor:

Suggested Reading
Boutros S. Reconstruction of the lips. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:367–374
Citardi MJ, Chaloupak JC, Son YU, et
al. Management of carotid artery
rupture by monitored endovascular
therapeutic occlusion (1988-1994).
Laryngoscope 1995;105:1086-1092
Cordeiro PG, Chen CM. A 15-year
review of midface reconstruction
after total and subtotal
maxillectomy, I: Algorithm and
outcomes. Plast Reconstr Surg
Cordeiro PG, Chen CM. A 15-year
review of midface reconstruction
after total and subtotal
maxillectomy, II: Technical
modifications to maximize aesthetic
and functional outcomes. Plast
Reconstr Surg 2012;129(1):139–
Janis JE, Leedy JE. Lip, Cheek, and
Scalp Reconstruction. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2006:1–34. Selected
Readings in Plastic Surgery; vol
10, issue 13
Langstein HN, Robb GL. Lip and
perioral reconstruction. Clin Plast
Surg 2005;32(3):431–445, viii
Mahoney EJ, Spiegel JH. Evaluation
and management of malignant
cervical lymphadenopathy with an
unknown primary tumor.
Otolaryngol Clin North Am
2005;38(1):87–97, viii–ix
Lip and oral cavity cancer treatment.
O'Brien JC. Head and Neck: Oral
Cavity and Oropharyngeal Tumors;
Salivary Gland Tumors. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2004:1–84. Selected
Readings in Plastic Surgery; vol
10, issue 4
Saadeh PB, DeLacure MD. Head and
neck cancer and salivary gland
tumors. In: Thorne CH, Beasley RW,
Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:333–346
Smartt JM Jr, Kim EM, Tobias AM, Yan
AC, Kirschner RE. Aplasia cutis
congenita with calvarial defects: a
simplified management strategy
using acellular dermal matrix. Plast
Reconstr Surg 2008;121(4):1224–
Snyder MC, Gutowski KA. Head and
Neck II: Reconstruction. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2004:1–73. Selected
Readings in Plastic Surgery; vol
10, issue 4
Wilkie TF, Brody GS. The Surgical
Treatment of Drooling: a Ten Year
Review. Plast. Reconstr. Surg
1977;59(5): 791-797
Yap LH, Langstein HN. Reconstruction
of the scalp, calvarium, and
forehead. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:358–366
Yu P. Reinnervated anterolateral thigh
flap for tongue reconstruction. Head
Neck 2004;26(12):1038–1044
22 Maxillofacial Trauma
Reviewed by Richard Hopper

General Information
• 10% of facial trauma associated with
cervical spine injury
• Vertical buttresses
• Facial height determined by
Mandible ramus
Inadequate reduction of Le Fort I,
II, and III fractures, and
subcondylar fractures leads to
decreased facial height
• Facial width: inadequate reduction of
zygoma fractures leads to increased
facial width and is made worse with
palatal split fractures

Le Fort Fractures (Fig. 22.1)

• Le Fort I fracture
Separates maxillary alveolus from
superior midface
Runs above maxillary teeth, across
pyriform aperture
Involves pterygoid plates
Palate mobile
Fig. 22.1 Le Fort fracture patterns. (From Woo
A. Plastic Surgery Case Review. New York,
NY: Thieme; 2014. Used with permission.)
• Le Fort II fracture
Pyramidal fracture separates
central nasomaxillary segment
from zygoma and lateral upper
Crosses nasofrontal area, includes
medial infraorbital rims
Midface mobile
• Le Fort III fracture
Craniofacial dysjunction
Separates frontozygomatic suture,
nasofrontal junction, medial
orbital walls, orbital floor,
zygomatic arches
Maxilla intact

Zygoma Fractures
• Four zygoma articulations (“tetrapod
Zygomaticofrontal suture
Infraorbital rim
Zygomaticomaxillary buttress
Zygomatic arch
• Inadequate reduction: increases
facial width, malar flattening on
worm's eye view, vertical dystopia
(inferiorly displaced eye)
• Landmark for reduction: lateral
orbital wall (articulation between
zygoma and greater wing of the
• Gillies approach
For isolated arch reduction
Deep temporal fascia splits into
superficial and deep layers toward
the zygomatic arch to surround the
superficial temporal fat pad
Dissect between deep layer of the
deep temporal fascia and
temporalis muscle
Reverse Gillies approach through
intraoral upper gingivobuccal
incision, sub-periosteal approach,
elevator under zygomatic body

Nasal Fractures
• General management
Closed realignment
Drain septal hematoma
Intranasal packing
Dorsal nasal splint
Do not do osteotomy because of
nasal collapse
Do not use alloplastic material for
traumatic reconstruction because
of risks of infection and exposure
• Upper vault nasal fracture
Affects: nasal bones, ethmoid,
vomer, cephalic septal border
May need: spreader grafts
• Middle vault nasal fracture
Affects: upper lateral cartilage,
septum, maxilla
May need: spreader grafts
• Lower vault nasal fracture
Affects: lower lateral cartilage,
caudal septum
May need: columellar strut, shield
• Septal fracture
Diagnosis: mucosal tear
Depressed dorsum, deviated
septum, and epistaxis are not
accurate to diagnose
• Septal hematoma
Diagnosis: intranasal inspection
with speculum
Treatment: incision, drainage,
septal packing or quilting sutures,
antibiotics, close follow-up
If bilateral: incise on different
levels on either side to prevent
through and through septal
Do not do needle aspiration
because recurs
Complication: saddle nose
deformity requiring cantilever
bone graft

Orbital Fractures
• Ophthalmology consult
Indications for consult: diplopia,
pain, blindness, hyphema
Hyphema: blood in anterior
chamber can clot and obstruct the
fluid out of the canal of Schlemm
leading to glaucoma and
potentially blindness (requires
immediate consult)
• Enophthalmos
Posteriorly displaced eye seen on
worm's eye view
> 5% increase in orbital volume
can lead to enophthalmos
Secondary to fracture (floor,
medial wall) and inadequate
fracture reduction
• Floor fracture
Absolute indications to repair:
entrapment, loss > 50% orbital
floor, diplopia > 2 weeks, > 1 cm2
defect, enophthalmos > 6 weeks
Relative indications to repair:
diplopia within 20 to 30 degrees
of primary gaze (diplopia at
extreme gazes (i.e., > 40 degrees)
are acceptable
Rounding of inferior rectus on
coronal CT scan suggests loss of
fascial support and need for
surgery, while a flat rectus profile
indicates adequate support and no
need for surgery
• Medial wall fracture
Lamina papyracea fractures easily
because thin
Transcaruncular approach: incise
conjunctiva lateral to caruncle,
dissect toward periosteum in a
plane deep to Horner muscle
(medial portion of orbicularis
oculi muscle) and superficial to
medial orbital septum
• Edema: most common nonmechanical
cause of diplopia (after entrapment)
• Traumatic optic neuropathy (TON)
Shear force injury to cranial nerve
Severe case: blindness
Less severe case: diminished color
perception, afferent pupillary
Treatment: steroids, optic canal
• Afferent pupillary defect (Marcus
Gunn pupil)
Affected eye fails to constrict with
direct light but constricts with
consensual light
Appears to dilate as swing light
from unaffected to affected eye
• Superior orbital fissure syndrome
CN III, IV, VI, and V1 affected
Paralysis of extraocular
movements from CN III, IV, and VI
Anesthesia from CNV1 injury
Ptosis from CN III injury
• Orbital apex syndrome: superior
orbital fissure syndrome and

Nasoorbitoethmoid (NOE)
• Symptoms: deep nasofrontal angle
(saddle nose), epiphora (tearing
secondary to occluded punctum),
• NOE fracture classification
(Manson) (Table 22.1)
• Cantilever bone graft: if comminuted
fragments with loss of bony nasal
support to avoid saddlenose

Frontal Sinus Fractures

• Anterior and posterior table fractures
Nondisplaced fracture: no
Displaced fracture (> 1 table
width): reduction
• Nasofrontal duct injury
Obliterate duct using fat, muscle,
bone, Surgicel (Ethicon, Blue Ash,
OH), cartilage
Mucocele: secondary to
inflammation and infection from
continued frontal sinus mucous
production if injured nasofrontal
duct is not obliterated and frontal
sinus is not stripped
• Cerebrospinal fluid (CSF) leakage
Diagnose by checking rhinorrhea
for beta-2 transferrin
Metrizamide computed
tomographic (CT) scan detects
other sources of CSF leakage
Table 22.1 Nasoorbitoethmoid (NOE) fracture
classification (Manson)

Grade Characteristics Treatment

Single plates, wires of
I comminuted central canthal
central fragment bearing

Comminution of
II Same as type I
central fragment

Open transnasal
Disruption of canthoplasty in
III medial canthal a
tendon posterosuperior

Wait 10 days if nondisplaced

fracture to see if resolves before
Treatment: cranialization with
galeal and pericranial flaps, and
repair of dural tear, consider
lumbar drain
Cranialization: allows for
expansion of swelling brain while
keeping anterior table for contour
Riedel procedure: stripping
anterior frontal sinus, not done
because poor cosmetic result

Mandibular Fractures
• Bilateral condylar neck fracture
Loss of vertical height, results in
anterior open bite (apergnathia =
molars contact, incisors open),
bilateral preauricular pain
Condylar fracture segment
distracted anteromedially by
lateral pterygoid muscle
No numbness because fracture
proximal to body and ramus where
nerve passes through
If see open bite after removing
maxilla-mandibular fixation
(MMF), immediately reapply
• Subcondylar fractures
Zide's Absolute Indications for
Open Reduction and Rigid Internal
Fixation (ORIF) of Subcondylar
Displacement into middle cranial
fossa or external auditory canal
Impossibility obtaining adequate
dental occlusion by closed
Lateral extracapsular
displacement of condyle (not
just mild lateral displacement)
Invasion by foreign body (e.g.,
gunshot wound bullet)
ORIF treatment subcondylar
fracture: keep in MMF for 2 weeks
(> 4 weeks causes ankylosis)
Closed reduction treatment
subcondylar fracture: for
minimally displaced fractures,
treat with short period of MMF, do
physical therapy postop to prevent
• Champy principle
Treatment for mandibular angle
One miniplate with monocortical
screws along external oblique
Requires favorable fracture based
on pterygo-masseteric sling pull
• Indications to extract teeth in line of
Tooth prevents adequate reduction
Displaced or comminuted fracture
containing teeth
Fracture of tooth and/or root
Periodontal disease (caries) with
loosening teeth
Functionless tooth in absence of
opposing teeth
• MMF in edentulous patients: use
Gunning splints (dentures or molds)
to establish occlusion
• Postop infection in MMF with rigid
Treat with antibiotics
Do not remove plates unless loose
hardware or infection
Infection and exposed teeth:
remove and extract tooth

Pediatric Facial Fractures

• Most common cause: motor vehicle
crash (MVC) (in adults, most
common cause is assault, then MVC)
• Mandible
Most common pediatric facial
Subcondylar region is most
common site involved causing
increased risk of growth
disturbance (risk mandibular
In adults, the angle is the most
common site involved
Treatment: closed reduction unless
severe then open
• Nasal bone fracture: second most
common pediatric facial fracture
• Orbit
Elastic orbital floor bone, small
fracture can trap herniated tissue
causing vertical gaze defect
(trapdoor or white-eyed blowout
Causes: entrapment, vertical gaze
defect, oculocardiac reflex (brady-
cardia, nausea, syncope)
Emergent repair if evidence of
entrapment to prevent
irreversible muscle ischemia
and fibrosis
Observe if no entrapment or
• Frontal bone
Earliest age frontal sinus viewed
on X-ray: 6 years
Growing skull fracture
< 1% of skull fractures
Unrepaired dural tear leads to
fracture enlargement
Treatment: craniectomy, dural
repair, and autogenous

Suggested Reading
Alcalá-Galiano A, Arribas-García IJ,
Martín-Pérez MA, Romance A,
Montalvo-Moreno JJ, Juncos JM.
Pediatric facial fractures: children
are not just small adults.
Radiographics 2008;28(2):441–
461, quiz 618
Chiasson G, Matic DB. Muscle Shape
as a Predictor of Traumatic
Enophthalmos. Craniomaxillofac.
Trauma Reconstr 2010;3(3): 125-
Evans BG, Evans GR. MOC-PSSM
CME article: Zygomatic fractures.
Plast Reconstr Surg 2008;121(1,
Evans GR, Daniels M, Hewell L. An
evidence-based approach to
zygomatic fractures. Plast Reconstr
Surg 2011;127(2):891–897
Goldberg RA, Mancini R, Demer JL.
The transcaruncular approach:
surgical anatomy and technique.
Arch Facial Plast Surg
Hollier L, Kelley P. Soft tissue and
skeletal injuries of the face. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:315–332
Hollier LH, Thornton JF. Facial
Fractures. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005:1–70. Selected Readings in
Plastic Surgery; vol 10, issue 6
Jordan DR, Allen LH, White J, et al.
Intervention Within Days for Some
Orbital Floor Fractures: the White-
Eyeds Blowout. Ophthal. Plast.
Reconstr. Surg 1998;14(6): 379-390
Kelly KJ, Manson PN, Vander Kolk CA,
et al. Sequencing LeFort fracture
treatment (organization of treatment
for a panfacial fracture). J Craniofac
Surg 1990;1(4):168–178
Losee JE, Afifi A, Jiang S, et al.
Pediatric orbital fractures:
classification, management, and
early follow-up. Plast Reconstr Surg
Markowitz BL, Manson PN, Sargent L,
et al. Management of the Medial
Canthal Tendon in
Nasoethmoid Orbital Fractures: the
Importance of the Central Fragment
in Classification and Treatment.
Plast. Reconstr. Surg 1991;87(5):
Rodriguez ED, Stanwix MG, Nam AJ, et
al. Twenty-six-year experience
treating frontal sinus fractures: a
novel algorithm based on
anatomical fracture pattern and
failure of conventional techniques.
Plast Reconstr Surg
Sharabi SE, Koshy JC, Thornton JF,
Hollier LH Jr. Facial fractures.
Plast Reconstr Surg
Smartt JM Jr, Low DW, Bartlett SP. The
pediatric mandible: II. Management
of traumatic injury or fracture. Plast
Reconstr Surg 2005;116(2):28e–41e
Tessier P. The classic reprint.
experimental study of fractures of
the upper jaw I and II. René Le Fort,
M.D. Plast Reconstr Surg
Tessier P. The classic reprint:
experimental study of fractures of
the upper jaw. 3. René Le Fort,
M.D., Lille, France. Plast Reconstr
Surg 1972;50(6):600–607
Zide MF, Kent JN. Indications for open
reduction of mandibular condyle
fractures. J Oral Maxillofac Surg
23 Ear Reconstruction
Reviewed by Reza Jarrahy

Ear Anatomy
• External ear (Fig. 23.1)
Pinna or auricle: outer ear
Helix: peripheral prominent rim
extending from concha to lobule
Antihelix: prominence anterior to
helical rim
Superior crus: superior division of
Inferior crus: inferior division of
Triangular fossa: depression
between superior and inferior crus
Scapha: depression between helix
and antihelix
Concha: depression anterior to
antihelix, divided by root of helix
Cavum concha: concha inferior to
root of helix
Cymba concha: concha superior to
root of helix
Tragus: cartilage ridge anterior to
external auditory meatus, opposite
to antitragus
Antitragus: cartilage ridge opposite
to tragus
Intertragus notch: depression
between tragus and antitragus,
superior to the lobule
Lobule: soft tissue on inferior of
• Arteries
Posterior auricular artery: primary
Occipital artery
Superficial temporal artery
• Nerves
Great auricular nerve (GAN): can
injure during neck dissection,
supplies lower lateral and lower
cranial ear
Fig. 23.1 Structure of the auricle. (From
Gilroy AM, MacPherson B, Ross L. Atlas of
Anatomy. New York, NY: Thieme; 2009. Used
with Permission.)

Auriculotemporal nerve (cranial

nerve V3): superior lateral ear,
anterior superior external auditory
Lesser occipital nerve: superior
cranial ear
Arnold nerve (cranial nerve X):
conchal bowl and posterior
auditory canal; ring block would
not anesthetize this nerve without
direct infiltration
• Embryology of external ear
First branchial arch: three anterior
hillocks form tragus, helical root,
and superior helix
Second branchial arch: three
posterior hillocks form antitragus,
inferior helix, and lobule
First branchial groove: forms
external auditory meatus
• Epidemiology
Incidence: 1/7,000 births
Craniofacial microsomia:
unilateral or bilateral microtia
Treacher Collins: bilateral
Goldenhar syndrome: also called
oculoauricular vertebral syndrome
(OAVS), includes microtia,
epibulbar dermoids, and vertebral
• Types
Varying degrees from small ear to
Lobular type: only lobule present
Conchal type: conchal bowl,
tragus, antitragus, and lobule
Anotia: complete absence of
middle and external ear
• Meurmann classification of microtia
Grade I: small malformed ear, all
components present
Grade II: partial absence of
recognizable structures
Grade III: complete absence of
auricular components, remnant
usually lobule
• Ear reconstruction options for
Autologous costal cartilage
Alloplastic implant
Silicone or porous polyethylene
Reinisch initially had 44%
infection rate with Medpor
implants, infection rate was
reduced by adding a TPF flap
Osteointegrated auricular
Difficult compliance with
children because they are too
active to keep attached, may
lose it, and may not care for it
Salvage for autologous and
implant technique failure
Useful if no local tissue to cover
autologous or alloplastic
Indicated in elderly with medical
comorbidities, anesthetic risks,
and calcified costal cartilage
that is too brittle for autologous
• Hearing in microtia
Hearing aids used in patients with
functioning inner ear cochlea
Bone conduction hearing aids at 6
to 12 months in patients with
bilateral microtia before ear
Bone anchored hearing aids
(BAHAs) placed after external ear
reconstruction in patients with
bilateral microtia
Aural atresia repair: ear canal
created after external ear
reconstruction when indicated per
temporal bone computed
tomographic scan, may assist
hearing and improve cosmesis

Autologous Ear
Reconstruction (Table 23.1)
• Technical details of autologous ear
Remove vestigial cartilage at
initial stage from same incision
used to place framework
Closed suction drains promote skin
adherence to cartilage construct
Bulky gauze dressing to avoid skin
necrosis due to compression
Elevation combined with local
fascial flap (TPF or retroauricular
fascial flap) and skin graft
Tragus formed with costal cartilage
(Nagata technique), or with
composite chrondrocutaneous
conchal graft from contralateral
ear (Brent technique)
Remove hair over construct with
electrolysis, laser, or direct
follicular excision
• Complications of autologous ear
Skin necrosis without cartilage
exposure: treat conservatively,
allow skin to heal secondarily,
topical local wound care, let
Skin necrosis with cartilage
exposure: debride exposed
cartilage, close skin, antibiotics
Suppurative wound infection:
incision and drainage, antibiotics,
if does not resolve may need to do
delayed secondary procedure to
remove cartilage framework
Table 23.1 Autologous costal cartilage ear

Technique Timing Stages

7 years old
Contralateral 1. Base plate
unaffected and helical rim
ear growth 2. Lobule
Brent complete to rotation
base 3. Elevation
construct 4. Tragus
design on
10 years old
donor site 1. Base plate,
cartilage helical rim,
Nagata exists lobule rotation,
Larger tragus/antitragus
construct 2. Elevation
than Brent

Traumatic Deformities
• Cauliflower ear
Subperichondrial hematoma in
boxers and wrestlers
Treatment: evacuation of hematoma
via lateral incision parallel to
helix, and compressive dressing
with cotton bolster
If no treatment: new cartilage
forms a thick, deformed ear
• Skin avulsion
Treatment with perichondrium
intact: skin grafting over
Treatment if no perichondrium
intact: excise cartilage if small
• Ear avulsion
Microsurgical reconstruction gives
best cosmetic result
Anastomose to posterior auricular
artery, anterior auricular branch of
superficial temporal artery, and
branch of occipital artery
Head of bed elevated
May be difficult to anastomose
veins, but there is success of using
leeches if reattached ear turns blue
due to venous congestion
If fails microsurgical
reconstruction, remove ear and
bury in pocket to salvage
Pocket principle for salvage:
dermabrade ear skin, bury for 21
days, unbury and let spontaneously
• Burned ear
Autologous costal cartilage
reconstruction with local
fasciocutaneous flap and skin
graft: better result than under local
stiff, scarred skin
Prosthesis: if no skin or local
fasciocutaneous flap present to
cover autologous reconstruction
Alloplastic implants: risk for
infection and exposure when
placed under burned scar tissue
Tissue expansion: does not stretch
burned skin well, at risk for
infection and exposure

Congenital Deformities
• Cryptotia
Superior auricle buried beneath
Absent auriculocephalic sulcus
Treatment: helical release with
split-thickness skin graft to
retroauricular sulcus
• Constricted ear (Fig. 23.2)
Lop ear or cup ear
Treatment: banner flap (flag flap)
where split helical cartilage,
partially detaching each helical
flap from scapha to expand and
resuture in a new position to the
• Stahl ear
Also called: Spock ear, baboon
ear, Vulcan ear, satyr ear
Seen in Asians
Fig. 23.2 Constricted ear banner flap.

Characteristics: third crus, flat

antihelix, malformed scaphoid,
upper cartilage deformed
Treatment: wedge excision of third
crus, helical advancement
Miscellaneous Ear Defects
and Reconstruction
• Antia–Buch flap (Fig. 23.3)
Chondrocutaneous helical rim
advancement flap
For superior and middle third
helical rim defects < 2.5 cm
Makes smaller ear
Defects > 2.5 cm may require local
fasciocutaneous flaps and costal
• Chondrocutaneous composite conchal
transposition flap (Fig. 23.4)
Reconstructs defects in upper third
of helical rim
Pedicle based on crus of helix
Needs antihelical support to be
Split-thickness skin graft covers
donor site raw surface
• Upper third helical rim defect
reconstruction options
Antia–Buch flap
Chondrocutaneous composite
conchal transposition flap
Local fascial cutaneous flap and
costal cartilage
• Middle third helical rim defect
reconstruction options
Antia–Buch flap
Wedge resection
Postauricular flap and costal
Local tissue rearrangement
• Chondrodermatitis nodularis helicis
Benign inflammation of helical or
antihelical cartilage
Chronic, painful, nodular, can
ulcerate through the skin
Mimics skin cancer on exam
Do biopsy to rule out cancer
Excision and primary closure or
skin graft
Fig. 23.3 Bilateral helical advancement flaps.
(From Sherris DA, Larrabee WF. Principles of
Facial Reconstruction: A Subunit Approach
to Cutaneous Repair. New York, NY: Thieme;
2009. Used with permission.)

Fig. 23.4 Chondrocutaneous composite

conchal transposition flap.

Suggested Reading
Brent B. Technical advances in ear
reconstruction with autogenous rib
cartilage grafts: personal experience
with 1200 cases. Plast Reconstr
Surg 1999;104(2):319–334,
discussion 335–338
Davis J. Reconstruction upper third of
ear with chondrocutaneous
composite flap based on crus helix.
In: Tanzer RC, Edgerton MT, eds.
Symposium on Reconstruction of the
Auricle. St. Louis: Mosby;
Donelan MB. Conchal transposition flap
for postburn ear deformities. Plast
Reconstr Surg 1989;83(4):641–654
Firmin F. Auricular reconstruction in
cases of microtia: principles,
methods and classification [in
French]. Ann Chir Plast Esthet
Firmin F. Ear reconstruction in cases of
typical microtia. Personal
experience based on 352 microtic
ear corrections. Scand J Plast
Reconstr Surg Hand Surg
Firmin F. State-of-the-art autogenous ear
reconstruction in cases of microtia.
Adv Otorhinolaryngol 2010;68:25–
Ha RY, Hackney F. Plastic Surgery of
the Ear. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005:1–36. Selected Readings in
Plastic Surgery; vol 10, issue 9
Nagata S. A new method of total
reconstruction of the auricle for
microtia. Plast Reconstr Surg
Reinisch J. Microtia reconstruction
using a polyethylene implant: an 8-
year surgical experience. Presented
at the 78th Annual Meeting of the
American Association of Plastic
Surgeons; Colorado Springs, CO;
May 5, 1999
Tanzer RC. Microtia—a long-term
follow-up of 44 reconstructed
auricles. Plast Reconstr Surg
Thorne CH. Otoplasty and ear
reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:297–312
Thorne CH, Wilkes G. Ear deformities,
otoplasty, and ear reconstruction.
Plast Reconstr Surg
24 Mandible Reconstruction
Reviewed by Nidal Farhan ALDeek and Fu-
Chan Wei

• Mandible reconstruction
Rewarding procedure
Technically demanding
Necessitates teamwork approach
• Indications
Trauma: gun shot wounds
• Reconstructive goals
• Extensive preoperative planning
Reconstruction needs: bone, soft
tissue, or both
Flap selection
Neck vessel availability
Need for functional rehabilitation
Timing of reconstruction
• Intraoperative factors
Meticulous execution of the
Constant communication with the
ablative team during surgery
• Postoperative factors critical for
successful mandibular reconstruction
Intense postoperative monitoring
Oral rehabilitation

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

Mandible Tumors
• Odontogenic Tumors
Keratocystic odontogenic tumor
Benign dental lamina remnant,
associated with impacted teeth
Table 24.1 Chang Gung mandible defect
classification and flap selection

Classification Defect Flap selection

Bone osteoseptocutaneo
alone (OSC) flap is enou
in most cases

Bone with
Fibula OSC flap is
Compound enough in most
mucosa or

Double free flap:

fibula OSC and
Bone, anterolateral thigh
Composite mucosa, (ALT) flaps; in sma
and skin selected cases, one
bony flap can be

Double free flaps:
Extensive with
fibula OSC and ALT
composite lateral

Symptoms: pain and swelling in

molar and premolar region, may
be asymptomatic
Diagnosis: X-ray and histologic
appearance of keratin containing
Associated with Gorlin
syndrome: triad of basal cell
carcinomas, odontogenic
keratocyst, and skin pits in
palms and soles
Treatment: enucleate/curettage
Benign tumor of posterior
mandible in 20 to 30 year olds
Location: 80% mandible, 20%
Unicystic or multicystic
Histology: palisading
odontogenic cells
Diagnosis: X-ray or CT scan,
multicystic lesion has soap
bubble or honeycomb
Enucleate/curettage: commonly
If extends to bone: resect with
1 cm margin
If extends to
hemimandibulectomy, and
excise involved soft tissue
Radiation therapy not needed
because benign
Chang Gung comprehensive
single stage treatment
complete excision is only one
option that ensures zero-
recurrence of this benign
Mandibular reconstruction:
bony reconstruction, soft
tissue coverage or
augmentation when needed
Inferior alveolar nerve repair
with nerve graft
Osseointegrated dental
implants with dental
• Giant cell tumor
Benign tumor
Histology: multinucleated giant
If small tumor: treat with
If large: treat with
• Osteogenic Sarcoma
Rare malignant tumor: 0.5% of all
head and neck tumors
Radiation therapy

Osteonecrosis of Mandible
• Chemotherapy or radiotherapy
• Osteoradionecrosis
Late complication secondary to
radiation therapy for cancer
Incidence could be as high as 22%,
and the risk is lifetime
Most common location: body of the
Risk factors include: advanced
tumor stage, degree of bony
invasion, total radiotherapy dose
(> 64 Gy), and poor oral care
Symptoms: pain, exposed bone,
orocutaneous fistula
CT scan: bony erosions
Gold standard of treatment:
segmental resection of the entire
involved mandible and
surrounding unhealthy soft tissue
then reconstruction with
vascularized bone graft
Antibiotics for accompanying
infection or underlying
Hyperbaric oxygen therapy: not
indicated once the bone is
• Bisphosphonate-Related
Osteonecrosis of Jaw (BRONJ)
(Table 24.2)
Related to taking osteoporosis

Mandible Reconstruction
• Mandible Reconstruction Options
(Table 24.3)
• Mandibulectomy indications
Marginal mandibulectomy: tumor
extending to periosteum without
bony erosion/invasion
Segmental mandibulectomy: tumor
extending through cortex with bony
• Osseous Free Flaps for Mandible
Fibula osteoseptocutaneous flap:
most common, multiple
osteotomies possible for large and
anterior defects
Radial and scapular
osteocutaneous flaps
Useful for large soft tissue
defects/small bony defects
Table 24.2 BRONJ staging
Stage Characteristics Treatment

I exposed/necrotic
antibiotic rinses

II Infection, pain

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

Table 24.3 Mandible reconstruction options

Type of
Indication Example
Nonvascularized Mandible Iliac crest
bone grafts defects < 6 cm

defects > 6 cm,
Fibula +/- sk
bone grafts Fibula
Marginal flap (first ch
mandibulectomy radial forear

flap (ALT) h
major advan
other free fl
Floor of mouth, because of t
Soft tissue flaps oral cavity approach; ra
defects, no bony forearm free
defect supraclavicu
artery island
(transverse c
artery); pect
major rotati

Titanium pla
infection, ex
plate breakin
avoid in ante
mandibular d
due to high e
Metal plates defects, no
rate; when in
without a
graft, lateral
are more su
their applica
Radial osteocutaneous flap bone
dimensions are inadequate to
support dental implants of 10 ×
5 mm and is not frequently used
for mandibular reconstruction
Deep circumflex iliac artery
osteocutaneous flap (ilium)
• Osseointegrated dental implant
Factors affecting osseointegration
survival rates: oral hygiene,
patient motivation, irradiation,
implant dimensions
Survival rates in nonirradiated
vascularized bone grafts
95% 3-year survival
87% at 5 years
79% at 10-years follow-up
Radiotherapy and dental implants
Radiotherapy is not a
contraindication to
osseointegrated dental implants
Timing of irradiation has been
shown to affect success rate
When irradiation preceded
implantation, success rate
dropped to 64% compared to
86% when irradiation was given

Free Fibula Flap (Fig. 24.1)

• Mathes-Nahai muscle flap
Type V
Dominant pedicle: nutrient
endosteal artery (off peroneal
Secondary segmental pedicles:
periosteal and muscular branches
(off peroneal artery)
In multiple-osteotomy setting,
which is usually the case in
mandible reconstruction,
periosteal blood supply becomes
the only blood supply to the bone
• Uses
Fig. 24.1 Lower leg transverse cross-section
anatomy. EDL, extensor digitorum longus;
EHL, extensor hallucis longus; FDL, flexor
digitorum longus; FHL, flexor hallucis longus;
Fib, fibula; Gastroc, gastrocnemius; PB,
peroneus brevis; PL, peroneus longus; TA,
tibialis anterior; Tib, tibia; TP, tibialis posterior.
Upper extremity
Lower extremity
• Technical pearls
Fibula length: 40 cm
Leave: at least 7 cm of fibula
proximally and distally for support
Flap can provide reliable skin
paddle of 14 × 24 cm
Flap can include the soleus muscle
to provide volume and bulk, when
In flap harvest, septocutaneous
vessels are the major blood supply
to the skin, and they should be
identified early in flap dissection
Harvesting with cuff of flexor
hallucis longus muscle is
controversial: may protect the
pedicle, but at the possible
expense of additional donor site
• Salvage flap
A second free fibula OSC flap
from the opposite leg is the
salvage flap in case of free fibula
OSC flap failure
Do not use pedicled pectoralis
major muscle/musculocutaneous
If a free bony flap was indicated
the first time, the indication
remains the same (free bony flap)
after flap failure

Computer Simulation
Surgery in Mandible
Reconstruction by Fibula
Osteoseptocutaneous Flap
• Background
The complex, three-dimensional
shape of the mandible along with
its crucial role in speech,
deglutition, and social integration
complicate mandible
Computer simulation surgery
simplifies the procedure,
especially when the surgeon's
experience is limited
Entire surgery from resection to
reconstruction can be planned and
executed virtually
Computer-aided design and
modeling (CAD/CAM) software
are utilized to design and produce
customized surgical devices for
transition from virtual into actual
• Benefits of this new technology
Easiness in osteotomies
Decreased surgical time
Training potential
• Limitations
Necessitates teleconference
Cannot address all the factors
involved in mandible
reconstruction by the fibula OSC
Variable fibula cross-section
topography, especially for
osseointegrated dental implants
Skin vessel anatomy, which is
critical in simultaneous
coverage reconstruction
Inflexibility in revisiting the
design due to changes in
resection margins
• Freehand technique is still useful,
and at the present time, even more
practical than computer-simulated
mandible reconstruction for more
complicated reconstruction

Suggested Reading
Chang YM, Tsai CY, Wei FC. One-stage,
double-barrel fibula
osteoseptocutaneous flap and
immediate dental implants for
functional and aesthetic
reconstruction of segmental
mandibular defects. Plast Reconstr
Surg 2008;122(1):143–145
Chang YM, Wallace CG, Tsai CY, et al.
Dental implant outcome after
primary implantation into double-
barreled fibula osteoseptocutaneous
free flap-reconstructed mandible.
Plast Reconstr Surg
Cordeiro PG, Disa JJ, Hidalgo DA, et
al. Reconstruction of the mandible
with osseous free flaps: a 10-year
experience with 150 consecutive
patients. Plast Reconstr Surg
David DJ, Tan E, Katsaros J, et al.
Mandibular reconstruction with
vascularized iliac crest: a 10-year
experience. 82(5): 792-801
Disa JJ, Hidalgo DA. Mandible
reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery,
6th ed. Philadelphia: Lippincott
Williams & Wilkins; 2006: 428–437
Fernandes R, Nikitakis NG, Pazoki A, et
al. osteogenic sarcoma of the jaw: a
10-year experience. J Oral
Maxillofac Surg 2007;65(7):1286–
Foster RD, Anthony JP, Sharma A, et al.
Vascularized bone flaps versus
nonvascularized bone grafts for
mandibular reconstruction: an
outcome analysis of primary bony
union and endosseous implant
success. Head Neck 1999;21(1):66–
Frodel JL Jr, Funk GF, Capper DT, et al.
Osseointegrated implants: a
comparative study of bone thickness
in four vascularized bone flaps.
Plast Reconstr Surg
O'Brien JC. Head and neck: oral cavity
and oropharyngeal tumors; salivary
gland tumors. Selected Readings in
Plastic Surgery 2004;10(4):1–84
Roumanas ED, Chang TL, Beumer J.
Use of osseointegrated implants in
the restoration of head and neck
defects. J Calif Dent Assoc
Snyder MC, Gutowski KA. Head and
neck II: reconstruction. Selected
Readings in Plastic Surgery
Urken ML, Buchbinder D, Costantino
PD, et al. Oromandibular
reconstruction using microvascular
composite flaps: report of 210
cases. Arch Otolaryngol Head Neck
Surg 1998;124(1):46–55
Wallace CG, Chang YM, Tsai CY, et al.
Harnessing the potential of the free
fibula osteoseptocutaneous flap in
mandible reconstruction. Plast
Reconstr Surg 2010;125:305–314
Wei FC, Chen HC, Chuang CC, et al.
Fibular osteoseptocutaneous flap:
anatomic study and clinical
application. Plast Reconstr Surg
Wei FC, Demirkan F, Chen HC, et al.
Double free flaps in reconstruction
of extensive composite mandibular
defects in head and neck cancer.
Plast Reconstr Surg
Wong CH, Wei FC. Microsurgical free
flap in head and neck reconstruction.
Head Neck 2010;32(9):1236–1245
Wu YQ, Huang W, Zhang ZY, et al.
Clinical outcome of dental implants
placed in fibula-free flaps for
orofacial reconstruction. Chin Med
J 2008;121(19):1861–1865
Yim KK, Wei FC. Fibula
osteoseptocutaneous flap for
mandible reconstruction.
Microsurgery 1994;15(4):245–249
25 Nasal Reconstruction
Reviewed by Robert L. Walton

Nasal Reconstruction
• Nine aesthetic subunits (Fig. 25.1)
Two soft triangles
One columella
Two ala
One dorsum
Two sidewalls
One tip
• Subunit rule (controversial)
If > 50% lost, excise remainder of
subunit and reconstruct the entire
• Reconstruct three layers
Coverage: skin
Support: cartilage
Lining: mucosa
• Septal perforation (Table 25.1)
Fig. 25.1 Nasal subunits. (From Sherris D,
Larrabee W. Principles of Facial
Reconstruction: A Subunit Approach to
Cutaneous Repair. Stuttgart: Thieme, 2009.)

Table 25.1 Septal perforation

Defect size Approach Management

< 5 mm in
or bipedicled
anterior Closed
mucosal flap

< 5 mm in
or bipedicled
posterior Open
mucosal flap

5 mm–2 cm Open based septal
mucosal flaps

> 2 cm based
mucosal flaps
Facial artery
(FAMM) flap

• Characteristics
Sebaceous hyperplasia of nasal
skin, which has pits
Caucasian males > 60 years old
Secondary to severe acne rosacea
• Treatment
Mild rhinophyma: good hygiene,
oral isotretinoin (Accutane), and
Severe rhinophyma: tangential
excision, dermabrasion, CO2 laser
for hemostasis, let heal by
secondary intention, cover with
moist bacteriostatic dressing
(xeroform, bacitracin), sunscreen,

Auricular Composite Graft

• Uses
Reconstruction of alar rim lining
and support defects measuring <
1.5 cm
Consists of ear cartilage and skin
for support and lining
• Clinical appearance
First 6 to 8 hours: white
First week: cyanotic
After first week: pink
If appears necrotic: observe and let
eschar slough

Full Thickness Skin Graft

• Uses: any nasal defect not requiring
cartilage support
• Prerequisites: subcutaneous base
with intact perichondrium
• Skin-graft donor sources
Forehead or preauricular donor
site closed primarily
May include fat for composite
restoration and contour

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

Forehead Flap (Fig. 25.2)

• Use
> 1.5 cm defects on nasal tip and
• Technique
First stage: elevate on
supratrochlear artery
Subperiosteal elevation 1.5 cm
above brow to preserve periosteal
and subcutaneous branches from
supraorbital artery (Fig. 25.3)
Fig. 25.2 Standard paramedian forehead flap.
Fig. 25.3 Rohrich modification of standard
paramedian forehead flap. (Reece E,
Schaverien M, and Rohrich R. The paramedian
forehead flap: a dynamic anatomical vascular
study verifying safety and clinical implications.
Plast Reconstr Surg. 2008 Jun;121(6): 1956-
63. Used with permission.)
Second stage: division and inset
after 3 to 4 weeks
Subsequent contouring for final
shape after 6 to 8 weeks: insertion
of cartilage support combined with
thinning of lining
Expanded forehead flap for larger
Folded forehead flap for alar
defects with vestibular lining

Dorsal Nasal (Rieger) Flap

(Fig. 25.4)
• Use
< 2 cm defect along central and
lower thirds of dorsum
• Technique
Nasoglabellar flap based on
infratrochlear and angular artery
Flap elevation in
submuscular/supraperiosteal plane

Nasal Lining
• Isolated vestibular lining defects
Full thickness skin graft
Composite skin cartilage graft from
Nasolabial flap
Facial artery musculomucosal
(FAMM) flap
Local bipedicle mucosal flap with
skin graft
• Total and subtotal lining defects
Radial forearm “Bat” flap
Multi island radial forearm free
Bilateral FAMM flaps

Fig. 25.4 Reiger flap.

For placement posteriorly in

Weep mucous if placed
anteriorly near rim

Partial Nasal
• Alar defects
Bipedicle mucosal advancement
flap: for lining of alar defects
Used infrequently
Risks for scarring and
obstruction of nasal airway
Technique replaced with
Composite skin cartilage graft
Full thickness graft
Folded forehead flap
Auricular composite graft: ear
cartilage and skin for lining and
support of alar defects < 1.5 cm
Septal pivot flap: septal cartilage
and mucosa used to line and
support larger defects
Bilobed flap
Nasolabial flap: two-stage
procedure with division and inset
for coverage; turnover flap used
for lining
• Lateral aspect of nose
Banner flap: single-lobed finger
Bilobed flap
Nasolabial flap: superiorly based
for lateral nose
Geometric advancement flap
• Nasal tip
Bilobed flap
Forehead flap
Nasolabial flap
• Cheek, alar, nasal sidewall defect
Cheek advancement, septal
mucoperichondrial flap with septal
or conchal cartilage grafts, and
staged paramedian forehead flap
• Nasal dorsum
Dorsal nasal (Rieger) flap
Cantilever bone graft: used for
dorsal nasal support, in
conjunction with craniofacial
procedures, calvarial bone graft
keeps donor and recipient sites in
the same field, inherently unstable
Rib cartilage graft: L-strut
provides for stable dorsal support
• Nasal defects < 0.5 cm
Primary closure
Delayed closure by secondary
• Full-thickness skin grafts
Used for upper two-thirds of nose
Composite skin/fat grafts from
forehead for lower third of nose
• Nasal septum
Local septal chondromucosal
advancement flap
Septal pivot flap
Septal cartilage and mucosa used
to line and support anterior
midline defects
Based on septal branch of
superior labial artery
Used for support of middle nasal
vault and tip

Total Nasal Reconstruction

• Requires lining, support and external
Radial forearm free flap for lining
Multi island for element
Folded radial forearm for middle
nasal vault and vestibular
Anastomosis to facial artery and
Rib cartilage support
Side wall
External cover
Paramedian forehead flap
• Scalping flap (Fig. 25.5)
Forehead scalp flap
Used when supratrochlear inflow
has been compromised
Combine median forehead flap if
needed for nasal lining
Split-thickness skin grafts for
donor defect coverage
Second-stage division and inset,
cartilage grafts placed for support,
return of unused portion of scalp
• Sickle flap
Median forehead flap based on
superficial temporal artery
Donor site temporal forehead
Fig 25.5 Scalping flap.

Split-thickness skin grafts used for

nasal lining if needed
Second-stage division and inset,
cartilage grafts, and closure are
similar to scalping flap
• Temporomastoid (Washio) flap
Last local flap option after
forehead and scalp flaps
Postauricular and mastoid skin
elevated based on superficial
temporal arteries
• Prelaminated radial forearm free flap
and paramedian forehead flap after
cheek advancement
• Remote free flap for lining and/or
external cover
Suggested Reading
Burget GC, Menick FJ. Nasal support
and lining: the marriage of beauty
and blood supply. Plast Reconstr
Surg 1989;84(2):189–202
Burget GC, Walton RL. Optimal use of
microvascular free flaps, cartilage
grafts, and a paramedian forehead
flap for aesthetic reconstruction of
the nose and adjacent facial units.
Plast Reconstr Surg
2007;120(5):1171–1207, discussion
Jackson IT. Nose reconstruction. In:
Jackson IT. Local Flaps in Head and
Neck Reconstruction. 2nd ed. St.
Louis, MO: Quality Medical
Publishing; 2007:101–239
Menick FJ. Nasal reconstruction. Plast
Reconstr Surg 2010;125(4):138e–
Menick FJ. Nasal reconstruction. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:389–396
Ramsey KW, Georgeu GA, Pereira JA,
El-Muttardi N. Nasal reconstruction
in the Yemen with the Converse
scalping flap. J R Soc Med
Reece EM, Schaverien M, Rohrich RJ.
The Paramedian Forehead Flap: A
Dynamic Anatomical Vascular Study
Verifying Safety and Clinical
Implications. Plast. Reconstr. Surg
2008;121: 1956-1963
Romo T III, Sclafani AP, Falk AN,
Toffel PH. A graduated approach to
the repair of nasal septal
perforations. Plast Reconstr Surg
Thornton JF, Griffin JR. Nasal
Reconstruction. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2006:1–41. Selected
Readings in Plastic Surgery; vol
10, issue 12
Walton RL, Burget GC, Beahm EK.
Microsurgical reconstruction of the
nasal lining. Plast Reconstr Surg
Zitelli JA. The bilobed flap for nasal
reconstruction. Arch Dermatol
26 Eyelid and Lacrimal
System Reconstruction
Reviewed by S. Anthony Wolfe

Eyelid Anatomy (Fig. 33.1)

Eyelid Defect
Reconstructive Algorithm
• Evaluation of eyelid defects
Zone injured (Fig. 26.1)
Percent lid length affected
Thickness of defect
Partial thickness (PT): skin and
Full thickness (FT): conjunctiva,
• Zone I defects (upper eyelid)
< 50%
Primary closure with local
tissue advancement
> 50%
Full thickness skin graft
(FTSG) from retroauricular
FTSG from contralateral upper
Medium thickness split
thickness skin graft (STSG)
from upper inner arm
< 25%
Primary closure, canthotomy,
cantholysis, with local tissue

Fig. 26.1 Spinelli–Jelks periocular

reconstructive zones.

25 to 75%
Sliding tarsoconjunctival flap
(superiorly based upper eyelid
posterior lamella flap)
covered with FTSG: used for
medial or lateral defects, not
central defects
Cutler Beard full thickness
advancement flap from lower
lid leaving tarsus intact
> 75%
Mustardé lower lid switch flap
• Zone II defects (lower eyelid)
< 50%
Primary closure with local tissue
> 50%
FTSG from contralateral upper
FTSG from retroauricular sulcus
Upper eyelid Fricke unipedicle
myocutaneous transposition flap
Upper eyelid Tripier bipedicle
myocutaneous transposition flap
• FT
< 50%
Primary closure with
canthotomy, cantholysis, local
tissue advancement
Hughes sliding tarsoconjunctival
flap with FTSG
50 to 75%
Hughes sliding tarsoconjunctival
flap with FTSG
> 75%
Mustardé cheek advancement
flap with septal cartilage and
lining composite graft
Tessier nasojugal flap
• Zone III defects (medial canthus)
Nasoglabellar flap
Medially based upper eyelid
rotational flap
Probe and stent lacrimal ducts
• Zone IV defects (lateral canthus)
Lateral canthal support
Cheek advancement flap
• Zone V defects (periocular)
Outside zones I-IV but may affect
the eyelids
Cervicofacial advancement flap
Moderate to large defects of
upper medial cheek
Better color and texture than
Fixate to periosteum to decrease
risk of ectropion
Stabilize lower eyelid with
canthopexy or canthoplasty to
avoid ectropion

• Definition
Upper eyelid malposition where
upper eyelid droops below the
ideal position
Ideal upper eyelid position: ciliary
margin lies halfway between
corneal-scleral junction and pupil
(eyelid overlaps the superior
limbus 1 to 2 mm)
• Etiology
True ptosis: related to levator
complex malfunction
Horner syndrome
Symptoms triad: miosis,
anhidrosis, ptosis
Etiology: loss of sympathetic
innervation at superior
cervical ganglion, affects
Muller muscle
Myasthenia gravis
Symptoms: unilateral or
bilateral ptosis exaggerated by
fatigue, worsens toward end
of the day, seen in young
Etiology: myoneural
dysfunction, antibodies block
acetylcholine at
neuromuscular junction
Pharmacologic diagnosis:
symptoms relieved with
edrophonium (Tensilon test) or
neostigmine to block
acetylcholine breakdown
Senile, involutional, or
aponeurotic ptosis: most
common cause of ptosis in
High or absent supratarsal lid
crease due to levator dehiscence
(levator disinserts from tarsus
and skin)
Treatment: levator plication or
Unrelated to levator complex
Brow ptosis
Dermatochalasia: baggy eyelids
with skin redundancy of middle
age, upper lids more commonly
affected, due to loss of elasticity
idiopathic hypertrophic
osteoarthropathy with enlarging
eyelids, hands, feet, and toes
Blepharochalasia: unknown
cause, occurs in young
adulthood, recurrent episodes of
mild to moderate painless
edema of eyelids, giving a baggy
appearance, treatment is
excision of redundant skin to
improve vision
• Patient assessment
Visual acuity exam
Establish ptosis grade (Table 26.1)
Levator function (Table 26.2)
Measure excursion between
upward and downward gaze
Hold brow to avoid
compensatory brow elevation in
severe ptosis
Schirmer's test
Measures tear film production
Normal: >10 mm moisture on
filter paper in 5 minutes
Poor film production can signal
potential of dry eye after ptosis
Hering's law of equal innervation
Some patients with unilateral
ptosis may have induced
contralateral eyelid retraction
masking ptosis
Hering's test
Hold brow in relaxed position
Manually retract the ptotic
Positive test: contralateral
eyelid drops
Do bilateral ptosis repair if
Hering's test unmasks
contralateral ptosis to avoid
postop contralateral ptosis
• Ptosis repair (Table 26.3)
Table 26.1 Grades of ptosis

Grade Ptosis

Mild 2–3 mm

Moderate 3–5 mm
Severe > 5 mm

Table 26.2 Grades of levator function

Grade Levator function

Good 10–15 mm

Fair 6–9 mm

Poor < 5 mm

Table 26.3 Ptosis management

Ptosis Levator Surgical

degree function options
Mild Good levator

Moderate Good

Severe Good

Mild, Levator
moderate, Fair advancement
Mild, Poor Frontalis sling

Levator advancement: most

common ptosis repair
Tarsal conjunctival mullerectomy
(Fasanella-Servat procedure)
Technique: running suture behind
clamps on posterior lamella,
trim excess clamped tissue
Disadvantage: does not address
excess eyelid skin
Levator plication: can address
excess eyelid skin
Frontalis sling
Indication: poor levator function,
congenital ptosis
Grafts: fascia lata or palmaris
longus (PL)
• Complications after ptosis repair
Asymmetry: most common
Undercorrection: most common
Lagophthalmos: overcorrection
resulting in inability to close eye
Corneal abrasion
Entropion or ectropion

Lower Lid Malposition

• Patient assessment
Visual acuity exam
Lid position
Normal: 2 mm superior to
inferior limbus
Vertical shortening: can cause
scleral show
Horizontal lid laxity
Snap-back test
Describes horizontal lid laxity
Should spring back immediately
>1 second is abnormal
Grade 1: 2 to 3 seconds
Grade 2: 4 to 5 seconds
Grade 3: > 5 seconds, lower lid
returns with blink
Grade 4: lower lid never returns
Distraction test
If 1 to 2 mm: do suborbicularis
oculi fat (SOOF) lift
If 3 to 6 mm distraction: do
Lower lid pulled > 6 mm from
globe: do lateral strip
tarsoplasty to correct laxity
Malar support
Hertel exophthalmometry:
measures globe position relative
to anterior part of lateral orbital
< 15 mm: enophthalmos
15 to 18 mm: normal
> 18 mm: exophthalmos
Negative vector: globe anterior
to rim (poor globe support)
Positive vector: globe posterior
to rim (can be due to
Schirmer's test
• Ectropion
Lid turns outward
Most common type of ectropion
Results in horizontal lid laxity
Lateral canthoplasty
procedure: split lower lid
along grey line, shorten
posterior lamella
Pentagonal wedge excision
Congenital: vertical shortening
anterior lamella
Vertical shortening anterior
Steroid injections: for early
ectropion with minor scarring
Massage and tear supplements
for first 6 to 9 months
Excise scar and full thickness
skin graft to lower eyelid to
address vertical contracture if
cutaneous deficiency
Alloplastic spacer graft, hard
palate graft, or auricular
cartilage graft for midlamellar
Lateral canthopexy or
canthoplasty to correct
horizontal lid laxity
Tarsorrhaphy to temporarily
protect the cornea
Neurogenic: paralysis of
orbicularis oculi muscle
Neoplasia within the lower eyelid
• Entropion
Lid turns inward
Animation test: attempt to close
eye contracts orbicularis oculi
muscle causing inversion of lower
eyelid on attempted
May have horizontal lid laxity
similar to ectropion
Abnormal horizontal skin excess
causes eyelashes to turn inward
Seen in Asians
Mild corneal irritation: topical
Severe corneal irritation: skin
and orbicularis oculi muscle
• Canthopexy vs canthoplasty
Canthoplasty: division and
repositioning of the lateral canthal
Canthopexy: no division of
canthus, only repositioning of
canthal tendon
If vertical shortening and
horizontal laxity: correct with
tarsal strip canthoplasty and full
thickness skin graft
Vector of lateral canthal
repositioning: superior, lateral,
and posterior

• Definition: inability to close eyelids
• Etiology
Facial nerve paralysis
Bell's palsy most common cause
of facial nerve paralysis
Affects cranial nerve VII
innervation to orbicularis oris
Upper eyelid surgery complication
Upper eyelid blepharoplasty
Ptosis repair complication
Lower eyelid laxity or ectropion
Graves’ thyroid ophthalmopathy
Craniofacial syndrome
• Management
Conservative management first
Topical lubrication with eye
drops and gel
Temporary tarsorraphy
Facial nerve paralysis
Gold weight
Upper eyelid surgery complication
Massage eyelid with downward
Definitive surgical repair with
split thickness skin graft
Lower eyelid laxity or ectropion:
see above management
Graves’ thyroid ophthalmopathy
management (see Chapter 33,
Blepharoplasty and Brow Lift)
Craniofacial syndrome: frontal-
orbital advancement, monobloc
advancement, or Le Fort III
advancement as needed
Trauma: reduce fractures causing
Lacrimal System Anatomy
(Fig. 26.2)
• Components of lacrimal system
Lacrimal gland
Microscopic accessory glands
Common canaliculus
Lacrimal sac
Nasolacrimal duct: drains into
inferior meatus
Fig. 26.2 Lacrimal system.
• Eyelid closure dynamics
Lacrimal punctum closes
Tears milk lateral to medial
Deep heads of preseptal muscle
Canaliculi shorten
Ampulla closes
Negative pressure created
Lacrimal sac opens
• Eyelid reopening dynamics
Lacrimal diaphragm returns to
relaxed position
Creates sufficient pressure to
propel tears into nasolacrimal duct
Canaliculi reopen to collect more
Lacrimal System
• Epiphora (excess tearing)
Traumatic: due to injury or edema
to the lacrimal system
Blepharoplasty complication
• Diagnosis
Jones tests
• Jones Tests
Jones 1: instill drops and check
dye coming out of nose
Jones 2: do if failed Jones 1, inject
dye forcefully
• Dacryocystorhinostomy
Reconstructs lower lacrimal
system burring a hole in the
lacrimal fossa
Connects nasolacrimal sac to nasal
• Canaliculodacryocystorhinostomy
Reconstructs the upper canaliculus
Also called
• Congenital epiphora management
Massage and antibiotic drops until
12 months
Probing of the duct
Silastic intubation
• Dry eye management
Eye drops and lubrication
Punctal occlusion: treats dry eye
caused by increased exposure not
treatable by eye drops and

Suggested Reading
Codner MA, McCord CD, Mejia JD, et
al. Upper and Lower Eyelid
Reconstruction. Plast Reconstr Surg
126(5): 231e-245e, 2010
Glat PM, Jelks GW, Jelks EB, et al.
Evolution of the Lateral
Canthoplasty: Techniques and
Indications. Plast Reconstr Surg
100: 1396-1405, 1997
Jelks GW, Glat PM, Jelks EB, et al. The
Inferior Retinacular Lateral
Canthoplasty: A New Technique.
Plast Reconstr Surg 100: 1262-
1270, 1997
Liu TM, Totonchi A, Katira K, et al.
Outcomes of Mild to Moderate
Upper Eyelid Ptosis Correction
Using Muller's Muscle-Conjunctival
Resection. Plast Reconstr Surg 130:
799e-809e, 2012
Newman MI, Spinelli HM.
Reconstruction of the Eyelids,
Correction of Ptosis, and
Cantoplasty. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2006: 397-416
Spinelli HM, Jelks GW. Periocular
Reconstruction: A Systematic
Approach. Plast Reconstr Surg
91(6): 1017–1024, 1993
Thornton JF, Kenkel JM. Eyelid
Reconstruction. Selected Readings
in Plastic Surgery. 10(8): 1-51,
Zide BM, Jelks GW. Surgical Anatomy
of the Orbit. New York: Raven
Press, 1985
Zoumalan CI, Lisman RD. Evaluation
and Management of Unilateral
Ptosis and Avoiding Contralateral
Ptosis. Aesthet Surg J 30(3): 320-
328, 2010
Section III Breast and
Cosmetic Surgery
27 Anesthesia
Reviewed by Derek M. Steinbacher

Local Anesthesia
• Classes of local anesthetics (Table
• Mechanism of action: block voltage-
gated sodium channels preventing
depolarization of neurons
• Lidocaine peak absorption
12 hours in trunk for liposuction
6 hours in face (2× faster than in
trunk), therefore liposuction the
face first
• Local anesthesia toxic doses (Table
Practice toxic dosage calculations
Maximum dose of 1% lidocaine
for 70 kg patient: (70 kg × 5
mg/kg)/(10 mg/mL) = 35 mL
Maximum dose of 2% lidocaine
for a 70 kg patient: (70 kg × 5
mg/kg)/(20 mg/mL) = 17.5 mL
• Lidocaine toxicity (Table 27.3)
• Pharmacokinetics of local anesthetics
p Ka: affects onset of action. When
the pH = p Ka of the drug, half of
drug is in uncharged anionic active
form. Higher p Ka = slower onset.
Add bicarbonate to speed the
Table 27.1 Classes of local anesthetics
Class Examples Metabolism

to para-
Ester procaine,
benzoic acid
(PABA) in

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

Table 27.2 Local anesthesia toxic doses

Medication Toxic dose Notes

Only local with
Cocaine 1.5 mg/kg sympathomimetic

Can cause heart

block Most
Bupivacaine cardiotoxic
2.5 mg/kg
(Marcaine) (ventricular
tachycardia or

1% has 10
5 mg/kg in
mg/mL lidocaine,
Lidocaine subcutaneous
2% has 20
mg/mL lidocaine

epinephrine in
7 mg/kg in tumescence
subcutaneous injected into
Lidocaine hypovascular
with tissue 35–55 space, 20%
epinephrine mg/kg sucked out, long
liposuction peak time;
tumescence 1:200,000
epinephrine in
local anesthesia

Table 27.3 Lidocaine toxicity

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

Add epinephrine to
solution (decreases
systemic dose), give
premedication to
raise seizure
Prevention of threshold), sodium
toxicity bicarbonate, test
dose, give lowest
dose and
possible, check Bier
block cuff and

Stop injecting,
check composition
infiltrate, assess for
(IV) injection, do
not cardiovert unless
Treatment for normalize heart rate
toxicity (beta-blockers,
calcium blockers,
procainamide), IV
thiopental, IV
establish airway,
give oxygen,

Lipid solubility: affects potency

Protein binding: affects duration of
• EMLA cream
EMLA = Eutectic Mixture of Local
Combination of lidocaine and
Minimal time to effect: 60 minutes
Apply and keep in place with
Tegaderm (3M, St. Paul, MN) or
Opsite dressing (Smith & Nephew,
Andover, MA)
• Methemogloblinemia
Idiosyncratic reaction to local
Symptoms: tachycardia, cyanosis,
palpitations, headache,
Treatment: antidote is methylene
blue; can also give oxygen
• Ketamine
Sedative: useful with pediatric
Intravenous (IV) administration:
less vomiting, faster onset, shorter
duration, less laryngospasm
compared with intramuscular

Regional Anesthesia
• Brachial plexus block: resolve
within 6 hours postop
• Radial sensory nerve block: inject
along styloid process of radius
• Median nerve block: inject between
palmaris longus and flexor carpi
• Finger blocks with epinephrine
Inject around A-1 pulley
1:200,000 epinephrine decreases
Contrary to dogma, research shows
that epinephrine can be used safely
in fingers (half-life of epinephrine
is 60 to 90 minutes; finger
amputations survive after 24-hour
Epinephrine-induced ischemia is
reversed with phentolamine
injection (alpha antagonist)
Warm compresses treat
hypothermically induced ischemia

General Anesthesia
• Malignant hyperthermia
Rare life-threatening inherited
myopathy secondary to
inhalational agent or depolarizing
muscle relaxant (succinylcholine)
Symptoms: sweat, tachycardia,
rigidity, cyanosis, can lead to
Treatment: stop surgery and
anesthesia, administer dantrolene
(muscle relaxant), 100% oxygen,
call for help, treat hyperkalemia
• Benzodiazepine half-lives
Short (midazolam)
Intermediate (lorazepam)
Long (diazepam). Note: diazepam
is teratogenic
• Postop nausea and vomiting (PONV)
Medication with minimal PONV:
Medications with higher PONV:
nitrous oxide, opioids, inhalational
Risk factors for PONV: female
gender, history of motion sickness,
use of postop opioids, history of
PONV, nonsmoking status
• Minimal ambient temperature in the
operating room (OR)
OR temperature should be kept
above 70°F (21.1°C) to reduce
Prewarm patients with bedwarmer
in preanesthesia room is the best
adjunctive measure
Warmed IV fluids for patients
undergoing liposuction with
• Radial nerve palsy
Secondary to ischemia from
pressure below tourniquet cuff,
faulty pressure gauges
Occurs in 1/5,000 to 8,000
patients, unable to extend
fingers/wrist, resolves within 6
• Stop drugs that can cause bleeding
Garlic: stop 7 days preop
Aspirin: stop 7 to 10 days preop
Heparin drip: can be shut off hours
before surgery
Deep Vein Thrombosis
(Table 27.4)
• Fatal pulmonary embolism (PE)
Deep vein thrombosis (DVT): can
lead to potentially fatal PE
Abdominoplasty: most common
ambulatory procedure associated
with fatal PE
• Risk factors for DVT
Long procedure duration
Use of oral contraceptives
• DVT prophylaxis (Table 27.5)
Sequential compressive devices
(SCDs): all patients should get
Early ambulation
Heparin subcutaneous
Elastic stockings
Stop oral contraceptives, estrogen,
and smoking
• Factor V Leiden
Most common genetic
hypercoagulability disorder (3 to
7% population)
Clotting factor V resistant to
inactivation by activated protein C
• PE differential diagnosis
Congestive heart failure: chest X-
ray with venous congestion,
history of hypertension, left
ventricular hypertrophy on
electrocardiogram (EKG), can be
exacerbated with several liters of
intravenous fluid
Acute coronary syndrome: elevated
ST segment on EKG, chest pain
Wernicke encephalopathy: mental
status changes, malnutrition; treat
with thiamine
Table 27.4 Deep vein thrombosis (DVT) and
pulmonary embolism (PE) diagnosis

Symptoms/Signs Workup

Leg edema, calf

DVT tenderness, Ultrasound
palpable cords
Chest pain,
respiratory Chest
distress, anxiety, computed
PE tomographic
shortness of scan (or VQ
breath scan)

Table 27.5 DVT risk level and prophylaxis

Clinical criteria Prophylaxi

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

> 40 years old, under heparin, low
general anesthesia >
Moderate 30 min, taking molecular
estrogen weight
heparin, SCD

> 60 years old, long

immobilization, Heparin
cancer, subcutaneou
hypercoagulable state, three times
prior deep vein day, SCD

Suggested Reading
Horton JB, Janis JE, Rohrich RJ. MOC-
PS (SM) CME article: patient safety
in the office-based setting. Plast
Reconstr Surg 2008;122(3,
Iverson RE; ASPS Task Force on Patient
Safety in Office-Based Surgery
Facilities. Patient safety in office-
based surgery facilities: I.
Procedures in the office-based
surgery setting. Plast Reconstr Surg
2002;110(5):1337–1342, discussion
Lipshitz AH, Kenkel JM. Local
Anesthetics. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2007:1–32. Selected Readings in
Plastic Surgery; vol 10, issue 18
Mustoe TA, Buck DW II, Lalonde DH.
The safe management of anesthesia,
sedation, and pain in plastic surgery.
Plast Reconstr Surg
Seruya M, Baker SB. MOC-PS (SM)
CME article: venous
thromboembolism prophylaxis in
plastic surgery patients. Plast
Reconstr Surg 2008;122(3,
Taub PJ, Bashey S, Hausman LM.
Anesthesia for cosmetic surgery.
Plast Reconstr Surg
Thorne AC. Local Anesthesia. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:91–95
28 Breast Augmentation,
Mastopexy, and Reduction
Reviewed by Luis O. Vasconez

Breast Anatomy
• Breast location: between ribs 2 and 6
in nonptotic state
• Blood supply
Internal mammary artery
perforators: account for majority
(60%) of breast blood supply
Branches from axillary artery
Lateral branches from the third,
fourth, and fifth posterior
intercostal arteries
Thoracoacromial artery: lies deep
to pectoralis muscle, preserved
during submuscular augmentation
• Innervation
Anterior lateral cutaneous branches
of T2–T6 intercostal nerves supply
the breast
T4 branch supplies the nipple
Do blunt dissection along lateral
border of pectoralis major to
avoid injuring nerves
• Average male nipple
3 cm diameter
Fourth to fifth intercostal spaces
• Cooper ligaments
Suspensory ligaments of the breast
Stretch over time, causing ptosis

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

Deformity Breast Nipple

Amastia Absent Absent

Athelia Present Absent

Amazia Absent Present

Two-stage procedure: tissue

expander placement followed by
exchange for permanent implant in
(1) patients with severely deficient
skin envelope and (2) adolescent
patients whose contralateral breast
has not reached maturity
• Poland syndrome
Most common finding is absence of
sternal head of pectoralis major
Absent or hypoplastic breast,
latissimus dorsi (LD), ribs,
serratus, nipple, sternum, shoulder
girdle anomalies
Brachysyndactyly is most common
limb abnormality, may also have
atypical cleft hand
Treatment during puberty: tissue
expander initially, exchange for
permanent prosthesis after
contralateral breast stops growing,
avoid LD flap with expander
because can attenuate muscle
Treatment in adulthood:
submuscular implant and LD
• Jeune syndrome: narrow immobile
breast, renal disease
• Benign premature thelarche:
formation of breasts before formation
of puberty elsewhere (no pubic hair
or vaginal mucosal thickening)
• Accessory mammary tissue
Supernumerary breast: along
embryonic milk line (axilla to
Ectopic breast: outside of
embryonic milk line (example: in

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

Generation Characteristic

1st Hard shell

2nd Soft shell, leaked

Internal barrier
3rd coating

Cohesive gel
(semisolid) with
increased cross-

Classes III and IV require

management with capsulectomy
Textured implants
Subglandular pocket: has less
contraction than smooth implants
(leads to disorganized
periprosthetic collagen
Subpectoral pocket has no effect
on contraction rate compared to
smooth implants
Textured implants can form
seromas early and late post
• Saline implant complications
Statistics based on 13-year study
by Cunningham published in 2000
25% reoperations
20% contracture (MC complication
and reason for reoperations)
3% hematoma: treatment is
evacuation, puts patient at risk for
infection, do not do needle
aspiration because may injure
1% infection
1% annual deflation rate: easy to
tell because saline is absorbed in
the body, notice wrinkling and a
smaller breast
Ruptures can be due to underfilling
because rippling induces stress
(lower fill, not underfill, can result
in more sloping and softer breasts)
• Silicone implant complications
Statistics based on 6-year studies
by Cunningham published in 2009
and Spear in 2007, and on a 10-
year study by Spear in 2014
Rupture: 1.1% (Cunningham),
5.5% (Spear 2007), 9.3% in MRI
cohort (Spear 2014)
Contracture: 9.8% (Cunningham),
14.8% (Spear 2007), 18.9%
(Spear 2014)
Infection: 2.2% (Courtiss 1979)
Reoperation: 36.1% (Spear 2014)
Implant removal with replacement
18.6% (Spear 2014)
There is no increased risk for
rheumatologic disease
There is no increased amount of
silicone in breast milk of
implanted patients versus controls
• Silicone implant ruptures
Over time the silicone shell
weakens, leading to rupture (loss
of biomechanical strength)
Hard to tell if there is a rupture
because breast retains volume,
may notice subtle softness or slight
decrease in upper-pole fullness
Rupture may be intracapsular
(silicone within capsule), or
extracapsular (out of the capsule)
Screening magnetic resonance
imaging (MRI) recommendations
for silicone implant rupture: do
MRI 3 years postop, then every 2
MRI is the most sensitive
radiological test to detect rupture
Diagnose with linguini sign on
MRI or snowstorm sign on
ultrasound (multiple echogenic
Silicone granuloma: common
response to foreign material, rare
in breast augmentation, should
resect to rule out carcinoma or if
• Minimum age requirement for
silicone gel implant placement: 22
years old
• Breast pocket irrigation
Bacitracin 50,000 U, Ancef 1 g,
and gentamicin 80 mg in 500 mL
normal saline
Previous combination was
Betadine (Purdue Pharma, L.P.,
Stamford, CT), Ancef, and
Betadine is contraindicated unless
it is used and then washed out with
• Double bubble
Results from implant riding below
the inframammary fold (IMF), or if
native glandular tissue falls over
and below the lower pole of the
Treatment: change location of
• Eklund displacement or compression
Breast cancer screening method
displaces implant away from
compressed breast tissue
Cannot do if contraction (class III
or IV)
Better view if implant is
Size of implant has no effect on
Bad views if small breast
• Change in nipple sensitivity
Based on prosthesis volume
Not based on implant pocket
placement or incision location
• Symmastia
Soft tissue connection between two
Congenital or iatrogenic from
breast augmentation
• Galactorrhea
Uncommon complication after
breast augmentation
Related to pregnancy, menstruation,
medications (TCA, fluoxetine),
thyroid disease, and pituitary
tumors (check prolactin level, if
elevated obtain an MRI scan)
Treatment: bromocriptine
• Implant exchange for larger implant:
leads to increased thinning,
stretching, palpability, rippling,
sagging, and an unnatural appearance
• Rippling: change pocket from
subglandular to subpectoral
• Infected implants:
Severe infection: remove implant,
irrigate, antibiotics, debride
capsule, delayed reinsertion
several months later
Mild infection (with or without
exposure): can attempt salvage,
remove implant, irrigate, debride
capsule, antibiotics, and
immediate reinsertion of new
Threatened exposure, no infection:
excise skin and primary closure
Tuberculosis (Mycobacterium
tuberculosis): remove implants for
at least 6 months, 6 months of
antituberculosis medication
Nontuberculous Mycobacterium:
remove implants for at least 6
months, 6 months of ciprofloxacin
and bactrim
• Fat grafting
Unpredictable: 50% resorption
May lead to calcification
• Anaplastic large-cell lymphoma
Increased risk of non-Hodgkin
lymphoma in patients with breast
Rare: 0.1 to 0.3/100,000 patients
with implants
If asymptomatic no need to remove

• Periareolar mastopexy
Most common complication:
widening of areola
Can avoid areola widening with a
nonabsorbable purse-string stitch
• Vertical mastopexy: postop
pseudoptosis is a common complaint
over time
• Ptosis classification and management
(Table 28.4)

Mastopexy with
• Increases upper pole volume more
than mastopexy alone
• Use < 350 mL implant: less likely to
cause recurrent ptosis and thinning
• Staging mastopexy and augmentation
Can stage to avoid risk of nipple
If staging, do augmentation first
followed by mastopexy because
will know where to tailor tack to
find out how much skin resection
is needed
Caution in patients undergoing
augmentation first followed by
staged mastopexy with inferior
pedicle technique: augmentation
first may cause thinning and
atrophy of inferior pole of
augmented breast compromising
inferior pedicle in secondary
Table 28.4 Ptosis classification and

staging Characteristic Management

Nipple at level mastopexy,
of interlocking
1st degree
inframammary Gore-Tex
fold (IMF) keeps areola

Nipple below
2nd degree incision
level of IMF

Nipple at
Wise incision
3rd degree lowest point of

IMF wedge
Breast (not excision
Pseudoptosis nipple) below when nipple
(glandular IMF (increased to IMF
ptosis) nipple to IMF distance > 6
distance) cm
Breast Reduction
• Indications: shoulder, neck, back pain
secondary to trapezius strain;
cosmesis; intertrigo
• Pedicles used: superior, inferior,
• Skin incisions used: inverted-T
(anchor), short-scar techniques
(vertical circumareolar)
• Juvenile breast hypertrophy
Bilateral breasts are affected
Due to increased end organ
responsiveness to estrogen
Bilateral breast reduction, not
Timing: once breasts have
stopped growing for 1 year
• Rapid growth of 1 breast
In children: giant fibroadenoma
In adults: phyllodes tumor
• Free nipple grafts
Nipple to sternal notch distance:
> 40 cm
Nipple to inferior mammary fold
distance: > 20 cm
Cannot lactate afterward
• Breast cancer and breast reduction
Rate of cancer found in reduction
sample: 0.2%
If location known within specimen:
do radiation therapy
If location unknown: do completion
• Breastfeeding after breast reduction:
70% can breastfeed, 30% want to
• Complications: wound healing, scar,
asymmetry, infection, hematoma
(related to surgical technique,
intraoperative hypotension), nipple
loss/sensitivity (if pedicle
undermined or free nipple graft not
used when indicated)

• Age groups
Puberty: most common
hyperplastic breast anomaly in
• Diagnosis
If prepubescent or adult male with
unilateral gynecomastia, work up
for other causes
Work up: liver function tests, urine
studies, testicle exam, endocrine
studies (thyroid, adrenal), rule out
Klinefelter syndrome, cancer,
marijuana use, use of new
• Treatment
Wait 12 months prior to
considering surgery
Liposuction with or without staged
Liposuction of internal mammary
fold will help redrape excess skin
and possibly eliminate need for
• Adolescent breast cancer incidence:
• Klinefelter syndrome
Males have extra X chromosome
(47, XXY)
50% of cases have gynecomastia
Increased ER/PR, decreased
Increased risk of breast cancer
compared with idiopathic
Suggested Reading
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augmentation. Plast Reconstr Surg
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CME article: breast augmentation.
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Brzozowski D, Niessen M, Evans HB,
Hurst LN. Breast-feeding after
inferior pedicle reduction
mammaplasty. Plast Reconstr Surg
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GW. The fate of breast implants
with infections around them. Plast
Reconstr Surg 1979;63(6):812–816
Cunningham B. The Mentor Core Study
on Silicone MemoryGel Breast
Implants. Plast Reconstr Surg
2007;120(7, Suppl 1):19S–29S,
discussion 30S–32S
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KA. Saline-filled breast implant
safety and efficacy: a multicenter
retrospective review. Plast Reconstr
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discussion 2150–2151
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Grabb and Smith's Plastic Surgery.
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discussion 164S–165S, 166S–167S
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29 Breast Reconstruction
Reviewed by Stephen Vega

Breast Anatomy
• See additional information on breast
anatomy in Chapter 28
• Axillary dissection nerves
Medial pectoral nerve
Thoracodorsal nerve: latissimus
dorsi muscle weakness if injured
(affects arm extension and
Lateral pectoral nerve
Long thoracic nerve: serratus
anterior muscle weakness (winged
scapula) if injured
Intercostobrachial nerve: injury
leads to numbness of the medial
upper arm

Breast Cancer
• Risk factors
Family history
Previous breast biopsy
Early menarche
Late menopause
Previous breast radiation
Ductal carcinoma in situ (DCIS): <
2% recurrence risk over 4 years
Lobular carcinoma in situ (LCIS)
Sex: women have 100× risk of
breast cancer compared with men
5 to 10% of familial breast cancers
are associated with BRCA
Breast, cervical, uterine,
pancreatic, colon
85% risk of breast cancer
BRCA2: pancreatic, stomach,
gallbladder, bile duct, melanoma
BRCA1: breast, pancreatic,
testicular, prostate
BRCA2: breast, pancreatic,
prostate (more strongly
associated with BRCA2)
6% risk of breast cancer
• Incidence
Incidence is 1 in 8 women
1% of breast cancers occur in men
1% of breast cancers are sarcomas,
99% are carcinomas
• Diagnosis
Physical exam
Self-exam monthly
Annual physician breast exam
after 40
Annual beginning age 40
Fine-needle aspiration
• Prognostic factors
Lymph node status
Estrogen receptor status
Histological grade
• Breast cancer staging (Table 29.1)
• Treatment
Prophylactic mastectomy: done for
patient wishes, BRCA+, family
history, previous biopsy, dense
Modified radical mastectomy
Lumpectomy and radiation therapy
Nipple-sparing mastectomy
Used in negative intraoperative
retroareolar frozen sections
Tumor < 3 cm
Tumor > 2 cm from nipple
Not multicentric
No lymph node involvement
Skin-sparing mastectomy: has 2%
recurrence rate
Radiation therapy
• Indications for postmastectomy
radiation therapy
Tumor > 5 cm
Four or more positive lymph nodes
Close margins
Table 29.1 Breast cancer staging

Stage Description
In situ (ductal
carcinoma in situ,
0 lobular carcinoma in

Tumor < 2 cm; no

lymph node spread

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

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

Tumor > 5 cm with

IIIA nodes; tumor with
fixed nodes

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

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

Benign Breast Disease

• Rapid unilateral breast growth
Children and young women < 25
years old
Phyllodes tumor
85% benign, 15% malignant
Treatment: local excision, annual
• Rapid bilateral breast growth
Juvenile breast hypertrophy
Young females during puberty
Due to increased end organ
responsiveness to estrogen
Bilateral breast reduction after 1
year of growth cessation
• Burn contracture breast
Release to allow expansion
Integra Dermal Regeneration
Template (Integra LifeSciences
Corp., Plainsboro, NJ) and split-
thickness skin graft
Hard to find sufficient donor site
for full-thickness skin graft

Breast Reconstruction
• Principles (rule of thumb)
Early-stage I to II breast cancer
patients can undergo immediate
Later-stage III to IV breast cancer
patients should consider adjuvant
therapy first (chemotherapy,
radiation therapy) before
• Implant reconstruction
Tissue expander
Muscle coverage using
pectoralis and serratus
May use autologous dermal flap
in ptotic or macromastic patient
instead of acellular dermis
Acellular dermal matrix with tissue
Increases initial fill volume of
May allow more skin capture in
skin-sparing mastectomy
Consider immediate prosthetic
reconstruction without need for
Questions regarding seroma and
infection risks remain
Tissue expander combined with
latissimus dorsi flap
Useful in patients who have been
radiated or have compromised
mastectomy skin with no
autologous tissue donor sites (i.e.,
fitness instructors)
• Autologous
Pedicled flap options
Transverse rectus abdominis
muscle (TRAM) flap
Shorter operating room (OR)
time, decreased total flap loss,
and increased fat necrosis and
partial flap loss compared
with free TRAM
Delayed pedicled TRAM:
transect deep inferior
epigastric artery several
weeks prior to surgery
Perfusion zones (angiosomes)
Zone I: ipsilateral, directly
over blood supply, best
Zone II: contralateral,
immediately across midline
Zone III: ipsilateral, lateral to
Zone I
Zone IV: contralateral, lateral
to Zone II, farthest from
blood supply, worst
Based on superior epigastric
artery, which enters rectus
abdominis muscle on its
posterior and medial side
Latissimus dorsi
Extended flap by taking more
subscarpal fat has more tissue
than standard flap and may not
need implant
Useful in very obese patients
with excess back fat as flap
only reconstruction without
Serratus branch of
thoracodorsal artery: if using
thoracodorsal artery as
recipient for free-flap breast
reconstruction, divide
thoracodorsal artery proximal
to serratus branch to preserve
retrograde flow to latissimus
dorsi muscle, allowing harvest
in the future
Free flap options
Abdominally based free flaps
Free TRAM: longer OR time,
ease of shaping and insetting,
decreased hernia and
abdominal wall weakness
compared with pedicled
Muscle-sparing free TRAM:
more muscle spared than free
TRAM, dominant blood
supply of deep inferior
epigastric vessels maintained;
as more muscle is spared, less
abdominal morbidity
Deep inferior epigastric artery
perforator (DIEP) flap: no
muscle removed; higher
incidence of fat necrosis if
wrong perforator selected;
more tolerant of higher
ischemia times with less
muscle; spares the abdominal
wall while taking dominant
blood supply of rectus
abdominis muscle
Superficial inferior epigastric
artery (SIEA) flap
Least abdominal wall
morbidity; highest
complexity of abdominal
free flaps; look for arterial
diameters greater than 1.4
mm. Only consider for hemi-
abdominal flap
Superior gluteal artery perforator
(SGAP) flap
Second-line donor site after
abdominal free flaps
Requires molding gluteal fat
No gait dysfunction, but
possible contour deformity
Can hide donor site scar
Transverse upper gracilis (TUG)
Second-line donor site after
abdominal free flaps
Best for small to medium
Hidden donor site
Less skin available for delayed
cases, but excellent tissue for
breast molding
Hidden donor site
Less skin available for delayed
cases, but excellent tissue for
breast molding
• Radiation therapy and breast
Mechanism of action: damage
DNA leading to cell death
If radiotherapy already
administered avoid implant
reconstruction and use autologous
If need for postoperative radiation
therapy, strongly consider delayed
autologous reconstruction
Avoid tissue expansion in patients
because of risk of contraction and
If tissue expander is in place, and
radiotherapy indicated, either fully
expand and wait to reconstruct (>
6 months), or remove and use
autologous tissue
• Complications
Tissue expander complications
Threatened exposure, no
Excise necrotic or
compromised mastectomy
flaps, close primarily
If implant is submuscular can
treat with local wound care
and allow skin flap to slough
Exposure: antibiotics, remove
implant, delayed reinsertion
Mostly staphylococcal gram
positive organisms
Less severe infections or
infected seroma (usually
Staphylococcus epidermidis):
treat with antibiotics, salvage
More severe infections
(usually Staphylococcus
aureus): treat with antibiotics,
remove implant, delayed
Pain during expansion
Confirm not due to hematoma
or infection
Withdraw fluid from tissue
expander because pain may be
due to rapid expansion and
tissue ischemia
If pain does not improve with
fluid withdrawal, give pain
meds and warm compresses
In cases of encapsulation or
poor expansion consider
capsulotomy/capsulectomy or
other reconstruction
Pectoralis torque strength
reduction: due to subpectoral
Fat necrosis
Nontender hard lump presenting
approximately 6 weeks postop
If small: manage conservatively
with massage
If larger (> 2 cm) or bothersome
to patient: remove if persistent
or problematic at 6 to 12 months
If large and/or associated with
partial flap loss: debride and
treat with antibiotics
Abscess: tender, firm
Hematoma: tender, firm
No evidence postop antibiotics
or antibiotics for drains reduce
Preop, intraop, and
postoperative antibiotic
prophylaxis is recommended
Seroma: soft consistency (35 to
60% of latissimus dorsi flaps)
Abdominal wall hernia (rectus
abdominis flaps)
Umbilical necrosis
Arterial supply: bilateral deep
inferior epigastric arteries,
ligamentum teres
Arterial supply after bilateral
TRAM: only ligamentum teres
Smoking-related complications
Hernia, skin and abdominal flap
No increased risk of
microvascular complications

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muscle-sparing TRAM flaps for
breast reconstruction. Plast Reconstr
Surg 2008;122(3):702–709
30 Body Contouring,
Abdominoplasty, and
Reviewed by Jeffrey A. Gusenoff

Body Contouring
• Photography parameters
Used to maintain constant
width/height of picture
For body and breast: camera 35
mm, focal length 55 mm, distance
from patient 5 to 6 feet
For face, head, and neck: camera
35 mm, focal length 90 to 105 mm,
shorter distance (< 3 feet)
Hold camera with the flash on the
side of camera that you are taking
profile picture of to prevent
• Brachioplasty
Goal: corrects posteromedial arm
ptosis caused by weight loss, age,
gravity, loosening of clavipectoral
Clavipectoral fascia: lies deep to
pectoralis major muscle, extends
from clavicle to dome of axillary
fascia, attaches to superficial
fascia and soft tissue of
posteromedial arm
Resuspend superficial fascia of
arm flap to axillary fascia
Complications: scarring (most
common), medial antebrachial
cutaneous nerve injury (most
common nerve injury, travels with
basilic vein superficial to deep
fascia, treated with time, massage,
and gabapentin), medial
intercostobrachial nerve injury,
basilic vein injury (not cephalic
vein), lymphedema (often
temporary, but may be chronic),
horizontal furrows, recurrent skin
Liposuction upper arm: useful in
mild to moderate arm fat with
good skin tone, beware liposuction
of thin skin of medial distal upper
arm because can lead to contour
• Medial thigh lift
Crescent incision
Limited to deformities of the
upper third of the thigh
Risks of skin pleating and vulvar
Medial longitudinal incision
Can be short if addressing upper
and middle thirds of the thigh
Full-length to the knee for skin
laxity of the entire medial thigh
Risks include delayed wound
healing, seroma, lymphedema,
and vulvar distortion
Avoid lymphedema: by superficial
dissection around the femoral
triangle (bordered by inguinal
ligament, sartorius, and adductor
Fascial anchoring: anchor the
inferior thigh flap fascia to Colles
Colles fascia: deep layer of
superficial perineal fascia
continuous with superficial fascia
layer (Scarpa fascia) of anterior
abdominal wall, high in elastin
content gives yellow hue
compared with nearby white
muscular fascia (note: superficial
layer of superficial thigh fascia is
thin, loose, areolar)
• Lower body lift
Goal: corrects ptosis of buttock
and thigh
Is based lower than a belt
lipectomy and gives better control
of the buttock and thigh contour
Allows for autoaugmentation of the
buttocks using local tissue
Can combine with liposuction
Most common complication:
delayed wound healing
• Belt lipectomy
Circumferential excision is based
higher than a lower body lift to
address buttock, thigh, and
abdominal ptosis
Better for addressing flank
lipodystrophy; less control of the
buttocks and thighs
Most common complication:
seroma (37.5%)
• Monsplasty
Lower incision of abdominoplasty
should be 5 to 7 cm above vulvar
Liposuction or direct excision of
the excess mons tissue with
resuspension of the mons to
abdominal wall fascia
• Labiaplasty
Most common preop complaints:
painful intercourse, painful
exercise, cosmetic concerns
Labia majora: longitudinal
Labia minora: longitudinal or
wedge resection
Most common postop complaint:
incomplete correction
• Gluteal autoaugmentation
Use gluteal tissue flaps
Fat grafting has unpredictable graft
Silicone (gel or solid) is palpable,
increases risk of infection, and can
cause granulomas
• Mastopexy and autoaugmentation of
breasts after massive weight loss
Breast appearance after massive
weight loss: medialized nipples,
axillary fat roll, flat upper pole,
lower inferior mammary fold due
to deflation
Treatment: dermal suspension,
parenchymal reshaping
Breast augmentation with implants
has a higher risk of implant
malposition or recurrent ptosis in
massive weight loss patients
• Gastric bypass procedures
Malabsorptive: biliopancreatic
Restrictive: gastric banding
Combination of malabsorptive and
restrictive: Roux-en-Y (most
• Nutrition in massive weight loss
Dietitian preoperative evaluation:
protein and vitamin deficiency due
to aversion to animal proteins,
malabsorption, or dumping
syndrome may result in poor
wound healing after body
contouring surgery
• Protein minimum pre- and
postoperative levels: 70 to 100 g/d
• Vitamins: correct for iron (most
common deficiency), calcium (fat-
soluble vitamin D not absorbed),
folate, and vitamin B12
• Body contouring complications in
massive weight loss patients
Rate: 50%
Wound dehiscence: most common
Early dehiscence: secondary to
patient movement
Late dehiscence: after immediate
postop period, secondary to
Seroma: second most common
complication, prevented by
securing flaps with quilting
sutures, maintaining lymphatic
containing tissues deep to Scarpa's
fascia inferior to the umbilicus,
adequate use of drains
• Mesotherapy
Nonsurgical body contouring
Variety of medications (e.g.,
phosphatidylcholine) injected into
mesoderm (fat layer) to induce
Not Food and Drug Administration
(FDA) approved
• Pseudogynecomastia (Table 30.1)
Predominately excess loose skin
and subareolar fat in men after
massive weight loss
Different from gynecomastia which
is characterized by excess of
glandular tissue

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

Minimal excess
skin and fat,
alteration nipple
I Liposuction
areola complex,
fold (IMF)

NAC/IMF Pedicled
descended nipple flap

descended, excision,
upper abdominal free nipple
laxity graft
• Selection of proper surgical
procedure depends on deformity
Abdominal skin
Abdominal fat
Status musculofascial support
(rectus diastasis?)
• Miniabdominoplasty
Lower abdominoplasty
Suprapubic skin excision without
translocation umbilicus; umbilicus
can be floated and sutured into
place, but will be lower on the
Plication infraumbilical rectus
Can add suction lipectomy if
excess fat involved
Useful for young, thin, postpartum
female with excess skin, striae,
and diastasis
• Abdominoplasty
Panniculectomy plus plication
and/or transposition of the
Major undermining
Plication above and below
umbilicus: bulge in upper abdomen
after abdominoplasty can be due to
incomplete plication
Relocate umbilicus in midline at
level of anterosuperior iliac spine
• Wedge resection
Single, transverse, elliptical wedge
excision with no undermining
Safest approach for high-risk
patient with obesity, massive
panniculus (patient cannot exercise
and is prone to infection)
• Nerves injured during
Lateral femoral cutaneous nerve:
most common nerve injured causes
meralgia paresthetica with anterior
lateral thigh burning, tingling, and
Iliohypogastric: innervates
suprapubic region
Ilioinguinal: innervates skin along
inguinal ligament, medial groin,
labia majora, scrotum, inner thigh
Note: genitofemoral nerve is not
injured, it originates from L1–L2,
courses deep to wall
Diagnosis: injection of local
anesthetic, short-acting nerve
Treatment: neurectomy
• Arterial supply to abdominoplasty
Lateral intercostal perforators
Preexisting abdominal scars
(cholecystectomy right subcostal,
paramedian supraumbilical)
predispose to wound
complications because decreased
blood flow to flap: when
operating, avoid undermining
above these scars
Infraumbilical scars and previous
liposuction do not cause
complications: can add suction
lipectomy to blend area of
resection and sculpture
• Seroma
Most common complication in
Management algorithm: aspiration,
closed suction drains, sclerosing
agent, excision of seroma cavity
Table 30.2 Tumescence techniques

EBL (%
Technique Infiltrate aspirate

3 mL
Tumescent infiltrate to 1 1%
mL aspirate
1 mL
Superwet infiltrate to 1 1%
mL aspirate

200–300 mL
Wet infiltrate per 4–30%

Dry No infiltrate 20–45%

• Tumescence (Table 30.2)
Components: normal saline or
lactated Ringer solution,
epinephrine, lidocaine (70%
infiltrate remains postop)
• Suction lipectomy fluid management
Combination of infiltrate +
intravenous fluid (IVF) = 2×
aspirate removed
Do not liposuction > 5 L aspirate
(fat and fluid) in an outpatient
setting (according to American
Society of Plastic Surgeons
Committee on Patient Safety,
Large-volume liposuction (e.g., 5 L
aspirate) can cause fluid overload
and lidocaine toxicity with
tumescent technique (3 mL
infiltrate to 1 mL aspirate);
therefore, consider using superwet
technique (1 mL infiltrate to 1 mL
Perform in appropriate facility to
monitor postop vital signs and
urine output (Foley catheter for
large volume liposuction)
Signs of volume overload:
hypertension, jugular venous
distention, full bounding pulses,
cough, dyspnea, lung crackles,
pulmonary edema, change in urine
Do not combine large-volume
liposuction with additional
• Ultrasound-assisted liposuction
Piezoelectric quartz crystal or
ceramic transducers transform
electrical into mechanical
vibrations, producing ultrasound
Disrupts adipocyte cell membrane
via microbubble formation and
rupture within cell membrane
Fat is liquefied, causing cavitation,
leaving behind fibrous septations
Tumescent fluid infiltration
minimizes thermal injury
Dysesthesia postop may be due to
myelin injury to nerves by
ultrasonic energy
Increased risk of seroma compared
with suction-assisted liposuction
May induce some degree of skin
• Suction-assisted lipectomy
Surface irregularity: most common
complication (20%), prevent by
cross-tunneling from two separate
sites at right angles, use a small
cannula in the deep fat, do not
liposuction in zones of adherence
(inferolateral IT band area, lateral
gluteal depression, gluteal crease,
distal posterior thigh, midmedial
Thromboembolism: most common
cause of death (1 in 5,000
Fatalities: thromboembolism 23%,
abdominal wall perforation 15%,
anesthesia 10%, fat embolism 8%,
infection 5%
Risks for complications: aspiration
excess tissue (do not liposuction >
5 L in office), increased volume
tumescence, concomitant

Suggested Reading
Aly A. Abdominoplasty and lower
truncal circumferential body
contouring. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:542–550
Buck DW II, Mustoe TA. An evidence-
based approach to abdominoplasty.
Plast Reconstr Surg
Friedland JA, Maffi TR. MOC-PS (SM)
CME article: abdominoplasty. Plast
Reconstr Surg 2008;121(4,
Gingrass MK. Liposuction. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Gusenoff JA, Coon D, Rubin JP.
Pseudogynecomastia after massive
weight loss: detectability of
technique, patient satisfaction, and
classification. Plast Reconstr Surg
Iverson RE, Lynch DJ; American
Society of Plastic Surgeons
Committee on Patient Safety.
Practice advisory on liposuction.
Plast Reconstr Surg
2004;113(5):1478–1490, discussion
Iverson RE, Pao VS. MOC-PS (SM)
CME article: liposuction. Plast
Reconstr Surg 2008;121(4,
Koltz PF, Chen R, Messing S, Gusenoff
JA. Prospective assessment of
nutrition and exercise parameters
before body contouring surgery:
optimizing attainability in the
massive weight loss population.
Plast Reconstr Surg
Lockwood T. Brachioplasty with
superficial fascial system
suspension. Plast Reconstr Surg
Lockwood TE. Fascial anchoring
technique in medial thigh lifts. Plast
Reconstr Surg 1988;82(2):299–304
Rohrich RJ, Smith PD, Marcantonio DR,
Kenkel JM. The zones of adherence:
role in minimizing and preventing
contour deformities in liposuction.
Plast Reconstr Sur g
Rubin JP. Mastopexy after massive
weight loss: dermal suspension and
total parenchymal reshaping.
Aesthet Surg J 2006;26(2):214–222
Shermak MA. Body contouring. Plast
Reconstr Surg 2012;129(6):963e–
Shermak MA, Rotellini-Coltvet LA,
Chang D. Seroma development
following body contouring surgery
for massive weight loss: patient risk
factors and treatment strategies.
Plast Reconstr Surg
Trussler A. Body Contouring. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2008:1–52. Selected
Readings in Plastic Surgery; vol
10, issue 22
Wells JH, Hurvitz KA. An evidence-
based approach to liposuction. Plast
Reconstr Surg 2011;127(2):949–
31 Facelift and Neck
Reviewed by Val Lambos

• Anatomy (Table 31.1)
Facial nerve
Acronym for facial nerve
Ten zillion bucks means cash
Temporal (frontal), zygomatic,
buccal, mandibular, and
Innervates superficial facial
muscles on their deep surface
Innervates only three deep facial
muscles on their superficial
Levator anguli oris
Pitanguy line: frontal nerve
courses from 0.5 cm below
tragus to 1.5 cm above lateral
Facial blood supply
Superficial temporal artery: deep
to plane of dissection, supplies
scalp and forehead
Transverse facial artery: branch
of superficial temporal artery,
arises medial to plane of
dissection, undermined in
facelift skin flap, supplies
preauricular skin
Facial, labial, angular,
ophthalmic, and infraorbital
arteries: arise more medially
and contribute to vascular
arcade of facelift skin flap
Retaining ligaments (Table 31.2)
Support facial skin in position
relative to deep fixed underlying
Loosening of zygomatic
ligaments leads to prominent
nasolabial folds
Loosening of masseteric
ligaments leads to jowls
• Patient assessment
One looks at nearly all the aspects
of the face and how it has aged
from brow position to the lower
lid fat to skin quality and apparent
excesses or deficiencies of skin,
fat, and muscle
Youthful face: egg or cone shape
with wider side superior
Aging face: midface descends,
creating jowls and nasolabial
folds (there is controversy about
• Techniques
Subcutaneous facelift
Can include superficial
musculoaponeurotic system
(SMAS) modifications (SMAS-
ectomy, SMAS-plication,
SMAS-stacking, MACS lift)
Sub-SMAS (deep-plane) facelift
Subperiosteal facelift
Added volume in the face with fat
or fillers
Incision placement: pre- versus
posttragal, pre- versus posthairline
• Complications
Most common facelift
complication (4%)
May compromise airway or skin
flap viability
Risk factors
High blood pressure: most
important risk factor to control
Blood thinners, including
ginkgo, garlic, and vitamin E
Cough, pain, anxiety, vomiting
Lack of gentle compression
dressing or suction drains
Table 31.2 Retaining ligaments

Ligament Attachment

Zygomatic arch and

Zygomatic malar eminence

Anterior border
masseter muscle

Parotid Parotid gland

Anterior mandible
Mandibular (parasymphysis)

Return to operating room (OR)
for evacuation of hematoma if
large, rapidly expanding, and
painful; otherwise will have
firmness, irregularity, and skin
discoloration for months
(often there is no active
5 days postop, hematoma may
be solid: release sutures and
evacuation of hematoma
7 to 10 days postop, hematoma
may have liquefied: aspirate
the hematoma
Skin slough
Second most common facelift
complication (2%)
Clinically important ones are in
the front of the ear
Associated with cigarette
Management: local wound care
with antibacterial ointment,
frequent postop visits, allow to
heal by secondary intention
Nerve injury
Third most common facelift
complication (1%)
Greater auricular nerve
Most common nerve injured in
Originates from C2–C3
Crosses sternocleidomastoid
muscle 6 cm inferior to the
Supplies sensation to inferior
Frontal nerve
Injury results in weakness in
eyebrow elevation
Can be injured with any
facelift, though not as common
as with subperiosteal
Buccal nerve
Most common facial nerve
Not noticed because cross-
over connections
Frequently improves over 4
months, but there may be
Marginal mandibular nerve
Most common facial nerve
injury noticed
Affects orbicularis oris, lip
depressors, and mentalis
Ipsilateral lip does not
depress, causing an
asymmetrical smile
Observe because spontaneous
recovery within 6 months in
Treat contralateral depressor
labii inferioris with botulinum
toxin injection
Cervical nerve
Only depressors affected
Usually resolves within 4 to 12
Ratio of facial nerve injury with
sub-SMAS dissection versus
subcutaneous dissection is 4:1
Nerve repair
Microsurgical repair if nerve
transection identified in the
Distal end of transected nerve
can be identified by nerve
stimulation for up to 72 hours
after injury
Rare complication (0.18%)
Staphylococcus aureus is most
common pathogen
Hairline distortion
Most common complication of
secondary facelift
Hairline shaft injury, sideburn
elevation (this has to do with
poor incision placement)
• Male facelift
Thick skin obscures results
Increased risk for hematoma
compared to female facelift
patients because higher blood
pressure (unless blood pressure
controlled) and greater blood
Bald patients require different
Retrotragal incision leads to
posteriorly displaced beard over
Sideburns are an advantage in men
because superiorly displaced
beard can grow as a new sideburn
• Skin diseases
Cutis laxa
Etiology: nonfunctional elastase
inhibitor, premature
degeneration of elastin fibers
Skin laxity, does not recoil when
Facelift may address associated
Increased risk for ventral hernias
Ehlers–Danlos syndrome
Collagen disorder: lysyl oxidase
enzyme deficiency
Hyperextension of joints, skin
recoils, subcutaneous
Avoid cosmetic surgery because
poor wound healing
Localized skin laxity
Avoid cosmetic surgery because
poor wound healing
Progeria (Hutchinson–Gilford
Autosomal dominant disorder
Childhood-onset premature aging
Do not get facelifts because
suffer from early cardiac death
Werner syndrome
Autosomal recessive disorder
Adult-onset premature aging
Do not get facelifts because
suffer from early cardiac death

Neck Rejuvenation
• Patient assessment: youthful neck
Cervicomental angle 105 to 120
Thyroid bulge
Subhyoid depression
Distinct mandibular border
Nasolabial chin plane (NLCP):
chin projection should be 3 mm
posterior to NLCP (line dropped
from midpoint of nasal length
through upper and lower lip
Youthful neck has no playsmal
bands, and minimal pre- and
subplatysmal fat
• Neck rejuvenation treatment
algorithm (Table 31.3)
Table 31.3 Neck rejuvenation treatment
Presentation Treatment

Lateral platysmal
Increased skin laxity advancement and

Ultrasound and
Excellent skin tone,
suction assisted

Wide medial Medial release,

platysmal bands (> 2 lateral closed
cm) approach

Narrow medial
platysmal bands (< 2
open submental
Suggested Reading
Furnas DW. The retaining ligaments of
the cheek. Plast Reconstr Surg
Gonyon DL, Barton FE. The Aging
Face: Rhytidectomy and Adjunctive
Procedures. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005:1–41. Selected Readings in
Plastic Surgery; vol 10, issue 11
Guyuron B. An evidence-based
approach to face lift. Plast Reconstr
Surg 2010;126(6):2230–2233
Rohrich RJ, Rios JL, Smith PD,
Gutowski KA. Neck rejuvenation
revisited. Plast Reconstr Surg
Stuzin JM. MOC-PSSM CME article:
Face lifting. Plast Reconstr Surg
2008; 121(1, Suppl) 1–19
Stuzin JM, Baker TJ, Gordon HL. The
relationship of the superficial and
deep facial fascias: relevance to
rhytidectomy and aging. Plast
Reconstr Surg 1992;89(3):441–449,
discussion 450–451
Stuzin JM, Wagstrom L, Kawamoto HK,
Wolfe SA. Anatomy of the frontal
branch of the facial nerve: the
significance of the temporal fat pad.
Plast Reconstr Surg
Thorne CH. Facelift. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:498–508
Tonnard PL, Verpaele A, Gaia S.
Optimising results from minimal
access cranial suspension lifting
(MACS-lift). Aesthetic Plast Surg
2005;29(4):213–220, discussion
Warren RJ, Aston SJ, Mendelson BC.
Face lift. Plast Reconstr Surg
32 Rhinoplasty
Reviewed by Ali Totonchi

Nasal Anatomy
• Basics of nasal anatomy
Two nasal bones
Two upper lateral cartilage
Two lower lateral cartilage
One septum
Six turbinates
• Arterial supply (Fig. 32.1)
External carotid artery supplies the
facial artery, which branches to
become angular artery and
superior labial artery (travels
between orbicularis oris and oral
Superior labial artery supplies the
columellar artery
Angular artery supplies the lateral
nasal artery, which anastomoses
with dorsal nasal artery from
ophthalmic artery from internal
carotid artery
Nasal septum perfused by anterior
and posterior septal arteries as
well as anterior and posterior
ethmoidal arteries
• Innervation from cranial nerve (CN)
Anterior ethmoid nerve: external
branch supplies midvault and tip
Fig. 32.1 Vascularization of the external nasal
pyramid. (From Huizing BH, de Groot J.
Functional Reconstructive Nasal Surgery.
Stuttgart, Germany: Thieme; 2003. Used with

Supratrochlear and supraorbital

nerves: supply cephalic nose
Infratrochlear nerve: supplies
cephalic sidewalls and radix
• Innervation from CN V2
Infraorbital nerve: supplies lateral
walls, ala, and columella
Pterygopalatine nerve: lateral
branch supplies upper and middle
turbinates, medial branch supplies
Nasopalatine nerve: terminal
branch of pterygopalatine nerve
innervates maxillary incisors,
gingival, and palate
• Muscles of the nose
Innervation: CN VII
Transverse nasalis: contracts the
Depressor septi nasi: depresses
nasal tip, narrows columellolabial
Procerus: moves eyebrows
Levator labii superior alaeque
nasi: dilates the nares

Nasal Airway Obstruction

• Etiology
Hypertrophic inferior turbinate:
most common cause of nasal
airway obstruction
Internal and external valve
Deviated septum: treat with
Infectious rhinitis: treat with
• Hypertrophic inferior turbinate
Most common cause of nasal
airway obstruction
Treatment of the enlarged turbinate
is done by partial resection of the
mucosa and/or bony reduction
Do not completely resect the
inferior turbinate because can
cause airway dryness, sensitivity
to cold, or paradoxical sensation
of nasal obstruction
Submucosal resection can leave
behind hypertrophic soft tissue
Anterior or posterior partial
resection of the inferior turbinate
leads to compensatory hypertrophy
later in remaining portion
• Internal valve
Junction between upper lateral
cartilage (ULC) and septum: 10 to
15 degrees is normal
Narrowing of the internal valve
can be secondary to nasal bone
Cottle maneuver: traction lateral on
cheek skin diagnoses internal
valve obstruction if improves
• Treatment of internal valve collapse
Spreader grafts: placed between
ULC and septum in
submucoperichondrial pocket
• ULC fold-in flap: this flap becomes
available after resection of a sizable
dorsal cartilaginous hump
Butterfly graft: conchal cartilage
placed on top of ULC to lateralize
Splay graft: conchal cartilage
placed under ULC
• External valve
External opening of the nostril
Collapse of lateral crura can be
treated with lateral crural strut
graft (batten graft)
Collapse of alar rim can be treated
with alar rim graft
Seasonal allergic rhinitis
Mediated by immunoglobulin E
Symptoms involve sneezing and
Treatment is decongestant and

Nasal Dorsum
• Nasal hump deformity on profile
< 3 mm: rasp without creating open
> 3 mm: component dorsal hump
reduction, may create open roof
• Component dorsal hump reduction
Emphasizes integrity of ULC by
stepwise approach
Separate ULC from septum, reduce
septum, reduce ULC if needed,
spreader graft if needed
• Osteotomies: reduce wide nasal
dorsum on frontal view (Table 32.1)
• Osteotomy techniques
Stay subperiosteal with anterior to
posterior osteotomy to avoid
injury to lateral nasal artery
Choose low to low or high to low
lateral osteotomy based on desired
anatomical change and position of
inferior turbinates
If inferior turbinates are anteriorly
located, do a high to low
osteotomy to avoid medializing the
inferior turbinate and decreasing
the airway space
Lateral external perforating
osteotomies can injure lateral
nasal arteries and contribute to tip
loss in open rhinoplasty where
columellar artery already cut
Low to high osteotomy can lead to
a step deformity cephalically
(rocker deformity)

Rocker deformity: nasal bone

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

Nasal Tip
• Anatomical landmarks
Transverse landmarks: domes
Vertical landmarks: supratip and
columellar breakpoint (junction of
middle and medial crura)
Lobule to nostril ratio: 1:2 (Fig.
• Angle of divergence (Fig. 32.3)
Angle between columellar
breakpoint and dome-defining
30 to 60 degrees: normal
> 60 degrees: tip appears boxy
< 30 degrees: tip appears narrow
• Boxy tip
Type 1: wide angle of divergence
(> 60 degrees), treat with
interdomal sutures
Fig. 32.2 Triangular shape of the lobule. (From
Huizing BH, de Groot J. Functional
Reconstructive Nasal Surgery. Stuttgart,
Germany: Thieme; 2003. Used with
Fig. 32.3 Angle of divergence.

Type 2: normal angle of divergence

(30 to 60 degrees) but lateral crus
more cephalad; treat with caudal
rotation of lateral crura or with
cephalic trim of cephalic portion
of lateral crura
• Sutures for tip rhinoplasty
Transdomal suture: placed within
the dome, to narrow a wide dome
Interdomal suture: placed between
domes, to narrow distance
between domes
Tip rotation suture: placed between
cephalic margin of medial crura
and the anterocaudal septum;
rotates the tip cephalically and
increases the columellolabial
• Columellolabial angle
Males: 94 to 97 degrees
Females: 97 to 100 degrees
• Techniques for cephalic tip rotation
Tip rotation suture
Columellar strut graft
Cephalic trim lower lateral
cartilage (LLC)
Anterocaudal septum resection
• Tip graft
Used to improve the tip shape or
add height to the lobule part of the
Different types and and shapes
Most common complication:
• Columellar strut graft
Maintains tip support and adds
height to collumellar part of the
nasal projection
Increases columellolabial angle
• Hanging columella management
Resection caudal septum
(overresection can cause retraction
of columella)
Fred technique: advancement of
medial crura and footplates over
caudal septum

Nasal Ala
• Flaring ala
Treatment: Weir excision (wedge
resection) of alar bases to reduce
• Alar retraction/collapse
Due to LLC, which is over-
resected, concave, or
Treatment: alar contour graft
and/or alar batten graft
Alar contour (rim) graft: placed in
subcutaneous pocket immediately
above and parallel to alar rim
Alar batten graft (lateral crus
graft): placed in pocket from
piriform aperture to lateral crus

Rhinoplasty in Particular
Patient Populations
• Advancing age rhinoplasty
Drooping, elongated tip complex
Loss of intrinsic LLC support
Weakening suspensory ligament
Loss of medial crural support
Prominent cartilages due to
thickening and ossification
Bulky tip due to thickened
subcutaneous tissue and skin
Maxillary alveolar hypoplasia with
divergence of medial crural feet
and columellar shortening
• Male rhinoplasty
Beware if requests just nasal tip
aesthetic refinement instead of
airway issues and gross concerns
• Asian rhinoplasty
Alar flaring: treat with alar base
narrowing, alar rim graft, and
excision of soft tissue triangle
Bulbous nasal tip: treat with tip
graft, columellar graft, cephalic
trim LLC
Wide, flat dorsum: treat with
dorsal augmentation using costal
cartilage (autologous graft
preferred over silicone implant),
nasal osteotomies if needed
Thick subcutaneous tissue
• Thick skin rhinoplasty
Thick sebaceous skin will cause
decreased likelihood of optimal
results with nasal tip work
Treatment: retin-A, defat the tip,
supratip suture to eliminate dead
space and improve tip definition
• Secondary rhinoplasty
Wait 1 year after primary
rhinoplasty prior to doing
secondary rhinoplasty
• Inverted V deformity
After infracturing nasal bones with
medialization of upper lateral
cartilages, or after overresection
of cartilaginous dorsal hump
reduction, there may be a collapse
of the upper lateral cartilages with
visibility of inverted V-shaped
nasal bones at the keystone area
(junction of upper lateral cartilage,
nasal bones, and perpendicular
plate of ethmoid bone)
Treat with spreader grafts between
upper lateral cartilages and
cartilaginous septum
• Open book deformity
After reduction of overprojected
bony dorsum there may be a broad
flat dorsal defect with exposed
mucosa or nasal cavity
Treat by infracturing nasal bones,
and placement of spreader grafts to
avoid inverted V deformity
• Saddle nose deformity
Dorsal collapse and over-rotation
of tip
Secondary to septal hematoma or L
strut smaller than 1 cm
Treatment: onlay graft if mild
deformity, more severe deformity
requires L strut reconstruction with
costal cartilage graft
• Polly beak (supratip) deformity
Convexity cephalad to nasal tip
From aggressive reduction
rhinoplasty, overresection of
supratip structures without
elimination of dead space with
supratip suture can lead to blood
filling this space and fibrofatty
deposition: can prevent with
supratip suture and tape; if still
less than 3 months after surgery
can inject steroids
Under-resection of supratip septum
and under-rotation of tip: treat
with resection of anterocaudal
septum, rotation of tip; may need to
trim, overlay, or reorient LLC
• Toxic shock syndrome
Seen with use of nasal packs
Patient presents with fever,
hypotension, erythroderma
Treat with antibiotics for
Staphylococcus aureus and
packing removal
• Periostitis
Erythema and hump after dorsal
hump reduction because rasped
bone is not irrigated out
Treatment: antibiotics and
surgically excise in 8 to 12 months
• Nasal surgery olfactory dysfunction
7 to 9% of patients after nasal
surgery have change in taste
• Gustatory rhinorrhea
Clear rhinorrhea when eating
Secondary to anomalous nerve
regeneration after septoplasty or
Similar to Frey syndrome
Treatment: atropine

Suggested Reading
Daniel RK. Hispanic rhinoplasty in the
United States, with emphasis on the
Mexican American nose. Plast
Reconstr Surg 2003;112(1):244–
256, discussion 257–258
Daniel RK. The nasal tip: anatomy and
aesthetics. Plast Reconstr Surg
Gunter JP, Landecker A, Cochran CS.
Frequently used grafts in
rhinoplasty: nomenclature and
analysis. Plast Reconstr Surg
Guyuron B. Alar rim deformities. Plast
Reconstr Surg 2001;107(3):856–
Guyuron B. Dynamics of rhinoplasty.
Plast Reconstr Surg
1991;88(6):970–978, discussion
Guyuron B. Rhinoplasty. New York:
Elsevier Saunders; 2012
Guyuron B. Soft tissue functional
anatomy of the nose. Aesthet Surg J
Guyuron B, Behmand RA. Caudal nasal
deviation. Plast Reconstr Surg
2003;111(7):2449–2457, discussion
Guyuron B, Behmand RA. Nasal tip
sutures part II: the interplays. Plast
Reconstr Surg 2003;112(4):1130–
1145, discussion 1146–1149
Guyuron B, DeLuca L, Lash R. Supratip
deformity: a closer look. Plast
Reconstr Surg 2000;105(3):1140–
1151, discussion 1152–1153
Guyuron B, Michelow B, Thomas T.
Gustatory rhinorrhea—a
complication of septoplasty. Plast
Reconstr Surg 1994;94(3):454–456
Ha RY, Meade RA. Rhinoplasty. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2007:1–60. Selected
Readings in Plastic Surgery; vol
10, issue 18
Harshbarger RJ, Sullivan PK. The
optimal medial osteotomy: a study
of nasal bone thickness and fracture
patterns. Plast Reconstr Surg
2001;108(7):2114–2119, discussion
Janis JE, Rohrich RJ. Rhinoplasty. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:517–532
Matarasso A, Greer SE, Longaker MT.
The true hanging columella:
simplified diagnosis and treatment
using a modified direct approach.
Plast Reconstr Surg
Ponsky D, Eshraghi Y, Guyuron B. The
frequency of surgical maneuvers
during open rhinoplasty. Plast
Reconstr Surg 2010;126(1):240–
Rohrich RJ, Adams WP Jr. The boxy
nasal tip: classification and
management based on alar cartilage
suturing techniques. Plast Reconstr
Surg 2001;107(7):1849–1863,
discussion 1864–1868
Rohrich RJ, Ahmad J. Rhinoplasty. Plast
Reconstr Surg 2011;128(2):49e–73e
Rohrich RJ, Gunter JP, Deuber MA,
Adams WP Jr. The deviated nose:
optimizing results using a simplified
classification and algorithmic
approach. Plast Reconstr Surg
2002;110(6):1509–1523, discussion
Rohrich RJ, Hollier LH Jr, Janis JE,
Kim J. Rhinoplasty with advancing
age. Plast Reconstr Surg
Rohrich RJ, Janis JE, Kenkel JM. Male
rhinoplasty. Plast Reconstr Surg
2003;112(4):1071–1085, quiz 1086
Rohrich RJ, Krueger JK, Adams WP Jr,
Hollier LH Jr. Achieving
consistency in the lateral nasal
osteotomy during rhinoplasty: an
external perforated technique. Plast
Reconstr Surg 2001;108(7):2122–
2130, discussion 2131–2132
Rohrich RJ, Muzaffar AR. Rhinoplasty
in the African-American patient.
Plast Reconstr Surg
2003;111(3):1322–1339, discussion
Rohrich RJ, Muzaffar AR, Gunter JP.
Nasal tip blood supply: confirming
the safety of the transcolumellar
incision in rhinoplasty. Plast
Reconstr Surg 2000;106(7):1640–
Rohrich RJ, Muzaffar AR, Janis JE.
Component dorsal hump reduction:
the importance of maintaining dorsal
aesthetic lines in rhinoplasty. Plast
Reconstr Surg 2004;114(5):1298–
1308, discussion 1309–1312
Rohrich RJ, Raniere J Jr, Ha RY. The
alar contour graft: correction and
prevention of alar rim deformities in
rhinoplasty. Plast Reconstr Surg
2002;109(7):2495–2505, discussion
Sajjadian A, Guyuron B. An algorithm
for treatment of the drooping nose.
Aesthet Surg J 2009;29(3):199–206
Sajjadian A, Naghshineh N, Rubinstein
R. Current status of grafts and
implants in rhinoplasty: Part II.
Homologous grafts and allogenic
implants. Plast Reconstr Surg
Sajjadian A, Rubinstein R, Naghshineh
N. Current status of grafts and
implants in rhinoplasty: part I.
Autologous grafts. Plast Reconstr
Surg 2010;125(2):40e–49e
Sheen JH. Achieving more nasal tip
projection by the use of a small
autogenous vomer or septal
cartilage graft. A preliminary report.
Plast Reconstr Surg 1975;56(1):35–
Sheen JH. Rhinoplasty: personal
evolution and milestones. Plast
Reconstr Surg 2000;105(5):1820–
1852, discussion 1853
Toriumi DM, Mueller RA, Grosch T,
Bhattacharyya TK, Larrabee WF Jr.
Vascular anatomy of the nose and the
external rhinoplasty approach. Arch
Otolaryngol Head Neck Surg
33 Blepharoplasty and Brow
Reviewed by Oren Tepper

Eyelid Anatomy (Fig. 33.1)

• Anterior lamella
Orbicularis oculi muscle:
innervated by cranial nerve (CN)
VII to close eye (blink)
• Posterior lamella
Tarsoligamentous structures
Conjunctiva: palpebral conjunctiva
lines posterior aspect of eyelid,
bulbar conjunctiva lines globe
Fig. 33.1 Eyebrow and eyelid anatomy. (From
Chen W. Oculoplastic Surgery: The
Essentials. New York: Thieme; 2001. Used
with permission.)

Lid retractors
Intraorbital fat
• Orbital septum
Divides anterior and posterior
Originates from arcus marginalis of
the lower eyelid (point of
confluence onto the periosteum)
Join the capsulopalpebral fascia
(lower eyelid) or levator
aponeurosis (upper eyelid) prior
to inserting into tarsal plate
• Tarsoligamentous structures (Fig.
Attach to orbital walls via
medial and lateral canthal
Lid retractors attach to superior
and inferior borders of tarsal
Orbicularis oculi attaches to
tarsal plates anteriorly
Conjunctiva attaches to posterior
edge of tarsal plates
Superior tarsus: ~ 10 mm in
Inferior tarsus: ~ 6 mm in height
Canthal tendons
Medial canthal tendon
Posterior limb (PL): attaches
to posterior lacrimal crest on
lacrimal bone
Anterior limb (AL): attaches to
anterior lacrimal crest on
frontal process of maxilla
Lateral canthal tendon: superior
and inferior limbs (SL, IL)
attach to Whitnall tubercle on
zygomatic bone inside lateral
orbital rim (approximately 10 to
11 mm within rim)
Canthal tilt: relationship of
lateral and medial canthus.
Lateral canthus is typically 1 to
2 mm superior to medial canthus
(“positive canthal tilt”) versus
level (“neutral tilt”) or inferior
(“negative tilt”)

Fig. 33.2 Canthal tendons. AL, anterior limb;

LCT, lateral canthal tendon; MCT, medial
canthal tendon; PL, posterior limb.

Lockwood ligament
Suspensory ligament to globe
Arises from capsulopalpebral
fascia off lower eyelid
Medial attachment is posterior
lacrimal crest
Lateral attachment is Whitnall
Invests inferior oblique and
inferior rectus muscles
Whitnall ligament
Lateral horn of the fascial
condensation of levator
Contributes to the lateral
Stabilizes eye
Lateral retinaculum
Composed of
Lateral canthal tendon
Whitnall ligament lateral horn
Lockwood ligament
Whitnall tubercle: lateral
retinaculum attachment inside
orbital rim on zygomatic bone
• Lid retractors
Upper eyelid
Levator palpebral muscle:
originates from sphenoid bone,
striated muscle, innervated by
oculomotor nerve (CN III)
Levator aponeurosis:
continuation of levator palpebral
muscle, attaches to tarsal plate
and eyelid skin
Müller muscle: innervated by
sympathetic nervous system
Lower eyelid
Capsulopalpebral fascia:
analogous to levator
• Periorbital fat
Upper eyelid
Two postseptal fat pads
Nasal and central fat pads
Lacrimal gland occupies space
where lateral fat pad would be
Nasal fat pad color is more
pale than central fat pad
Anterior to upper eyelid
Retro-orbicularis oculi fat
(ROOF): preseptal, posterior to
orbicularis oculi
Eisler fat pocket: bordered by
lacrimal gland, orbital rim,
orbital septum, lateral canthal
Lower eyelid
Three postseptal fat pads
Nasal, central, and lateral fat
Anterior to lower eyelid
Medial/nasal fat pad color is
most pale
Suborbicularis oculi fat (SOOF):
preseptal, posterior to
orbicularis oculi

• Patient assessment (see additional
details in Chapter 26, Eyelid and
Lacrimal System Reconstruction)
Visual acuity exam
Schirmer test
Malar support (vector analysis)
Upper and lower lid position
Skin excess
Fat protrusion
Ptosis (eyelid and/or brow)
Levator excursion
Lower eyelid snap-back test
Lower eyelid distraction test
Evaluate for lateral upper eyelid
Prominent superolateral orbital
Brow ptosis
Excess ROOF
Lacrimal gland ptosis
Do not resect because can
cause dry eye
Resuspend pseudocapsule to
the periosteum of lateral
orbital rim
Excess periorbital fat
• Upper eyelid blepharoplasty
Caudal incision along the upper
eyelid crease
Cephalic incision based on excess
skin pinched in supine position
Skin only is excised in most cases
If muscle is performed, must be
careful not to injure levator apo-
Nasal and central fat compartments
are excised through cephalic
incision to avoid injury to levator
• Lower eyelid blepharoplasty
Transconjunctival incision
Incision below tarsus through
conjunctiva and
capsulopalpebral fascia
Dissection between orbicularis
oculi and orbital septum
No external scar
Decreased risk of eyelid
retraction compared to external
subciliary approach
Addresses lower eyelid fat
Does not address excess lower
eyelid skin and muscle
Subciliary incision
Incision below ciliary margin
Can remove excess skin and
muscle in addition to addressing
lower eyelid fat compartments
Increased risk of eyelid
retraction compared with
transconjunctival approach
Fat repositioning
Reposition lower eyelid
periorbital fat to the tear trough
deformity along the lid–cheek
Requires release of arcus
marginalis and incision of
septum; orbital fat repositioned
• Prominent eye blepharoplasty
Scleral show: eyelids do not
overlap corneal–scleral junction
Negative vector: globe position is
anterior to malar region
predisposing to lower eyelid
malposition after blepharoplasty
Need variation in blepharoplasty
Conservative skin and muscle
resection to prevent ectropion
Canthoplasty or canthopexy to
reposition lateral canthus more
superior and lateral in orbit to
prevent lower eyelid retraction
below the limbus
Graves thyroid ophthalmopathy
Etiology: autoantibodies
stimulate thyroid to produce
excess thyroid hormone resulting
in intraorbital soft tissue
Presentation: bilateral prominent
eyes, proptosis, eyelid
retraction, dry eye, conjunctival
Treatment: steroids, radiation
therapy, orbital decompression,
modified blepharoplasty
techniques to decrease risk of
lid malposition
• Asian eyelid
Lack of supratarsal fold
50% lack levator aponeurosis
insertion into dermis
Fusion of orbital septum to
levator aponeurosis more
Levator fibers insert more
caudad into canthus
Increased appearance of ROOF
Prominent epicanthal fold
Creation of prominent crease:
levator aponeurosis fixation to
underlying dermis
• Blepharoplasty complications
Malposition: most common
Lower eyelid malposition
Risk factors
Negative vector (e.g.,
proptosis, Graves thyroid
Lower eyelid laxity
Midface descent
Scarring between septum and
capsulopalpebral fascia
causing vertical restriction
Excess scleral show after
May need to perform
canthopexy or canthoplasty if
lower eyelid needs
Upper eyelid malposition
Lagophthalmos: inability to
close eyelids completely
Extraocular muscle injury
Superior oblique muscle injury
Most common extraocular
muscle injured
Inferior oblique muscle injury
Second most common
extraocular muscle injured
Found between medial and
central fat compartments
Injury caused by bovie injury,
scarring, or suturing can result in
strabismus or diplopia
Visual loss
Retrobulbar hematoma
Presentation: pain,
exophthalmos, ecchymosis,
worsening vision, which can
lead to blindness
Associated with hypertension
and anticoagulant use
Treatment: emergent lateral
canthotomy at the bedside to
Medical treatment to decrease
intraorbital pressure:
mannitol, acetazolamide,
Ectropion intraop
Due to overresection
Place portion of excised skin as
skin graft
Swelling of conjunctiva
secondary to disrupted
Separates lower lid from sclera,
exposing conjunctiva and
causing swelling, irritation,
Early postoperative
Treatment: dexamethasone
ophthalmic ointment, eye
lubricants, patch eye, temporary
tarsorrhaphy (if no
Cadaveric (hollowed out)
Due to excessive removal of
periorbital fat
Excessive tearing secondary to
edema, chemosis, temporary
paralysis of orbicularis oculi
Reassure and observe
Evaluate for lacrimal system
injury if no improvement

Brow Lift
• Brow anatomy
Superficial temporal artery
Supratrochlear artery
Supraorbital artery
Forehead muscles (Table 33.1)
Sensory (trigeminal nerve)
Supratrochlear nerve
Medial to supraorbital nerve
Supplies radix and central
Passes through corrugator
supercilii muscle
Supraorbital nerve
Lateral to supratrochlear
Superficial branch
• Supplies central forehead
• Courses superficial to
frontalis muscle
Deep branch
• Supplies frontoparietal
• Courses deep to frontalis
muscle immediately
medial to the superior
temporal fusion line
Frontal branch of facial nerve:
travels deep to superficial
temporal fascia along the
Pitanguy line (0.5 cm below
tragus to 1.5 cm superior to
lateral eyebrow)
• Patient assessment
Ideal eyebrow position
Medial eyebrow: at level of alar
Eyebrow peak: between lateral
limbus and lateral canthus
Lateral eyebrow: along plane of
alar base and lateral canthus
Women: eyebrow arches above
supraorbital rim
Men: eyebrow at the level of
supraorbital rim without
significant peaking
Brow ptosis
Lateral upper eyelid hooding
Narrow brow–lash distance
Transverse brow furrows: due to
compensatory brow elevation
Independently evaluate upper
eyelid and brow position
Brow can have compensatory
elevation when eyes are opened
Ask patient to close eyes and
relax brow
Ask patient to slowly reopen
eyes (watch for absence of
compensatory brow elevation)
to independently evaluate brow
and upper eyelid positions
Botox injections can also be
used preoperatively to eliminate
effects of compensatory brow
• Nonsurgical intervention
Botulinum toxin
Useful for patients who are not
interested in undergoing brow-
lift surgery
Food and Drug Administration
approved to treat glabellar and
crow's feet rhytids
Brow lift surgical techniques
(Table 33.2)
Coronal incision
Pretrichial incision
Transpalpebral: upper
blepharoplasty incision
• Lateral brow elevation
Release orbital retaining ligament
between superficial temporal
fascia and bone of the lateral
orbital rim
Suspend lateral brow with fixation
techniques laterally
• Medial brow elevation
Resection of corrugator supercilii
muscle elevates medial brow and
addresses vertical glabellar
Avoid release of periosteum
medially to prevent overcorrection
Avoid injury to supratrochlear
Replace excised corrugator with
fat graft (from upper eyelid or
temporal fat pad) to avoid contour
deformity and reattachment of
corrugator to bone
Transpalpebral corrugator
resection: corrugator resection can
be approached via upper
blepharoplasty incision
• Endoscopic approach
Plane of dissection
Central forehead: subperiosteal
Lateral forehead: between deep
and superficial temporal fascia
Table 33.2 Brow lift surgical approach

Forehead Forehead Surgical

shape measurement approach

Short < 6 cm

Normal 6–10 cm Endoscopic

Long > 10 cm Pretrichial

Fixation techniques
Lateral fascial suspension suture:
superficial temporal fascia
sutured to deep temporal fascia
Bone tunnel
Drill two small holes at 45-
degree angles and 3 mm apart
to pass suture through
Cheaper than anchor and
For bone fixation medial to the
deep temporal fascia
Mitek anchors (DePuy Mitek,
Inc., Raynham, MA)
Endotine anchor: do not use in
patients with thin skin < 5 mm
because 3.5 mm tines can be
External screws: remove 2
weeks postop (unlike Mitek and
Endotine anchors, which remain
as buried foreign bodies)
Endoscopic approach does not
allow for skin resection
• Brow lift complications
Overcorrection, undercorrection,
or asymmetry
Nerve injury
Infection or hematoma

Suggested Reading
Bahn RS. Graves’ ophthalmopathy. N
Engl J Med 2010;362(8):726–738
Behmand RA, Guyuron B. Endoscopic
forehead rejuvenation: II. Long-term
results. Plast Reconstr Surg
2006;117(4):1137–1143, discussion
Codner MA, Fored DT. Blepharoplasty.
In: Thorne CH, Beasley RW, Aston
SJ, et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:486–497
Codner MA, Kikkawa DO, Korn BS,
Pacella SJ. Blepharoplasty and
brow lift. Plast Reconstr Surg
Friedland JA, Lalonde DH, Rohrich RJ.
An evidence-based approach to
blepharoplasty. Plast Reconstr Surg
Guyuron B. Endoscopic forehead
rejuvenation: I. Limitations, flaws,
and rewards. Plast Reconstr Surg
2006;117(4):1121–1133, discussion
Knize DM. Forehead lift. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Lelli GJ Jr, Lisman RD. Blepharoplasty
complications. Plast Reconstr Surg
Marten TJ. Closed, nonendoscopic,
small-incision forehead lift. Clin
Plast Surg 2008;35(3): 363–378,
discussion 361
Potter JK, Janis JE, Clark CP.
Blepharoplasty and Browlift.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2005:1–37.
Selected Readings in Plastic
Surgery; vol 10, issue 10
Trussler AP, Rohrich RJ. MOC-PSSM
CME article: Blepharoplasty. Plast
Reconstr Surg 2008;121(1,
Zide BM, Jelks GW. Surgical Anatomy
of the Orbit. New York: Raven;
34 Otoplasty
Reviewed by Gaby Doumit

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

Otoplasty Anatomical
• Cephaloauricular angle
Normal: 20 degrees
Conchal valgus male: > 25 degrees
Conchal valgus female: > 21
• Conchal depth
Normal: 10 mm
Abnormal: > 1.5 cm
• Helical rim protrusion norms
Apex: 10 to 12 mm
Midpoint: 16 to 18 mm
Lobule: 20 to 22 mm
Think: 10, 15, 20 mm to remember
apex, midpoint, lobule protrusion
• Helical rim height: 7 mm (10% of
vertical height)
• Conchoscaphoid angle
Normal: 90 degrees
Effacement of scapha: > 90
• Ear height: 5.5 to 6 cm is double the
• Ear width: 3 to 4.5 cm

Otoplasty Techniques
• Mustarde sutures
4-0 permanent sutures are placed
to create an antihelical fold
Sutures placed between the scapha
and the concha (to create lower
and middle third fold), and/or
between the scapha and the
triangular fossa (to create upper
third fold)
Sutures should go through the full
thickness of cartilage to include
the anterior perichondrium
Three or four horizontal mattress
sutures are usually necessary to
create the antihelical fold
Avoid penetrating the lateral ear
All sutures are placed before tying
• Stenstrom technique
Abrade the antihelical fold
cartilage anteriorly to bend it
posteriorly (Gibson principle)
• Furnas sutures
Conchomastoid sutures between
conchal cartilage and mastoid
fascia treat prominent ear caused
by conchal valgus
Can also excise conchal cartilage
from posterior incision to reduce
conchal height
• Luckett procedure
Excision of posterior ear skin
• Webster technique
Corrects prominent helical tail by
fixation to concha
• Gosain earlobe technique
Excision of medial earlobe skin
Earlobe is then partially attached
to inferior surface of the concha
during closure
• Graham and Gault technique
Endoscopic scoring of posterior
Otoplasty Complications
• Recurrence
Most common complication (8 to
Cause of recurrence in upper half
of ear: inadequate placement
sutures to create antihelical fold
Cause of recurrence in lower half
of ear: inadequate resection of
excess concha or failure to
reposition the earlobe
Adults have less pliable cartilage
and may need rasping of the
• Hematoma
Severe unilateral pain < 24 hours
Need urgent evacuation
• Keloids and hypertrophic scarring
• Cellulitis
• Otitis externa
Starts > 24 hours postop
• Chondritis
Starts days postop, uncommon
Pain, swelling, tenderness
Treatment: intravenous (IV)
antibiotics, do incision and
drainage if suppurative
• Excessively tight dressing
Pain starts immediately postop in
bilateral ears when patient wakes
Postoperative dressing should
initially be noncompressive and
bulky for a few days, then
switched to a loose headband
worn at night for six weeks
• Skin necrosis
• Greater auricular nerve injury
Dysesthesias noted weeks later
• Telephone ear deformity
Secondary to overcorrection of
concha reduction or inadequate
reduction of upper/lower poles of
ear during otoplasty

Otoplasty Timing
• Neonatal molding timing
Neonatal prominent or lop ears are
most moldable during the first few
weeks of life secondary to
increased circulating maternal
Treatment with splints or molding
devices should last approximately
2 to 3 months
Splints and tape should be
replaced when they become loose
Skin needs to be examined
regularly for ulceration
• Otoplasty timing
4 to 6 years of age, before school
At 6 years of age, ears are within 7
mm of final vertical height

Suggested Reading
Davis J. Prominent ears. Clin Plast Surg
Gosain AK, Recinos RF. A Novel
Approach to Correctin of the
Prominent Lobule during Otoplasty.
Plast Reconstr Surg 112(2): 575–
583, 2003
Ha RY, Hackney F. Plastic Surgery of
the Ear. Dallas, TX: Selected
Readings in Plastic Surgery, Inc.;
2005:1–36. Selected Readings in
Plastic Surgery; vol 10, issue 9
Stal S, Klebuc M, Spira M. An
algorithm for otoplasty. Oper Tech
Plast Reconstr Surg 1997;4:88–103
Thorne CH. Otoplasty and Ear
Reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:297–312
Thorne CH, Wilkes G. Ear deformities,
otoplasty, and ear reconstruction.
Plast Reconstr Surg
35 Chemical Peels
Reviewed by David J. Rowe

Peel Classification (Table

• Superficial Peels
Use for 3 to 4 months before
effect is seen
Side effects
Erythema: most common
Photosensitivity: apply at night
Glycolic acid
Alpha hydroxyl acid
50 to 70% for deeper peels
30% peel has depth to stratum
Maintenance therapy with
monthly treatments
Neutralize or wash off with
Jessner solution
Stronger than glycolic acid
Use before trichloroacetic acid
14% resorcinol
14% salicylic acid
14% lactic acid
Salicylic acid
Indication: acne
Table 35.1 Peel classification

Classes Indications Examples

Superficial Retin-A,
wrinkles, glycolic acid,
acne scars, Jessner
uneven solution,
pigmentation salicylic acid

Medium Trichloroacetic
peels acid (TCA)

Coarse Phenol, Baker–

Deep peels severe sun Gordon
damage formula

• Medium Peels: TCA

10 to 25%
Light peel of superficial
Lower concentration for neck,
chest, hands to avoid
hypertrophic scarring, which
may occur in these areas
30 to 35%
Intermediate peel to papillary
Most common strength
50 to 60%
Deep peel through the
papillary dermis
Only half penetration and
neocollagen formation of
Degrease with Jessner solution
or alcohol
Remove surface oils, which
reduce absorption and result in
uneven peel
Variables that affect depth of
Number of coats
Clinical changes related to depth
Superficial peels: sparse and
pinkish-white changes
Intermediate to deep peels:
dense white frosting
No systemic toxicity
Neutralized in superficial dermis
by protein keratin
No systemic toxicity as with
Side effects
Pigmentary changes
• Deep Peels
Comparison with TCA
Double penetration/depth
Double neocollagen formation
Longer recovery time
More risk of pigmentary
Mechanism of action
Carbolic acid
Protoplasmic toxin
Disrupts cell walls and
denatures proteins
Rapid dermal absorption
Penetrates into the upper
reticular dermis
Half-life 3.5 hours
Most secreted unchanged in
urine (eliminated by kidneys)
Can conjugate with glucuronic
and sulfuric acids within 1 to
2 days
May be combined with
Croton oil: skin irritant
Glycerin or Septisol (Steris
Corp., Mentor, OH)
Acts as surfactant to lower
surface tension
Acts as emulsifier to aid in
Side effects
Cardiac toxicity
Monitor with
electrocardiography (EKG)
for arrhythmias
Stop application until normal
sinus rhythm
IV hydration to promote
Anti-arhythmia medication
Skin depigmentation
Baker–Gordon formula
Peel in 15 to 20 minute intervals
Effects: neocollagen formation,
scarring, skin tightening
3 mL phenol
2 mL tap H2O
8 drops Septisol
3 drops croton oil

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

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

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

Suggested Reading
Baker TJ, Stuzin JM, Baker TM. Facial
Skin Resurfacing. St. Louis, MO:
Quality Medical Publishing; 1998
Herbig K, Trussler AP, Khosla RK,
Rohrich RJ. Combination Jessner's
solution and trichloroacetic acid
chemical peel: technique and
outcomes. Plast Reconstr Surg
Nguyen AT, Ahmad J, Fagien S, Rohrich
RJ. Cosmetic medicine: facial
resurfacing and injectables. Plast
Reconstr Surg 2012;129(1):142e–
Perrotti JA. Cutaneous resurfacing:
chemical peeling, dermabrasion,
and laser resurfacing. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Rubin MG. Manual of Chemical Peels:
Superficial and Medium Depth.
Philadelphia, PA: Lippincott
Williams & Wilkins; 1995
36 Fillers and Injectables
Reviewed by Ivona Percec

Fillers (Table 36.1)

• Hyaluronic acid fillers
Filler formulation used today is
trademarked as NASHA
(nonanimal stabilized hyaluronic
Restylane, Perlane, Juvederm
Ultra, Juvederm Ultra Plus,
Juvederm Voluma, and Belotero
Indications: deep rhytids,
nasolabial folds, marionette lines,
scars, lips, cheeks, and fine
• Radiesse
Microspheres of biodegradable
calcium hydroxylapatite suspended
in an aqueous gel carrier, form
scaffold for tissue infiltration
Visible on X-ray
• Sculptra
Poly-L-lactic acid (PLLA), similar
to Vicryl
HIV lipoatrophy: inject SQ in
cheeks, subperiosteal in temples
Cosmetic: helps correct
nasolabial wrinkles and folds
Requires injections every 4 to 6
weeks for several months (results
not immediate)
• ArteFill
Permanent filler
20% polymethylmethacrylate
(PMMA), 80% bovine collagen
Requires pretesting
Approved for use in nasolabial
Table 36.1 Filler classification

Type Duration Examples

6 months to 2 acid fillers,
years Radiesse,
Permanent Permanent ArteFill

Volumizers Up to 1 year acid fillers,

Up to 2 years,
over time
Biostimulators because Sculptra
attract water
and stimulate

Fat Grafting
• Indications
Contour irregularities
Cosmetic deformities
Possible stem-cell effect: scar
therapy, correction of deformities
secondary to radiation
• Technique
Process lipoaspirate
Balanced centrifugation
Gravity sedimentation: takes
longer than centrifuge technique
Telfa processing
Inject from multiple sites
Fanning in different planes
Average survival of fat grafts: 50%
take at 3 months
May require multiple attempts to
correct deformity

Filler Complications
• Under-correction: most common
complaint (not a complication)
• Over-correction
• Visible irregularities
• Donor site problems (fat grafting
donor site)
• Migration of fat
• Infection
• Introduction of a foreign body
• Ischemia
Arterial injection can cause skin
Treat with immediate aspiration
when see blanching
May require hyperbaric oxygen
therapy, hyaluronidase (if
hyaluronic acid filler), steroid
injections, surgical debridement
and antibiotics
Prevent by using small needles,
inject as withdraw, inject minimum
quantity needed to achieve result
• Blindness
Rare complication
From fat embolism into ophthalmic
Avoid by retrograde injection and
use of blunt cannula
• Venous congestion
Excess injection can cause venous
Delayed presentation not amenable
to immediate aspiration
Treat with warm compresses,
nitroglycerin paste, hyaluronidase
injection for hyaluronic acid
fillers, may require operative
• Palpable nodules
Excess injection under thin
superficial skin (i.e., eyelids)
Dissolution unless injected
Radiesse, Sculptra, or ArteFill
May require steroid injection,
incision and drainage instead of
observation because not in a
vascular layer where it will be
easily metabolized
Prevent by injecting
subperiosteally in tear trough

• BOTOX (onabotulinumtoxinA)
Mechanism: inhibits acetylcholine
release at neuromuscular junction
FDA-approved uses
Glabellar lines
Crow's feet: lateral orbicularis
Cervical dystonia
Off-label uses
Forehead lines: frontalis muscle
Perioral, mentalis, neck regions,
other sites
On average 20U injected to 5
brow depressors: procerus
(transverse bunny line
wrinkles), corrugators supercilii
(vertical lines), and depressor
Inject approximately 2.5U per
site into muscle belly
Paralysis occurs within 3 to 7
days and lasts 3 to 4 months
Effects are potentiated by
calcium channel blockers,
aminoglycosides, and
Side effect of postinjection ptosis
Most common cause is
secondary to primary treatment
of glabellar region with
injection of corrugators
supercilii injection and diffusion
to levator
Less likely to affect Muller's
muscle deep to levator
Frontalis muscle injection when
brow elevator compensating for
ptosis may unveil ptosis
Do not massage because can
cause diffusion
Treat with alpha adrenergic
sympatheticomimetic (Iodipine)
to stimulate Muller muscle
(smooth muscle) to elevate
eyelid 2 mm
• Dysport (abobotulinumtoxinA)
FDA approved for glabellar lines
• XEOMIN (incobotulinumtoxinA)
FDA approved for glabellar lines
Does not need to be refrigerated

Suggested Reading
BOTOX Cosmetic [package insert].
Irvine, CA: Allergan, Inc.; 2011
Carruthers J, Fagien S, Matarasso SL;
Botox Consensus Group. Consensus
recommendations on the use of
botulinum toxin type a in facial
aesthetics. Plast Reconstr Surg
2004;114(6, Suppl):1S–22S
Coleman S. Structural Fat Grafting. St.
Louis, MO: Quality Medical
Publishers 2004
Coleman S. Structural fat grafting. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:480–485
Kane MA. Botulinum toxin. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Klein AW. Filler materials. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Lemperle G, Rullan PP, Gauthier-Hazan
N. Avoiding and treating dermal
filler complications. Plast Reconstr
Surg 2006;118(3, Suppl):92S–107S
Nguyen AT, Ahmad J, Fagien S, Rohrich
RJ. Cosmetic medicine: facial
resurfacing and injectables. Plast
Reconstr Surg 2012;129(1):142e–
Nguyen AT, Kenkel JM. Injectables.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2010:1–31.
Selected Readings in Plastic
Surgery; vol 10, issue 28
37 Hair Transplantation
Reviewed by Alfonso Barrera

Hair Anatomy (Fig. 37.1)

• Hair follicle
In subcutaneous (SQ) tissue
Matrix cells proliferate to produce
hair and keratin
• Cuticle: outer layer of hard keratin
anchors to skin by interlocking scales
• Shaft
Visible portion of hair
Composed of hard, dead keratin
Three layers (inner cortex, middle
medulla, outer cuticle)
Medulla and cortex contain
pigment cells that give hair its
Fig. 37.1 Hair anatomy.

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

Phases of Hair Growth

(Table 37.1)
Table 37.1 Hair growth phases

Phase Description

Active growth, lasts

1000 days in men, 2-5
years longer in women,
Anagen 85-90% hair in this
phase, grows 1
Catagen Degradation/transitional,
lasts weeks, bulb

Resting, 10% hair in this

Telogen phase, 50–100 hairs lost
per day

Male Pattern Baldness

• Characteristics
X-linked dominant
Increased telogen phase, decreased
anagen phase
Increased 5-alpha reductase
(converts testosterone to more
potent dihydrotestosterone)
Normal serum testosterone
Treatment with finasteride
(Propecia, Merck, Whitehouse
Station, NJ), a 5-alpha reductase
Norwood–Hamilton classification
(Fig. 37.2)

Female Alopecia
• Characteristics
Least amenable to surgery: if
chronic telogen effluvium
(persistent hair shedding/telogen)
More amenable to surgery: global
diffuse thinning with discrete areas
of alopecia, scar alopecia, frontal
temporal alopecia
Ludwig classification of female
alopecia (Fig. 37.3)

Hair Transplantation
• Follicular unit extraction
(FUE)/punch grafting
Large follicular units (> 4
Unnatural doll-appearance
• Micrografting
Transfer micrografts (1 to 2
follicles) or minigrafts (3 to 4
follicles) with dermal elements
(neurovascular bundle, sebaceous
glands, piloerectile muscle)
Follow angle of hair, put singles
along front
Do not do in patients prone to form
Donor site harvest from occipital
scalp if patient has thick hair
Fig. 37.2 Standards for classification of most
common types of male pattern baldness. (From
Buchwach KA, Konior RJ. Contemporary Hair
Transplant. New York: Thieme; 1997. Used
with permission.)

Fig. 37.3 Ludwig classification of female


• Hair regrowth timeline

Growth 1 month (false growth)
Hair loss 2 to 3 months (telogen
Normal hair growth at rate 1
Will likely require multiple
Wait at least 4 months before

Causes of Baldness
• Androgenic alopecia (thinning)
Most common cause of male and
female pattern baldness
May be related to increased
activity of 5-alpha reductase
Finasteride (Propecia)
Minoxidil (Rogaine, McNeil-
PPC, Inc., Fort Washington, PA)
Topical or oral
Previously used as vasodilator
to treat hypertension
Potential mechanism of action:
vasodilator to improve blood
flow to follicles
• Alopecia areata
T cell–mediated autoimmune
condition in genetically
Treatment: Kenalog steroid
injections (Bristol-Myers Squibb,
Princeton, NJ) every 4 to 6 weeks
leads to some regrowth
Responds poorly if rapidly
progressive, extensive, long-
Spontaneous remission possible in
patients with < 40% scalp affected
• Other causes of baldness
Cicatricial: scarring
Telogen effluvium: excess time in
telogen phase
Traction alopecia: pulling from
Poor nutrition
Medications: for gout, arthritis,
depression, hypertension
Disease: diabetes, lupus
Medical treatments: chemotherapy
and radiation therapy
Hormonal changes: polycystic
ovarian syndrome
Hair treatments
Scalp infection: ringworm
Trichotillomania: hair-pulling

Scalp Flaps
• Scalp flaps: historic interest, not
frequently performed, lead to
scarring, have recurrent baldness
• Scalp reduction: for male pattern
baldness unresponsive to medication
(Fig. 37.4)
• Bilateral advancement transposition
(BAT) flap: two-stage, expander,
hair grows anteriorly (Fig. 37.5)
• Temporoparieto-occipital (Juri) flap
(Fig. 37.6)
For frontal or frontoparietal hair
Hair grows posteriorly, exposing
anterior frontal scar
Staged procedure with delay
• Expansion
For burn scars
Can expand scalp and perform
rotational flaps
Not a cosmetic procedure
Micrografts take in scar tissue,
though not as readily as in
nonscarred areas
Useful in patients with
approximately 50% of scalp
Fig. 37.4 Scalp reduction for male pattern
Fig. 37.5 Bilateral advancement transposition
(BAT) flap.
Fig. 37.6 Temporoparieto-occipital (Juri) flap.

• Orticochea flap: three-flap technique

• Partial or total scalp loss
Free flap coverage and wig
No scalp transplants: not life-
threatening condition worth risks
of chronic immunosuppression

Suggested Reading
Janis JE, Leedy JE. Lip, Cheek, and
Scalp Reconstruction. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2006:1–49. Selected
Readings in Plastic Surgery; vol
10, issue 13
Reed ML. Hair transplantation. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:562–571
Vogel JE, Jimenez F, Cole J, et al. Hair
Restoration Surgery: the State of the
Art. Aesthet Surg J. 2013, 33(1):
38 Lasers
Reviewed by David W. Low

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

Type Use

Superficial red
capillary vessels
KTP 532 (telangiectasias)
on face light
skin tones

Vascular lesions
with light and
dark skin tones
(port wine
stains, macular
Pulsed dye stains,
(tunable dyes 585, 595 telangiectasias,
are no longer (most are spider
used) now 595) angiomas,
spider veins,

with broad
energy, useful
Intense for
pulsed light telangiectasias
Q-switched Black, purple,
ruby 694 and violet
tattoos, nevus of
Ota, hair

Black, blue, and

755 green tattoos,

Similar to
Diode 810
alexandrite laser

Nd:YAG Deeper blue

(neodymium: vessels on leg;
yttrium- 1,064 hair reduction,
aluminum- collagen
garnet) stimulation

Er:YAG Ablative, high

(erbium: affinity for
yttrium- 2,940 water, for skin
aluminum- resurfacing,
garnet) lymphatic

Ablative, high
affinity for
water, for skin
actinic keratitis,
and leukoplakia,
Carbon and benign skin
dioxide 10,600 lesions such as
(CO2) epidermal nevi,
vesicles, and

• The light produced is intense, in

phase, and parallel (coherent)
• Selective photothermolysis: tissue
injury based on wavelength specific
light absorption by a target
chromophore (Table 38.2)
• Lasers generate heat that dissipates
by conduction (thermal relaxation)
• The amount of heat generated is a
function of laser energy (joules),
laser power (watts, or joules/sec),
and/or power density (fluence, or
Skin Resurfacing
• High-energy lasers target water in all
living cells, including skin
Erbium and CO2
For acne scars, sun damage, fine
periocular, perioral, and facial
Uses light energy rather than
dermabrasion or chemical peels to
vaporize epidermis and superficial
dermis layers of the skin
• Erbium laser
May be gentler skin resurfacing
agent than CO2 because it is
absorbed 10 times more readily by
water and therefore penetrates less
deeply (less hypopigmentation,
erythema, faster healing, faster
healing, better for Fitzpatrick types
V and VI)
Produces a transudative wound
more than CO2 laser because the
depth of injury is more shallow
Causes less photomechanical
injury than CO2 laser resulting in
less collateral damage and less
collagen contraction
Table 38.2 Chromophores

Laser Chromophore

Water; erbium has

less thermal
CO2 and erbium diffusion to
surrounding tissue
than CO2

No specific
chromophore, so it
penetrates more
Nd:YAG deeply into tissues,
(neodymium:yttrium- but better absorbed
aluminum-garnet) by dark pigments
(blood vessels, red
blood cells,
collagen, melanin)

melanin (cannot use
on dark-skinned
people for
Pulsed yellow dye telangiectasias,
spider angiomas,
spider veins, cherry
hyperemic scars,

and melanin (benign
Intense pulsed light
superficial or

Melanin, dark tattoo

Alexandrite and ruby pigmentation (not
• CO2 laser–ablative handpieces
May have better effect on deep
coarse wrinkles but may cause
more hypopigmentation, especially
in Fitzpatrick types V and VI
Will tighten skin but not eliminate
gross skin excess or significant
soft tissue descent (need facelift)
• Resurfacing treatment schedule
First pass: vaporized epidermis,
exposing the pink papillary dermis
Subsequent passes: pink papillary
dermis gives way to the yellow
reticular dermis, stop now because
further penetration will result in
Terminate treatment: rhytides gone
or yellow coloration
• Fractional CO2 laser skin resurfacing
Handpiece vaporizes small tunnels
into the dermis separated by intact
skin, resulting in faster healing and
less erythema
Results may be less effective than
ablative laser skin resurfacing, but
patients may prefer faster healing
and shorter recovery
• Facial resurfacing complications
Hyperpigmentation and erythema
(most common short-term)
Hypopigmentation (most common
Hypertrophic scarring (excessive
thermal damage or penetration into
the reticular layer)
• Ice pick acne
Small, deep, jagged edges, steep
Requires excision of deep
crevices, not laser

Fitzpatrick Skin
Classification (Table 38.3)
• Stratifies patients according to
potential for pigmentary changes
(hyperpigmentation) following
chemical peels and laser skin
• Best candidates for skin resurfacing
have skin types I through III
• Skin type IV requires pre- and
posttreatment with retinoic acid,
hydroquinone, and sunscreens
• Skin types V and VI are not as
amenable to resurfacing
Table 38.3 Fitzpatrick skin classification

Color Characteristics
skin type

I White
burns/never tans

II White burns/tans with

III White mildly

Medium Rarely
brown burns/tans easily

V burns/tans very

Never burns/tans
VI Black
very easily

Pretreatments for Skin

• Retin-A, sunscreen, glycolic acid,
and hydroquinone
Used but little evidence that they
prevent postinflammatory
Hydroquinone is a tyrosine kinase
inhibitor and may lightly bleach
the skin, preventing
Hydroquinone can be used for
hyperpigmentation treatment
Do not use Accutane (isotretinoin)
within 18 months, because
prevents reepithelialization and
may lead to scarring
• Antiviral prophylaxis
All resurfacing procedures (lasers,
dermabrasion, peels) have
potential for herpes simplex virus
(HSV) vesicular rash, which
spreads rapidly and may scar
Prophylaxis with oral acyclovir
(Zovirax), famciclovir (Famvir,
Novartis, New York, NY), or
valacyclovir (Valtrex,
GlaxoSmithKline, Philadelphia,
PA) for 2 days preop and 7 to 10
days postop
• If herpes outbreak occurs
Do Tzanck smear and send viral,
fungal, and bacterial cultures
Increase treatment dose of
acyclovir to 800 mg 5×/day
If systemic infection occurs
(disseminated cutaneous lesions,
shortness of breath, fever, malaise,
headache, neurological changes):
admit to hospital for intravenous
antiviral and antibiotic therapy
• Photodynamic therapy-5-
aminolevulinic acid (ALA)
Topical medication converted into
protoporphyrin IX
Releases cytotoxic radicals to treat
cutaneous lesions such as actinic
Activated by blue light (400 to 450
nm), pulsed-dye systems (585 to
595 nm), and photorejuvenation
systems (560 to 1,200 nm)
Patients are sensitive to light and
must remain indoors for 2 days
Erbium, phenol, and tretinoin do
not activate it
• Types of tattoos
Professional tattoos: leave single
depth of multiple colors, often
extend deep within the dermis,
larger particles (> 50 µm) require
more sessions
Amateur tattoos: more superficial,
irregular depth, smaller pigment
particles (< 5 µm) require fewer
Traumatic: (e.g., road tattoo,
gunpowder tattoo [note: lasers can
ignite gunpowder in the skin])
• Tattoo removal (Table 38.4)
One laser not sufficient for
multiple colors
Q-switched (quality switched)
lasers deposit energy rapidly,
causing rupture of cells containing
tattoo pigment, and trigger
phagocytosis and packaging of
tattoo fragments for lymphatic
Table 38.4 Tattoo removal

Method Use

Superficial, bright
tattoos (red, yellow,
brown, orange)
Leaves purpura for
(Nd:YAG) (532 nm)
7–10 days
Q-switched Nd:YAG Darker, deeper
(1,064 nm) tattoos (blue, black)

Pulsed dye laser Superficial, bright

(510 nm) tattoos

Q-switched Black, blue, green

alexandrite (755 nm) tattoos

Q-switched ruby Black, violet, purple

(694 nm) tattoos

Rubbing crystals
over unanesthetized
Salabrasion skin with moist
gauze resulting in
redness and scarring

Traumatic tattoo in
Dermabrasion Unpredictable and
can lead to scarring
Q-switched ruby
laser, Nd:YAG laser
also used for
traumatic tattoos

Q-switched alexandrite and ruby

lasers are absorbed by melanin
and leave transient
hypopigmentation or permanent
depigmentation, particularly in
Fitzpatrick type V and VI skin
• Tattoo dyes
Test laser on skin first, because if
tattoo contains iron in the dye,
lasers convert ferrous oxide to
ferric oxide and can instantly turn
the skin black (hyperpigmentation)
May contain titanium oxide, which
is less common than iron but can
also turn black with lasers
Mercury, cobalt, and chromium are
contained in tattoos but do not turn
Mercury is used for red-based
tattoo inks and on dissemination
may cause allergic reaction

Vascular Anomalies (Table

• Selective photothermolysis
Lasers target the oxyhemoglobin in
erythrocytes in blood vessels
Pulsed lasers cause vascular
rupture and extravasation of blood
(purpura) with limited
extravascular damage (selective
Continuous wave lasers exceed the
thermal relaxation time of blood
vessels, causing more thermal
damage and potential dermal
Table 38.5 Vascular anomaly laser treatment

Vascular anomaly

cherry angiomas,
granulomas, venous
malformations, but
KTP (532 nm) not recommended
for port wine lesions
due to increased risk
of scarring, melanin
absorption limits
use in darker skin

Best laser for port

wine lesions; also
used for
spider angiomas,
cherry angiomas,
spider veins,
Pulsed-dye laser hyperemic scars,
(585, 595 nm) early hemangiomas,
and regressed
hemangiomas with
residual ectatic
vessels; can use with
light and dark skin
(use lower fluence
with dark skin)

First useful laser for

port wine stains,
absorbed by both
oxyhemoglobin and
melanin; continuous
rather than pulsed
laser energy can
Argon-pumped cause increased
tunable dye (488, thermal damage with
515 nm) higher incidences of
scarring, textural
especially in

Telangiectasias and
Copper vapour laser
ectatic port wine
(578 nm)

Erbium laser (2,910 Lymphatic

nm) malformations

angiofibromas, also
used to debulk
Carbon dioxide subglottic
(10,600 nm) hemangiomas (do
not laser
lesion because can
lead to stenosis)
Laser Hair Removal
• Mechanism of action
Targets melanin in hair follicle
during anagen (active hair growth
Sends hair follicles to telogen
(resting phase)
Must have multiple sessions to
capture hair in anagen
Not useful in fair-haired patients
who have low levels of melanin in
the hair follicles
Best candidates have fair skin and
dark hair, resulting in more
selective hair destruction
• Laser options
Q-switched neodymium:yttrium-
aluminum-garnet (Nd:YAG) (1,065
Long-pulse ruby laser (694 nm)
Alexandrite laser (755 nm)
Intense pulsed light (IPL)
• Complications
Erythema in light-skinned patients
Pigmentation changes in darker-
skinned patients because targets

Suggested Reading
Achauer BM. Lasers in plastic surgery:
current practice. Plast Reconstr Surg
Alster TS, Lupton JR. Prevention and
treatment of side effects and
complications of cutaneous laser
resurfacing. Plast Reconstr Surg
2002;109(1):308–316, discussion
Apfelberg DB; American Society for
Aesthetic Plastic Surgery. American
Society of Plastic and
Reconstructive Surgeons. Summary of
the 1997 ASAPS/ASPRS Laser
Task Force Survey on laser
resurfacing and laser
blepharoplasty. Plast Reconstr Surg
Burns JL. Lasers in Plastic Surgery.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2008:1–37.
Selected Readings in Plastic
Surgery; vol 10, issue 23
Low DW. Lasers in plastic surgery. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:169–176
Perrotti JA. Cutaneous resurfacing:
chemical peeling, dermabrasion,
and laser resurfacing. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Prado A, Andrades P, Danilla S, et al.
Full-face carbon dioxide laser
resurfacing: a 10-year follow-up
descriptive study. Plast Reconstr
Surg 2008;121(3):983–993
Section IV Hand and
Lower Extremity
39 Congenital Hand
Reviewed by Phuong D. Nguyen

• Limb and hand development
Limb bud forms at 3 weeks
Hand recognizable by fifth week
Fingers recognizable by eighth
week (digital separation via
apoptosis by 51 days)
Apical ectodermal ridge (AER):
proximal to distal axis, Wolffian
ridge secretes fibroblast growth
factor (FGF)
Zone of polarizing activity (ZPA):
anterior to posterior axis, secretes
sonic hedgehog, associated
anomalies are mirror hand, ulnar
duplication, and dimelia
Wnt-7a: dorsal to ventral axis,
associated with palmar duplication
(double ventral phenotype)
• Carpal bone development
Capitate is the first seen on X-ray
Birth to 6 months: capitate and
6 months to 4 years: triquetrum
6 months to 9 years: lunate
1 to 10 years: trapezium
2 to 5 years: trapezoid
2 to 9 years: scaphoid
8 to 12 years; pisiform (last seen)
Hand Anomalies
• International Federation of Societies
for Surgery of the Hand (IFSSH)
Classification of Congenital Hand
I. Failure formation (arrested
a. Transverse: amelia, distal
b. Longitudinal: phocomelia,
radial dysplasia, cleft hand
II. Failure of differentiation
(separation of parts): synostosis,
syndactyly, contracture, trigger
finger, camptodactyly, clinodactyly
III. Duplication: polydactyly,
triphalangeal thumb
IV. Overgrowth: macrodactyly
V. Undergrowth: hypoplastic thumb
VI. Constriction band syndrome
VII. Generalized skeletal deformity:
dystrophic dwarfism

Top 4 Most Common


• Incidence: 1/1000
Fig. 39.1 Wassel thumb duplication

• Preaxial (thumb duplication) is most

common in whites
• Postaxial (small finger duplication)
is most common in African
Americans and Asians
Type A: broad stalk, associated
with anomalies
Type B: thin, narrow stalk
• Wassel thumb duplication
classification (Fig. 39.1 and Table
Table 39.1 Wassel thumb duplication

No. bones
Type Characteristic

Bifid distal
1 1

2 2
distal phalanx

Bifid proximal
3 3

Most common,
4 4

5 Bifid 5

6 6

7 Triphalangism phalanx
phalanx also
seen with

Note: Remember classification based on

number of bones affected.
• Treatment
Must evaluate flexor/extensor
integrity prior to digit deletion
Usually excise radial digit
(weakest), preserve ulnar thumb
Maintain ulnar collateral ligament
from ulnar duplicate for pinch
May also be reconstructed with
abductor pollicis brevis,
otherwise you get a Z-deformity
from pulling proximal phalanx
ulnarly, distal phalanx radially

Syndactyly (Fig. 39.2)

• Conjoined fingers due to failure of
Incidence: 1/2000
Male:female = 2:1
• Definitions
Complete: webbing to fingertips
Incomplete: webbing not to
Simple: webbing soft tissue
Complex: fusion of bones, joints,
and nails
Complicated: disorganized bones
• Most common web space affected:
third (50% cases)
• Second most common web space:
fourth (30% of cases)
Fig. 39.2 Complex complete third web-space
syndactyly with Brunner incision and dorsal
web flap markings.

• Surgery
Perform between 6 months and 2
years of age
Operate on border digits first (6 to
9 months) because of differential
growth, risk of tethering, and
abnormal growth
• Goals
Complete separation bones and
soft tissue
Preservation both nerves and blood
Develop adequate web space with
flaps inset without tension
Interdigitating flap over proximal
interphalangeal (PIP) joint
Development of distal phalanges
and fingertips
Perforated full-thickness skin graft
(FTSG) for digital resurfacing for
contracture prevention
• Only one side of a digit should be
separated at a time for vascular
• Multiple Brunner incisions (local
• Dorsal web flap tucked two-thirds
from metacarpal head to PIP joint
• Triangular flaps to cover PIP joints
and break up grafted areas
• Full-thickness skin grafts to fill
remaining defects
• Long-arm cast

Trigger Thumb
• Characteristics
Incidence: 1 to 6/2,000
Thumb flexed at interphalangeal
(IP) joint
If flexed at MCP, known as
“clasped thumb”
30% resolve spontaneously by 3
years old
Notta nodule: thickening of flexor
pollicis longus (FPL) tendon
• Treatment
Observe until 3 years old, then do
A1 pulley release
Do not inject steroids because
needs MAC anesthesia
Do not resect, aspirate, or biopsy
node because it is benign

Constriction (Amniotic)
Band Syndrome
• Incidence: 1/15,000
• Factors associated
Low birth weight
Young multigravida mother
• Treatment
If less severe: observe, delayed
If severe, threatened limb loss:
surgical emergency; Z-plasty, two
stages if circumferential
Amputate only if failed attempts at
Do second toe to hand if only
thumb affected, because need

Other Hand Anomalies

(Apert syndrome)
• Characteristics
Fibroblastic growth factor receptor
anomaly (FGFR2 gene)
Bilateral syndactyly–index,
middle, ring fingers most involved
Type I: Spade (obstetrician's)
hand–four fingers fused, thumb
Type II: Spoon (mitten) hand–
thumb joined to thumb mass
Type III: Hoof (rosebud) hand–
osseous or cartilaginous fusion of
thumb to finger mass
• Treatment
Surgical release border digits (1.5
years old)
Digit reconstruction

Poland syndrome
• Characteristics
Unilateral chest wall hypoplasia–
absent sternocostal head of
pectoralis major is most common
Hypoplasia of hand and forearm
Brachysyndactyly and shortening of
middle fingers
Etiology thought to be subclavian
artery hypoplasia
• Treatment
Syndactyly release

• Flexion contractures multiple digits

Madelung deformity (Fig.

• Characteristics
Congenital dyschondrosis of distal
radial physis
Noticed during childhood and
Increased radial inclination
Ulna positive variance
Short radius
Carpal bones between radius and
Palmar subluxation of carpus
• Treatment
Observe if mild
Darrach procedure (ulna

Thumb in palm deformity

• Seen in cerebral palsy patients
• House classification
Fig. 39.3 Madelung deformity.

I. Adduction contracture, most

common secondary to spasticity of
adductor and first dorsal
II. Type I plus flexion deformity of
metacarpophalangeal (MCP) joint
secondary to spasticity of FPL
III. Hyperextension MCP joint,
spastic extensor pollicis brevis
IV. Type I and FPL contraction
• Treatment
Release of spastic muscles
Stabilize joint

Cleft hand (ectrodactyly)

(Table 39.2)
• Characteristics
Partial or total absence of fingers
in central hand
Split hand/split foot malformation
“Lobster claw hand”
Associated with EEC syndrome:
ectrodactyly, ectodermal
dysplasia, cleft lip and palate
Typical and atypical
Table 39.2 Cleft hand (ectrodactyly)

Typical Atypical

V-shaped U-shaped
Shape of
deformity missing LF missing LF,
ray IF, RF rays

Laterality Bilateral Unilateral

Inheritance Sporadic

Cleft foot,
SHFM1 (split
hand foot
gene on
chrom 7q21),
Associated EEC Poland
anomalies syndrome syndrome
• Characteristics: short fingers
• Treatment with lengthening
Nonvascularized toe to phalanx

• Characteristics
Overgrowth of hand and fingers
Secondary to lipomatous
hamartoma within digital nerves
• Treatment
Staged debulking: skin and
subcutaneous resection
Neurolysis, resection
Epiphysiodesis: premature closure
of growth plates
Osteotomies and shortening
Timing: when fingers are at adult

• Characteristics
Congenital flexion deformity, “bent
finger” of small finger (SF) PIP
joint in palmar-dorsal plane
Related to abnormal insertion of
lumbrical on flexor digitorum
superficialis (FDS)
Most cases within first year of life
Asymptomatic, painless
• Treatment
Observation and splinting for 6 to
12 months (majority of cases)
Surgery last resort because of
unsatisfactory results, stiffness,
residual flexion deformity
May operate if > 30 degree
Release accessory collateral
ligament to volar plate
Transfer lumbricals to extensor
central slip
Stabilization of MCP joint to
prevent hyperextension (i.e.,
Zancolli lasso procedure, volar
plate tightening)
Full-thickness skin graft to volar
deficient skin

• Characteristics
Congenital deviation in radial-
ulnar plane, most commonly radial
deviation of SF middle phalanx
Delta phalanx: trapezoidal bone
creates deviation of
interphalangeal joint
Associated with Down syndrome
• Treatment:
Excision and wedge osteotomy at
10 to 12 years old
Radial limb syndromes
(Table 39.3)
• Characteristics
Insult to apical ectodermal ridge
during fourth to seventh week
Thumb and radius
absent/hypoplastic, radial artery
Other radial limb syndromes
Nager, myositis ossificans, GI
(imperforate anus), Carpenter,
Apert, Rubinstein–Taybi (broad
thumb, short stature), trisomy 18,
hand-foot-uterus, Cornelia de
Lange (low-birth weight,
developmental delay,
clinodactyly, small hands)
Thumb hypoplasia (Table
• Characteristics
Blauth classification
Incidence: 1/30,000 to 100,000
80% associated anomalies (Table
• Timing of surgery
1 year old before bad habit forms
of side-to-side pinch between
fingers to compensate
Not before 1 year of age because
need blood vessel walls to thicken
and want cardiopulmonary system
to be better developed
Table 39.3 Radial limb syndromes
Syndrome Characteristics

Cardiac anomalies,
autosomal dominant
Holt–Oram mutation, absent
thumb, radial club

Autosomal recessive
mutation DNA repair
genes, lethal
diagnose with
mitomycin C,
Fanconi anemia hypoplastic thumb,
absent radii, café au
lait spots, short
stature, genital
microcephaly, die
20–30 years old

absent radii,
TAR thrombocytopenia
(seen later in
Fanconi), no

(similar to
phocomelia), brain
and craniofacial

Vertebral, anal
atresia, cardiac,
fistula, renal/radial
anomalies, limb
anomalies, single
umbilical artery If
VACTERLS total absence of
radius, centralize
ulna If thumb absent,
do index finger
pollicization If ulna
> 35 degree bowing,
do corrective
closing wedge

Table 39.4 Blauth's classification of thumb

Type Characteristic Treatment

Small thumb
I with all No treatment

Small thumb, (Huber
hypoplasia transfer),
thenar muscles, thumb
ulnar collateral lengthening
ligament with web space
instability deepening

joint (CMC), Tendon
type II, extrinsic transfers
Absent CMC, ablation
IIIB remaining

Pouce flottant,
IV no metacarpal Same as IIIB

V absence of Pollicization

• Transfer of index finger to thumb
• Steps
Ligate radial branch to long finger
Divide finger A1 and A2 pulleys
Extensor tendons mobilized by
dividing juncture
Shorten metacarpal by division
(shaft removed)
Index finger rotated 150 degrees
into pronation, 40 degrees in
abduction, and 70 degrees to palm
• Index finger tendon new roles
First dorsal interosseous
reattached to radial lateral band to
be abductor pollicis brevis (APB)
First palmar interosseous becomes
adductor pollicis (AP)
Flexor digitorum profundus (FDP)
becomes FPL
Flexor digitorum superficialis
(FDS) becomes flexor pollicis
brevis (FPB)
Extensor indicis proprius (EIP)
becomes extensor pollicis longus
Extensor digitorum communis
(EDC) becomes abductor pollicis
longus (APL)

• Characteristics
Fused PIP joint
Small finger is most common finger
• Treatment: arthroplasty into
functional position
Möbius syndrome
• Cranial nerve VI, VII palsy
• Cannot move facial muscles or eyes
• Associated with oligodactyly
(missing fingers)

Kirner deformity
• Palmar radial curving of small finger

Suggested Reading
Choi M, Sharma S, Louie O. Congenital
hand anomalies. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:856–863
Desai HJ, Bidic SM. Hand: Fractures
and Dislocations, the Wrist, and
Congenital Anomalies. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2011:1–68. Selected
Readings in Plastic Surgery; vol
10, issue 29
De Smet L; IFSSH. Classification for
Congenital Anomalies of the Hand:
the IFSSH classification and the
JSSH modification. Genet Couns.
13(3): 331–338, 2002
Havlik RJ. Common Congenital Hand
Anomalies. In: Thorne CH, Chung
KC, Gosain AK, et al, eds. Grabb
and Smith's Plastic Surgery. 7th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2013: 890–899
Oda T, Pushman AG, Chung KC.
Treatment of common congenital
hand conditions. Plast Reconstr Surg
Trumble TE. Congenital hand
deformities. In: Trumble Principles
of Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
Wassel HD. The results of surgery for
polydactyly of the thumb. A review.
Clin Orthop Relat Res
40 Fingertip Amputations
Reviewed by Fernando A. Herrera Jr.

Fingertip Anatomy (Fig.

• Nail plate and nailbed
Germinal matrix
Portion of nailbed proximal to
Produces 90% of the nail plate
White portion of nailbed
between sterile and germinal
matrix beneath the eponychium
Sterile matrix
Portion of nailbed distal to
Produces 10% of the nail plate
Responsible for adherence of the
nail plate to the nailbed
Covers the proximal nail plate
Overlies the lunula
Fingertip keratinized soft tissue
located where the sterile matrix
and fingertip skin meet
• Bone
Distal phalanx
• Tendons
Flexor digitorum profundus (FDP)
tendon or flexor pollicis longus
(FPL) tendon inserts
Terminal tendon of digital extensor
tendon or extensor pollicis longus
(EPL) inserts

Fig. 40.1 Fingertip anatomy.

Nailbed Injuries
• Principles
If significant crush injury or
laceration, remove nail plate to
evaluate nailbed
Repair nailbed directly if
laceration present
Minimal debridement
Repair with 7-0 chromic sutures
Suspect distal phalanx fractures
and always obtain X-rays
Sterile matrix injuries are easier to
repair primarily than germinal
matrix injuries
Nailbed injuries are grafted if they
cannot be repaired directly or
occupy > 50% of nailbed
If chronic injury remove scar and
attempt reapproximation or skin
graft if cannot reapproximate
After evaluation replace nail plate
to stent eponychial fold and avoid
• Sterile matrix injury
Primary repair if possible
Sterile matrix split thickness
graft (STG)
Donor site for STG
No resultant nail plate deformity
at donor site if thin graft
Same digit or uninjured adjacent
First or second toe
Multidigit injury spare parts
• Germinal matrix injury
Difficult to treat by primary
closure like sterile matrix
Bipedicle germinal matrix
advancement flap
Germinal matrix full-thickness
graft (FTG) needed if > 2 mm
Donor site for FTG
Resultant nail plate deformity at
donor site
First or second toe (second toe
has least cosmetic deformity)
Multidigit injury spare parts
• Combined sterile and germinal
matrix injury
Combined sterile and germinal
matrix FTG
• Nailbed hematoma
Decompress if subungual
hematoma occupies > 50% of
nailbed or if painful
Trephination: drainage with
cautery device
Suspect underlying nailbed injury

Fingertip Amputation
• Direct closure
Shorten bone and use remaining
volar or dorsal skin flap for direct
• Healing by secondary intention
Superficial pulp avulsions < 1 cm
with no local skin available for
direct closure and no exposed
structures requiring coverage
Better sensory recovery than full
thickness skin graft (FTSG)
• Skin grafts
FTSG does not take over bone or
tendon unless periosteum or
peritenon are present
Composite graft: for small defects
on volar tip with exposed bone
(best in children < 2 years of age)
• Local flaps (Table 40.1)
• Regional flaps
Reverse radial forearm flap: see
Chapter 4 for more information
Reverse posterior interosseous
artery flap: pedicled
fasciocutaneous flap to reconstruct
volar, dorsal, and first web space
• Distant flap
Groin flap: insensate
• Free flap
Venous flow through flaps:
harvested from volar forearm, can
be used for soft tissue coverage or
revascularization of the digit, can
be sensate
Fingertip Amputation
• Neuroma
Painful digital nerve endings at
amputation site
Prevention: resect digital nerve
proximal to amputation using
traction neurectomy technique
Treatment: resect neuroma,
vibration, massage, electrical
• Lumbrical plus
Paradoxical extension of proximal
interphalangeal (PIP) joint when
try to form fist
“FDP is too short”: due to retracted
FDP from amputation site pulling
on the lumbricals, resulting in
extension of the PIP
Prevention: reattach torn FDP to
distal interphalangeal (DIP) volar
plate or A4 pulley
Treatment: divide lumbricals
• Quadriga
Decreased flexion of uninjured
digits because FDP tendons share
a common muscle belly (except the
index finger, which has an
additional independent flexor
Can be caused by over advancing
FDP when repairing tendon,
adhesions, suturing FDP to
extensor tendons in distal
amputation, or PIP arthrodesis
• Hook nail deformity: see below

Nail Plate Deformities

• Pincer nail syndrome
Constriction and transverse
overcurvature of distal nail plate
Etiology: tight shoes, osteoarthritis,
beta-blockers, congenital,
psoriasis, epidermoid cyst
Remove constricted nail, incise
sterile matrix longitudinally,
elevate edges
Excise lateral matrix horns,
dermal graft under nail matrix
• Hook nail deformity
Volar-sided tissue loss, nail
follows curvature of residual
nailbed over tip
Remove nailbed curving around
tip with additional 2 mm over
dorsal distal phalanx so that
healing wound will not draw
nailbed around tip again
Cover resulting wound with V-Y
advancement flap

Suggested Reading
Baran R, Haneke E, Richert B. Pincer
nails: definition and surgical
treatment. Dermatol Surg
Braga-Silva J, Kuyven CR, Albertoni
W, Faloppa F. The adipofascial
turn-over flap for coverage of the
dorsum of the finger: a modified
surgical technique. J Hand Surg Am
Dolan M, Saint-Cyr M. Hand:
Fingernails, Infections, Tumors, and
Soft-Tissue Reconstruction. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2009:1–54. Selected
Readings in Plastic Surgery; vol
10, issue 25
Krag C, Rasmussen KB. The
neurovascular island flap for
defective sensibility of the thumb. J
Bone Joint Surg Br
Kumar VP, Satku K. Treatment and
prevention of “hook nail” deformity
with anatomic correlation. J Hand
Surg Am 1993;18(4):617–620
Trumble TE. Fingertip and nail bed
injuries. In: Trumble Principles of
Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
Tymchak J. Soft-tissue reconstruction of
the hand. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:771–780
41 Mutilating Hand Injuries
Reviewed by Ryan Katz

Mutilating Hand Injuries

and Replantation
• Reconstructive goals
Painless use
Prehensile function (grasp and
Thumb function (thumb accounts
for 40 to 50% of hand function)
Supple web spaces
Durable, high-quality soft tissue
Two digits for pinch function
Three digits for tripod function
• Factors that affect successful
Mechanism of injury
Crush, traction and avulsive
mechanisms create wide zones
of injury as compared to clean
cut mechanisms
The arterial intimal injury may
be extensive and may require
debridement and grafting to get
outside of the zone of injury
Ischemia time
Amputated digits appropriately
preserved by cooling have been
successfully replanted after
prolonged cold ischemia times
(up to 94 hrs)
The amputated digit should be
preserved by placing it in a
waterproof container (or plastic
bag) which is then placed within
a separate vessel containing a
cold water bath just above
freezing (not be frozen or placed
in direct contact with ice)
Infection: minimize infection risky
by thorough debridement of
devitalized or contaminated tissues
and use of antibiotics
• Indications for replantation
Thumb amputation
Amputation(s) in children or
musicians (nearly all parts)
Multiple digit amputations
Single-digit amputation distal to
flexor digitorum superficialis
Sharp amputation at any level with
no contamination
Hand and distal forearm
• Relative contraindications to
Single digit within zone II
If no functional benefit offered by
Psychotic patient
Segmental, multilevel injury
Crushed or mangled part(s)
Inability to tolerate a postoperative
rehabilitation protocol
• Contraindications to replantation
Multitrauma patient with more
immediate surgical needs
Gross contamination
> 6 hours warm ischemia time
(forearm level)
> 8 hours warm ischemia time
(digit level)
Serious comorbidities and inability
to tolerate surgery
Unsuitable part or recipient bed
(extensive soft tissue and/or bone
• Order of repair
Parts: “macro before micro”
Flexor tendons
Extensor tendons
Artery (one artery is usually
Veins (at least two is preferable)
Thumb takes first priority
Long finger or ring finger takes
second priority
In multidigit amputations, put
best-quality digit in best-quality
recipient bed—not every digit
needs to be replaced in its
original position
Digit-by-digit repair versus part-
by-part repair
Digit-by-digit repair rarely
If one digit has a prolonged
warm ischemia time, consider
replanting it first
Part-by-part repair more suitable
to the “macro before micro”
All bone repairs followed by
all flexors followed by all
extensors followed by all
nerves, arteries and veins
Performing all microvascular
work after all of the bone and
tendon work will protect
coaptations and anastomoses
from inadvertent iatrogenic
• Techniques to improve mutilated
hand function
Heterotopic replantation: consider
replanting amputated adjacent digit
to thumb position if amputated
thumb cannot be replanted
Finger transposition: index to long
finger transposition at metacarpal
base level or acute index finger
pollicization in combined
thumb/index finger injury
Ectopic banking: amputated part
can be banked in healthy ectopic
location in the setting of unsuitable
or contaminated recipient bed (i.e.,
amputated thumb banked on
contralateral arm while thumb
stump cleaned and covered with
groin flap)
• Distal palm injuries
Intrinsic muscles typically function
poorly after replantation or repair
Interossei: impaired abduction
and adduction
Lumbricals: impaired metacarpal
flexion, proximal
interphalangeal joint and distal
interphalangeal joint extension
Flexor tendons
Flexor digitorum profundus and
flexor digitorum superficialis,
outside of the flexor tendon
sheath at this level (Zone 3)
typically function well after
repair without significant
adhesions or tethering scar
Extensor tendons function well
after repair at this level (Zone 6)
• Forearm injuries
Management of exposed nerves and
tendons in the forearm
Cover with free fasciocutaneous
Contraindication to forearm
> 6 hours warm ischemia time
> 12 hours cold ischemia time
Amputations proximal to digits
have more muscle affected by
Prophylactic fasciotomy: if
forearm ischemic > 4 to 6 hours,
because postischemic swelling
may cause compartment syndrome

Thumb Reconstruction
• Principles
Attempt to preserve length: if
amputation at interphalangeal joint
and flexor pollicis longus and
extensor pollicis longus are
avulsed, replant and fuse
interphalangeal joint to preserve
length (Table 41.1; Fig. 41.1)
Close defect directly or cover with
local flaps if available: Moberg
flap or first dorsal metacarpal
artery (FDMA) flaps are well
suited to cover most distal thumb
Avoid immediate “shorten and
close” revision amputation
Thumb reconstruction for
unsalvageable thumb amputation
(web-space deepening and
metacarpal lengthening versus free
toe-to-thumb transfer)
• Osteoplastic thumb reconstruction
Rarely indicated as terminal bone
graft typically resorbs
Consider other reconstructive
options that could provide length,
sensibility, and aesthetic (toe-to-
thumb transfer)
Used for level C thumb
Combined bone graft with soft
Nonvascularized iliac bone graft
and groin flap
Radial forearm flap, vascularized
radius bone graft, and kite flap for
sensate skin
Table 41.1 Thumb amputation levels

Levels Landmarks Reconstruction

Primary closure,
Distal phalanx
A local flaps, toe
distal to IP joint
to thumb

Web deepening
Middle to distal (i.e., four-flap
proximal Z-plasty),
B metacarpal
lengthening, toe
to thumb

Toe to thumb
(use less morbid
second toe
based on first
metacarpal to
C dorsal
middle proximal

(index finger
longer and
Carpometacarpal improved
D to middle sensation
metacarpal compared to
Fig. 41.1 Thumb amputation levels.

Ring Avulsion Injury

• Urbaniak Type I
Circulation adequate
Treatment: standard bone and soft
tissue management
• Urbaniak Type II
Circulation inadequate
Treatment: vessel repair, may need
to use vein graft
• Urbaniak Type III
Complete degloving
Treatment: ray amputation used to
be universally recommended, but
some authors would consider
replantation on a case-by-case

Infiltration Injury
• IV infiltration injury
Due to nonvesicant (nonblister-
forming agent) entering
surrounding tissue
Physical exam
Tissue loss
5 Ps
Pain on passive extension:
most indicative of
compartment syndrome
Pulselessness: late finding
Check compartment pressures (>
30 mm Hg requires compartment
The decision to release
compartments should be guided by
clinical exam and should not be
delayed if clinical suspicion
remains high despite absolute
pressures less than 30 mm Hg
Elevate extremity
Cold and warm compresses are
Compartment release
• Extravasation injury
Due to vesicant (blister-forming
agent) entering surrounding tissue
Diagnosis: same as IV infiltration
injury above
Local infiltration of
hyaluronidase may be of benefit
in decreasing the concentration
of vesicant by increasing the
area of diffusion
Saline irrigation into the injured
area through a small stab wound
and allowed to flow out through
another stab wound
Debridement of clearly necrotic
tissue and resurfacing with
local/regional tissue or free flap
Anthracycline (i.e., doxorubicin)
extravasation treatment
Topical dimethyl sulfoxide
Delayed excision if does not heal
Avoid cold or warm compresses,
which may localize or spread
• High-pressure injection injury
Paint or organic solvents worse
than air or water injections
Injectate travels proximally along
the neurovascular bundles
Difficult to remove all particulate
matter and foreign debris
High rate of amputation in organic
solvent injections
Early surgical washout and
Serial surgical debridements as
needed to minimize foreign
debris burden
Early range of motion exercises

Suggested Reading
An PC, Kuo YR, Lin TS, Yeh MC, Jeng
SF. Heterotopic replantation in
mutilating hand injury. Ann Plast
Surg 2003;50(2):113–118,
discussion 118–119
Bertelli G, Gozza A, Forno GB, et al.
Topical dimethylsulfoxide for the
prevention of soft tissue injury after
extravasation of vesicant cytotoxic
drugs: a prospective clinical study. J
Clin Oncol 1995;13(11):2851–2855
Brooks D, Buntic RF, Kind GM. Ring
Avulsion: Injury pattern, treatment,
and outcome. Clin. Plast. Surg 2007,
34(2): 187–195
del Piñal F. Severe mutilating injuries to
the hand: guidelines for organizing
the chaos. J Plast Reconstr Aesthet
Surg 2007, 60(7): 816–827
Firat C, Erbatur S, Aytekin AH.
Management of extravasation
injuries: a retrospective study. J.
Plast Surg Hand Surg 2013, 47(1):
Graham WC, Brown JB, Cannon B, et
al. Transposition of fingers in
severe injuries of the hand. J Bone
Joint Surg Am 1947;29(4):998–
Jones NF. Replantation in the upper
extremity. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:868–883
Soucacos PN. Indications and selection
for digital amputation and
replantation. J Hand Surg Br 2001,
26(6): 572–581
Trumble TE. Replantation. In: Trumble
Principles of Hand Surgery and
Therapy. Philadelphia, PA:
Saunders; 2000:469–477
Trumble TE. Thumb reconstruction. In:
Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:469–477
Urbaniak JR, Evans JP, Bright DS.
Microvascular management of ring
avulsion injuries. J Hand Surg Am
Wei FC, Chang YL, Chen HC, et al.
Three successful digital
replantations in a patient after 84,
86, and 94 hours of cold ischemia
time. Plast Reconstr Surg 1988,
82(2): 346–350
42 Dupuytren and Vascular
Reviewed by Alexander M. Spiess

Dupuytren Disease
• Description
Benign fibroproliferative disorder
of palmar fascia, which can result
in disabling finger contractures
(Table 42.1)
Northern European ancestry
Peak age: 40 to 60 years old
Men > Women
Heritable and sporadic forms
Heritable form: autosomal
dominant with incomplete
• Phases
Proliferative: increase in fibroblast
conversion to myofibroblasts
Involutional: alignment of
Residual: acellular devoid of
myofibroblasts, only collagen
remains (type III > type I)
• Structures involved in disease
Facial bands are natural structures
in the hand that become diseased
Pretendinous bands thicken to
become diseased pretendinous
Spiral bands become diseased
spiral cords
Natatory ligaments pass
transversely across web spaces
and become diseased natatory
cords (commissural cord in
thumb web space)
Perivascular structures
Grayson ligament
Volar to neurovascular bundle
Involved with disease at spiral
Cleland ligament
Dorsal to neurovascular
Not involved in disease
Ring finger: most common digit
Small finger Dupuytren disease:
ulnar cord originates at
musculotendinous junction of
abductor digiti minimi
• Indications for treatment
Metacarpophalangeal (MCP)
flexion > 30 degrees
Table 42.1 Dupuytren contractures

Band Contracture

Pretendinous phalangeal (MCP)

Spiral interphalangeal
(PIP) joint
Web space adduction
Natatory contracture (cannot

Any proximal interphalangeal

(PIP) flexion
Significant web space contracture
(especially thumb)
Hueston tabletop test: inability to
place palm flat on table is a
positive test
• Treatment
Painful nodules: steroid injection
Collagenase injection (Xiaflex):
improves MCP deformity, little
improvement of PIP deformity
Percutaneous needle aponeurotomy
Open fasciotomy
Open fasciectomy
McCash procedure
Excision of disease, leave skin
open, or cover with skin graft
Used for severe or recurrent
• Complications
Recurrence: 18 to 24% (most
common complication)
Reflex sympathetic dystrophy: 4 to
Digital nerve injury
Operate under tourniquet
control and loupe
Observe for digital nerve
displacement both centrally
and superficially by spiral
Arterial injury
< 1%
If digital ischemia related to
vasospasm: release incision,
inject papaverine, put in flexion
instead of extension splint,
serially over next few days put
back in extension
• Long-term outcome of joints affected
Age at presentation predicts
outcome: younger age at diagnosis
predicts worse outcome
Poor outcome
Poor response to therapy and
Early partial recurrence (1 to 3
years after surgery)
Treatment of recurrent PIP
disease may require more
aggressive management
More extensive joint release
(accessory collateral ligament,
palmar plate, checkrein
ligament, flexor sheath)
Dermatofasciectomy with full-
thickness skin graft
Arthrodesis: salvage
Good outcome
• Associated diseases
Ledderhose disease: plantar
Peyronie disease: penile

Vascular Disease
• Hypothenar hammer syndrome
Ulnar artery thrombosis or
aneurysm as a result of blunt
trauma to palm
Seen in manual laborers
Ischemic pain and occasional
digital ulcers due to relative
hypoperfusion or emboli
Numbness and tingling from
ulnar nerve compression in
Guyon's canal
Diagnosis: ultrasound or
If there is decreased or no flow
to digits: perform resection of
thrombosed or aneurysmal
segment and vein graft
If there is adequate digital flow:
ligate or resect involved
segment to avoid distal emboli
into digits and/or vasospasm
• Buerger disease
Thromboangiitis obliterans in male
smokers, leading to vascular
obstruction of hands
Symptoms: hands may be painful,
feel cold, look pale, red, or blue
Hands may have large, red,
tender blood vessels
Palpable pulses may be faint or
Ultrasound and magnetic
resonance imaging (MRI) can be
Biopsy blood vessels
Goal is to manage symptoms
Avoid using tobacco and cold
Warm extremity
Surgical sympathectomy (cutting
nerves to blood vessels) may
improve blood flow and help
control pain
Aspirin and vasodilators may be
It may be necessary to amputate
the affected limb if infected or if
tissue death occurs
• Raynaud disease
Vasospasm in women, affecting
fingers, toes, ears, and nose
Precipitating factors
Cold temperature
Other precipitating factors:
vasoconstrictive medications,
arthritis, autoimmune conditions
(scleroderma), smoking
Symptoms: pain, tingling, color
changes (white, then blue, then red
when blood flow reestablished)
Confirmatory tests: ultrasound and
cold stimulation test
Change lifestyle, cease smoking,
avoid caffeine, discontinue meds
that cause vasoconstriction,
avoid cold exposure, wear
mittens or gloves in cold
Vasodilators: topical
nitroglycerin, calcium channel
blockers, Viagra (Pfizer, New
York), Cialis, angiotensin-
converting enzyme (ACE)
Chemical (Botox) and surgical
sympathectomy: improves pain
and vasospasm
• Hand arteriovenous malformation
Congenital endothelialized
vascular connection between
artery and nearby veins
MRI angiogram with intravenous
(IV) gadolinium: accurately tells
involvement of nearby soft
Selective preoperative
intralesional embolization
Can do several preoperative
Staged surgical resection
• Radial artery pseudoaneurysm
Etiology: iatrogenic trauma to
artery (cannulation, gunshot
wound, stab wound)
Pseudoaneurysm is different from
an aneurysm
Pseudoaneurysm: leaking hole
from artery into surrounding
tissue, then forms a fibrous
capsule around area of bleeding
Aneurysm: all three layers of the
arterial wall are present and
Diagnosis: ultrasound or MRI
Direct repair with primary suture
or patch
Vein graft: if defect is large and
vessel critical to perfusion
• Scleroderma
Causes small blood vessel disease
Localized scleroderma: affects
skin, rarely internal organs
Systemic scleroderma: affects skin
and internal organs
Limited: involves less skin and
internal organs than diffuse
Diffuse: more widepread skin
and internal organ involvement
than limited
Type of limited scleroderma
Stands for: calcinosis, Raynaud
phenomenon, esophageal
dysfunction, sclerodactyly, and
Dorsal PIP joint skin may stretch
and ulcerate, causing pain
Ulcer debridement and limited
bone resection may facilitate
PIP joint arthrodesis
Locally excise erosive calcium
deposits from calcinosis

Suggested Reading
Bidic SM, Schaub T. Hand: Extensor
Tendons, Dupuytren Disease and
Rheumatoid Arthritis. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2009:1–60. Selected
Readings in Plastic Surgery; vol
10, issue 26
Brandt KE. An evidence-based
approach to Dupuytren's contracture.
Plast Reconstr Surg
Freshwater MF. Dupuytren's disease. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:864–867
Swartz WM, Lalonde DH. MOC-PS
(SM) CME article: Dupuytren's
disease. Plast Reconstr Surg
2008;121(4, Suppl):1–10
Trumble TE. Dupuytren's disease. In:
Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:453–461
Watt AJ, Shin AY, Vedder NB, Chang J.
Joint arthritis and soft-tissue
problems of the hand. Plast Reconstr
Surg 2010;126(6):288e–300e
43 Fractures and
Reviewed by Brent M. Egeland

Principles of Management
• History and physical
Metacarpal and phalangeal
fractures are the most common
upper extremity fractures
Fifth metacarpal fracture is the
most common fracture
• Fracture sites (Fig. 43.1)
Head: cam shaped, condyles
located on head, covered by
cartilage; rare, usually intra-
articular, most commonly affects
index finger, often comminuted
Neck (metaphysis): junction of
head and shaft, frequent site of
injury under compression; most
commonly involves ring and small
fingers; often significantly
Shaft (diaphysis): fractures can be
transverse or oblique; scissoring
often present
Base: considered high energy;
common thumb fracture site;
evaluate for dislocation at
carpometacarpal (CMC) joint;
small finger (reverse Bennett's) is
inherently unstable
• Dislocation (Fig. 43.2)
Simple dislocation: articular
surfaces in contact
Complete dislocation: articular
surfaces no longer in contact
Dorsal versus volar dislocation:
refers to location of distal bone
relative to proximal bone
• Imaging
Plain radiographs virtually always
CT and MRI based on injury type
and tissue involved
• Treatment
Treatment is specific to each site
and fracture or dislocation—see
Splint/Cast: acceptable for
nondisplaced fractures, consider in
minimally displaced fractures
without scissoring or instability

Fig. 43.1 Metacarpal anatomy.

Fig. 43.2 Simple and complete dislocations.

Closed reduction with or without

percutaneous fixation: can achieve
significant improvement in
alignment or rotation with minimal
soft tissue disruption
Open reduction with percutaneous
or internal fixation: used to
achieve anatomic reduction and
allow early mobilization
• Hand therapy
Should be considered in virtually
all cases to optimize outcome


Metacarpal Fractures
• Metacarpal neck (metaphysis)
Most common metacarpal fracture
“Boxer's fracture” results from
punching an object or person with
axial load applied to metacarpal
Ulnar digits have greatest
compensation for angulation due to
mobility at the carpometacarpal
Observation acceptable in most
cases if no scissoring, no
pseudoclawing [compensatory
metacarpophalangeal (MCP)
hyperextension and proximal
interphalangeal (PIP) joint
flexion], and angulation within
tolerated limits:
Small finger angulation < 40 to
As go radial, reduce 5° per ray
in ulnar to radial direction
Closed reduction if unacceptable
angulation or scissoring—Jahss
Percutaneous pinning if closed
reduction fails or unstable—may
require open reduction
• Metacarpal shaft (diaphysis)
Classified into four types:
transverse, oblique, spiral or
Transverse: usually from axial
load and tend to deform with
apex dorsal angulation due to
pull of interosseous muscles
Oblique/Spiral: usually result of
torsional forces
Comminuted: usually result of
direct impact or crush; can
tolerate 0.5 cm shortening
Unacceptable angulations
requiring treatment
Small finger angulation > 30°
Ring finger angulation > 20°
Long and index finger
angulation > 10°
Rotation: 5° at metacarpal can
lead to 1.5 cm digital overlap
Directed at fracture type, but
includes percutaneous pinning,
composite wiring, lag screws,
and plate fixation
Transverse fracture
Attempt closed reduction
followed by cast
Buddy taping can help control
Percutaneous pinning indicated
when reduction unstable or if
contraindication to casting
(e.g., open wound)
Open reduction internal
fixation (ORIF) with dorsally
applied plate if early motion
Comminuted fracture
ORIF with locking plate
External fixation if soft tissue
Spiral or oblique fracture
ORIF with lag screw: ideal
when fracture length > 2x bone
ORIF with plate when fracture
length < 2x width or when
Open fracture with segmental
Staged treatment—serial
debridement followed by soft
tissue coverage and fixation—
antibiotic bone cement, iliac
crest bone grafting, and
vascularized bone grafting all
possible, depending on
specific circumstances
Thumb Fractures
• 25% of metacarpal fractures occur at
thumb, 80% of those at base
• Bennett fracture
Most common thumb metacarpal
Fracture dislocation of thumb CMC
joint—two fragments:
Shaft is laterally displaced by
lateral pull of abductor pollicis
longus (APL), while base
attached to volar oblique
ligament remains in place—
often dynamically unstable
Thumb is more forgiving:
anteroposterior (AP) angulation
< 15 to 20° and lateral
angulation < 20 to 30° are
generally tolerated due to highly
mobile joint
Closed reduction: rarely
indicated—inherently unstable
Closed reduction and pinning:
common treatment—use when
Bennett's fragment < 15 to 20%
of articular surface
ORIF if closed reduction cannot
reach tolerated limits, articular
incongruity > 1 to 3 mm even
after pinning, or if large
Bennett's fragment (> 23 to 30%
of articular surface)
• Rolando fracture
T or Y pattern fracture dislocation
of thumb CMC—three fragments
Greater axial load compared to
Bennett fracture—fracture is
virtually always unstable
Treatment: ORIF with multiple K-
wires or T-shaped plate
External fixator is used when
fracture is very comminuted

Phalangeal Fractures and

• Tuft
Distal phalanx distal fracture—
frequently accompanied by nail
bed injury
Treatment: consider nail plate
removal and repair of nail bed
If nondisplaced, splint (Stax) for
Displaced fractures can be treated
with closed reduction
• Diaphysis
Frequently at proximal and middle
If nondisplaced or minimally
displaced, closed treatment with
splinting or buddy taping is
preferred treatment; requires
frequent surveillance X-rays to
monitor possible fracture
If displaced > 2 mm or if rotatory
deformity, reduction and pinning is
ORIF with lag screw or plate: can
be technically challenging due to
closely adherent extensor
mechanism, but allows early

Distal Interphalangeal
(DIP) Joint
• Mallet injury (Table 43.1)
DIP flexion deformity from DIP
extensor tendon injury—can be
bony fracture (distal phalanx
terminal tendon insertion) or soft-
tissue only (terminal tendon
Results from laceration or
“jamming” tip of finger
Swan neck deformity
Complication from untreated
mallet injury
Results from proximal retraction
of lateral bands: DIP flexion and
PIP hyperextension
Table 43.1 Mallet injury classification

Type Description Treatment

Splint (Stax)
DIP in full
extension, or
avulsed from
I proximal
pin to work
dorsal base of
distal phalanx
laceration of Tendon
II terminal repair and
extensor splint (Stax)

Extensor grafting, soft
tendon tissue
III avulsion and coverage;
soft tissue can also do
loss delayed

pin fixation;
> 30% ORIF if
articular cannot do
IV surface distal closed
phalanx reduction
avulsed Chronic:
which cuts
tendon to
restore DIP

• Jersey finger
Flexor digitorum profundus (FDP)
avulsion with or without fracture
of FDP from distal phalanx due to
forced DIP extension against
Most commonly involves ring
finger because weakest FDP
attachment to distal phalanx
Leddy classification (Table 43.2)
Treatment directed by
X-ray: can diagnose type 2 and 3
due to visualized bone fragment
Table 43.2 Jersey finger Leddy classification

Type Description Treatment

1 Proximal FDP within 2
retracts to weeks to
palm avoid
tendon graft

Proximal FDP
retracts to
maintained by
fracture Repair
fragment by within 3
2 A3 pulley; months to
small avoid
fragment may tendon graft
convert to
type 1 with

Proximal FDP
retracts past
A4 pulley, ORIF
3 large fracture anytime,
fragment seen even after 3
just proximal months
to DIP

Proximal Interphalangeal
(PIP) Fractures and
• PIP dislocation: volar
Often irreducible because proximal
phalanx condyle buttonholes and
traps between central slip and
lateral band—tightens with
traction and creates noose effect
May be associated with central
slip rupture
Nonoperative: if reduced and
extensor mechanism intact,
similar to boutonniere
Operative: must relocate lateral
bands and joint; central slip may
require repair; percutaneous
pinning to maintain reduction
• PIP dislocation: dorsal
Slips of flexor digitorum
superficialis (FDS) or volar plate
can block reduction
Treatment: extension block
splinting (or pinning); if unstable,
may require volar plate
arthroplasty with collateral
ligament repair
• PIP fracture/dislocation
Axial load leads to unstable
comminuted intra-articular fracture
of the base of the middle phalanx
Re-establishment of the articular
surface and autologous bone
grafting to maintain reduction
< 30% volar articular surface
involved: extension block
> 30% volar articular surface
involved: pinning or ORIF
Other options: skeletal dynamic
traction (ligamentotaxis)–Suzuki
Treatment chronic injury or > 60%
volar articular surface involved
Volar plate arthroplasty
After 2 weeks, begin extension
block splinting
After 4 weeks, begin light
work with buddy taping for
controlled extension
Alternative treatment:

Pediatric Fractures
• Pediatric growth plate fractures
Salter Harris Classification (Table
43.3; Fig. 43.3): describes
pediatric growth plate fractures
involving the epiphysis
Type II is most common fracture
Treatment: closed reduction,
casting, or pin
• Extra-octave fracture
Small finger proximal phalanx base
fracture leading to ulnar deviation
Not included in Salter Harris
Classification, because does not
involve growth plate
• Seymour fracture
Table 43.3 Salter–Harris classification of
pediatric growth plate fractures

Type Description

I Epiphyseal
II Epiphyseal
separation and
metaphyseal fracture

Articular surface
fracture and

Articular surface,
epiphyseal, and

Epiphyseal plate
Fig. 43.3 Salter-Harris classification of
pediatric growth plate fractures

Salter I or II fractures of the distal

phalanx physis, with nail avulsion
Mimics mallet finger due to
physeal separation with
differential extensor and flexor
tendon insertions
High rate of infection if untreated
—typically requires operative
Requires debridement and
reduction of soft tissue from
fracture and nail bed repair

• PIP joint flexion contracture
Early treatment
Serial casting
Dynamic splinting
Delayed treatment
Dynamic external fixator
Capsulectomy: release of
scarred soft tissue of capsule,
volar plate, collateral ligaments,
and checkrein ligaments
• PIP joint posttraumatic degeneration
Arthroplasty: best for radial digits
Arthrodesis: best for ulnar digits
Amputation: for nonfunctional
digits with neuropathic pain
• Malunion
Bone healed with abnormal
• Nonunion
Fracture does not heal

Other Dislocations and

Ligament Injuries
• Gamekeeper's/Skier's thumb
Thumb MCP ulnar collateral
ligament (UCL) injury following
forced abduction and
Stener lesion (Fig. 43.4): proximal
phalanx UCL fragment retracted
proximal to interposed adductor
aponeurosis—this blocks its
ability to spontaneously relocate to
normal position at base of
proximal phalanx—will not
Thumb MCP joint lateral laxity
X-rays—may see small Stener
fragment in first web space, but
not always
Complete tear
Open reduction internal
fixation if UCL instability >
30° in both flexion and
extension, or if > 15 degree
differential compared to
Dissection planes during
operative repair: skin,
aponeurosis, and ulnar
collateral ligament; in a Stener
lesion, the displaced UCL will
be encountered in the
subcutaneous space (i.e., on
top and proximal to the
Fig. 43.4 Stener lesion.

Repair of ligament: suture,

wire, screw, or bone anchor
fixation of fragment to phalanx
Cast for 4 weeks then thumb
spica splint for 4 weeks
Partial tear
If no UCL instability (i.e., 10
degree instability in flexion or
Immobilization with thumb
spica splint for 4 weeks
• Index finger MCP radial collateral
ligament injury
Due to forced ulnar deviation at
Weak key pinch with pain and
ulnar deviation of index finger
MRI confirms diagnosis
Closed reduction and
Open repair if unstable after
• MCP dorsal dislocation
Often irreducible due to interposed
volar plate, lumbricals (radially),
and flexor tendons (ulnarly), which
lead to noose effect with
longitudinal finger traction
Closed reduction: flex wrist to
loosen flexor tendons and apply
distally and volarly directed
pressure at base of proximal
Operative reduction under
sedation or relaxation will
loosen tendons
Partial A3 pulley division
allows condyle repositioning
from flexor tendon
Dorsal extension block splinting:
prevents instability in extension

Suggested Reading
Chin SH, Vedder NB. MOC-PS (SM)
CME Article: Metacarpal Fractures.
Plast Reconstr Surg 121(1S): 1-13,
Desai HJ, Bidic SM. Hand: Fractures
and Dislocations, the Wrist, and
Congenital Anomalies. Selected
Readings in Plastic Surgery.
10(29): 1-68, 2011
Eaton RG, Malerich MM. Volar Plate
Arthroplasty of the Proximal
Interphalangeal Joint: a Review of
Ten Years’ Experience. J Hand Surg
Am 5(3): 260-8, 1980
Lucas GL. Fowler Central Slip
Tenotomy for Old Mallet Deformity.
Plast Reconstr Surg 80(1): 92-94,
Friedman DW, Kells A, Aviles A.
Fractures, Dislocations, and
Ligamentous Injuries of the Hand.
In: Thorne CH, Beasley RW, Aston
SJ, et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2006: 790-802
Friedrich JB, Vedder NB. An Evidence-
Based Approach to Metacarpal
Fractures. Plast Reconstr Surg
126(6): 2205-2209, 2010
Jones NF, Jupiter JB, Lalonde DH.
Common Fractures and Dislocations
of the Hand. Plast Reconstr Surg
130 (5): 722e-736e, 2012
Rockwell WB, Butler PN, Byrne BA.
Extensor Tendon: Anatomy, Injury,
and Reconstruction. Plast Reconstr
Surg 106(7): 1592-1603, 2000
Stern PJ, Roman RJ, Kiefhaber TR, et
al. Pilon Fractures of the Proximal
Interphalangeal Joint. J Hand Surg
Am 16(5): 844-850, 1991
Trumble TE. Hand Fractures. In:
Trumble Principles of Hand
Surgery and Therapy. 1st ed.
Saunders; 2000: 41-89
44 Nerves and
Compartment Syndrome
Reviewed by Ida K. Fox

Anatomy and Physiology

• Median nerve
Motor component
Pronator teres (PT)
Flexor carpi radialis (FCR)
Flexor digitorum superficialis
Anterior interosseous nerve
Supplies: flexor pollicis
longus, radial half of flexor
digitorum profundus (FDP) to
the index and long fingers, and
pronator quadratus
Recurrent motor branch to
abductor pollicis brevis (APB),
opponens pollicis (OP), and
superficial head of flexor
pollicis brevis (FPB)
Lumbricals to index and long
Sensory component
Palmar cutaneous branch:
supplies skin over thenar
Digital sensory nerves
Supply palmar surface of
thumb, index finger, and long
finger, and radial half of ring
Provides some sensation of
dorsal thumb, index finger,
long finger, and radial half of
ring finger from the distal
interphalangeal (DIP) joint to
the fingertip (see radial
sensory nerve below)
• Ulnar nerve
Motor component
Flexor carpi ulnaris (FCU)
FDP to the index and small
Opponens digiti minimi (ODM)
Abductor digiti minimi (ADM)
Flexor digiti minimi (FDM)
Lumbricals to the ring and small
Palmar and dorsal interossei
FPB deep head
Adductor pollicis (terminal
Sensory component
Dorsal cutaneous branch:
supplies dorsal and ulnar distal
forearm, dorsal and ulnar hand,
dorsal and ulnar half of ring
finger, and dorsal small finger
Digital sensory nerves: supply
palmar surface of small finger,
palmar ulnar half of ring finger,
dorsal ulnar half of ring finger
distal to DIP joint, and dorsal
small finger distal to DIP joint
• Radial nerve
Motor component
Triceps brachii
Extensor carpi radialis longus
Posterior interosseous nerve
(PIN) branch
Extensor carpi radialis brevis
Digital extensors
Sensory component
Superficial sensory branch
supplies dorsal and radial distal
forearm, dorsal and radial hand,
and dorsal thumb, index finger,
long finger, and radial half of
ring finger
• Musculocutaneous nerve
Motor component
Biceps brachii
Sensory component
Lateral antebrachial cutaneous
nerve: provides sensation to
radial forearm
• Axillary nerve
Motor component
Teres minor
Sensory component
Superior lateral cutaneous nerve
provides sensation to lateral
upper arm
• Martin–Gruber connection
Forearm level anastomosis
between ulnar and median nerve
Most common pattern: motor
branch from median nerve
innervates ulnar nerve–innervated
intrinsic musculature
• Nerve layers
Endoneurium: surrounds individual
nerve fibers
Perineurium: surrounds individual
fascicles (bundles of nerve fibers)
Epineurium: surrounds bundles of
fascicles and the entire nerve
• Sensory receptors and nerve fibers
Merkel cells: static two-point
discrimination (slow-adapting
Meissner corpuscles: moving two-
point discrimination (quick-
adapting receptors)
Pacinian corpuscles: vibratory
light touch, unable to identify
location of vibration well because
supplies a broad area (quick-
adapting receptors)
A fiber: sharp pain (nociception)
C fiber: burning pain (nociception)

Nerve Injury Principles

• Sunderland, Seddon, and Mackinnon
classifications (Table 44.1)
Describe nerve injury,
degeneration, and recovery
• Wallerian degeneration
Axon degeneration distal to point
of nerve injury
Not seen in first-degree conduction
block or neurapraxia type injury
Seen in second-, third-, fourth-,
fifth-, and some areas of sixth-
degree injuries
Nerve requires time to recover but
in some cases may require surgical
• Nerve regrowth
1 in/mo (1 mm/d)
Rule of 18: (no. inches from injury
to muscle) + (no. months muscle
denervated) should be < 18 for
nerve recovery or reconstruction
to work before motor end-plate
degeneration occurs
• Evaluation and timing of repair
Open injury
Sharp nerve transection injuries
are best repaired immediately
Nerve transection with crush or
other nonsharp-mechanism may
benefit from reexploration at 2
weeks once zone of injury has
been demarcated
Closed (blunt, compression, crush)
or gunshot-wound injury
Observe and serial clinical exam
Electromyography (EMG) at 6
weeks then serially
If no return of function, consider
repair or nerve transfer early at
3 months
• Postoperative management
Splint if simultaneous bony and
tendon structures require
Early mobilization is critical to
prevent scarring and allow nerve
Nerve Repair
• Primary repair
For sharp, acute injuries
Contraindicated if large gap or
tension on the repair
• Nerve conduit/acellularized allograft
For short gap up to 2 to 3 cm to
restore noncritical sensation
Contraindicated if large gap > 3 cm
or motor nerve gap
Bioabsorbable polyglycolic acid
or collagen
Decellularized nerve allograft
• Nerve graft
For cases when other treatment
strategies not possible or
Shorter nerve grafts used to repair
digital nerve or other short gap
Medial antebrachial cutaneous
(MABC) nerve
Lateral antebrachial cutaneous
(LABC) nerve
Posterior interosseous nerve
Longer nerve grafts
Used in a cabled fashion to
repair longer nerve gaps in the
major peripheral nerves such as
the median, radial, ulnar, and
sciatic nerves
Sural nerve: harvest from
posterior calf
• Nerve transfer
Useful for brachial plexus injuries
or other high (proximal) nerve
Transfer expendable donor nerve
to a distal site on the recipient
injured nerve
Converts high (proximal) to low
(distal) nerve injury
Can be motor or sensory nerve
Demands knowledge of
intrafascicular anatomy of nerve
Nerve transfer to correct ulnar
nerve claw hand: median nerve's
AIN pronator branch-to-ulnar
• Bone shortening
Generally contraindicated except
in cases of replantation
Nerve grafts are indicated if the
repair cannot be done without
• Neuroma
Can occur after nerve injury and/or
Pain and decreased nerve
Excision and interposition nerve
Excision and proximal burying:
acceptable for noncritical
sensory neurons
Preserve functioning fascicles

Nerve Compression
• Nerve compression pathophysiology
Both acute and chronic nerve
compression injury have similar
At first
Local nerve ischemia prevents
depolarization causing a nerve
Adenosine triphosphate (ATP)
sodium/potassium (Na/K)
pumps unable to export sodium
to repolarize and maintain
resting potential (− 90 mV)
Recovery can occur as soon as
compression is released
As compression continues
Myelin sheath disintegrates
preventing saltatory jumping
between nodes of Ranvier
Recovery of function may take
12 weeks
More severe compression (crush
Leads to Wallerian degeneration
Will recover at rate of 1 in/mo
• Carpal tunnel syndrome (CTS)
Most common compressive
Median nerve compression at the
Carpal tunnel contents
Median nerve
9 tendons: FDS (4), FDP (4),
flexor pollicis longus (FPL) (1)
FDS 3 and 4 are palmar to FDS
2 and 5 in carpal tunnel
Lumbricals (attached to FDP
tendons) may enter with finger
flexion and can produce effort-
associated CTS, especially in
muscular hands
Numbness and tingling in median
nerve distribution
Thenar muscle weakness can
Tinel sign over carpal tunnel
Phalen sign
Electromyogram (EMG)
Fibrillations present if motor
end organ affected
Nerve conduction study (NCS)
Increased median sensory and
motor nerve latency across
transverse carpal ligament
Nonsteroidal anti-
inflammatory drugs (NSAIDs),
steroid injections, and activity
modification have variable
Surgical release of carpal tunnel
• Median nerve compression at the
Sites of compression
Supracondylar spur
Ligament of Struthers: ligament
between humeral supracondylar
process and medial epicondyle
Lacertus fibrosis and bicipital
Pronator teres (PT)
FDS fascial arch
Vascular arcade proximal to FDS
fascial arch
Pronator syndrome (more proximal
Both motor and sensory
Aching at proximal forearm
Worsened by resisted pronation
Anterior interosseous nerve (AIN)
syndrome (more distal injury)
Pure motor symptoms: inability
to pinch between thumb and
index finger
These less common areas of
median nerve compression
require diagnosis primarily
through history and physical
• Cubital tunnel syndrome
Second most common compressive
neuropathy is ulnar nerve
compression at the elbow
Sites of compression
Arcade of Struthers: medial
intermuscular septum (fascia
between triceps and biceps)
Anconeus epitrochlearis
(anomalous muscle)
Osborne ligament: fascial band
of FCU origin between
olecranon and medial
Involvement of dorsal sensory
nerve causes dorsal hand
numbness in addition to volar
small and ulnar ring finger
digital nerve involvement
Small and ring finger FDP
weakness can weaken grip
Intrinsic muscle (ADM, FDM,
interossei, and adductor
pollicis) weakness and atrophy
Tinel sign at the elbow
Froment sign: on attempted
pinch, see thumb interphalangeal
joint flexion as flexor pollicis
longus compensates for weak
Wartenberg sign: extensor digiti
minimi (EDM) abducts small
finger compensating for weak
third dorsal interosseous
EMG may show denervation of
ulnar-innervated muscles
NCS: slowing across cubital
Nonsurgical: activity
modification, therapy, NSAIDs,
steroid injections, splints, elbow
Surgical treatment options
Cubital tunnel release (in situ
Submuscular ulnar nerve
Subcutaneous ulnar nerve
Medial epicondylectomy
Complications from surgical
Neuroma of the MABC nerve:
treatment is to excise and
implant proximal stump into
nearby muscle
Incomplete release, tethering (in
part can be due to prolonged
postoperative immobilization),
• Guyon canal syndrome
Ulnar nerve compression at the
Sites of compression
Guyon canal between volar
carpal ligament and transverse
carpal ligament
Deep motor branch may also be
compressed by leading fibrous
edge of hypothenar muscle and
Tinel sign at wrist
Normal dorsal ulnar hand
Abnormal small and ulnar ring
finger sensation
Froment sign
Wartenberg sign
Nonsurgical: splinting, NSAIDs,
activity modification
Surgical: release of Guyon canal
and hypothenar fascia

Radial Nerve Compression

at the Forearm
• Radial nerve and its branches can be
compressed in the arm, antecubital
area, and forearm
• Sites of compression: “radial tunnel”
includes multiple areas along course
of nerve
Between brachialis and biceps
(medially), and brachioradialis
muscle (laterally)
Edge of ECRB
Arcade of Fröhse: fibrous arch
along superior portion of supinator
Leash of Henry: radial recurrent
artery and venae comitantes
• PIN entrapment
Pure motor syndrome
Loss of finger and thumb extension
• Radial sensory nerve entrapment
Pure sensory syndrome
Neuropathic pain and/or numbness
at distal forearm and dorsal hand

Brachial Plexus
• Anatomy
Composed of C5–T1 nerve roots
Dorsal sensory rootlets join ventral
motor rootlets to form roots that
divide into trunks, divisions,
cords, and branches
Branches innervated by nerve
roots: long thoracic (serratus
anterior), dorsal scapular (levator
scapulae and rhomboids)
Branches innervated by nerve
trunks: suprascapular nerve
(supraspinatus and infraspinatus)
Cords innervate most of the main
Medial cord innervates: median
nerve, ulnar nerve, and medial
antebrachial cutaneous nerve
Posterior cord innervates: radial
nerve, axillary nerve,
thoracodorsal nerve (latissimus
dorsi), and subscapular nerve
(subscapularis and teres major)
Lateral cord innervates:
musculocutaneous nerve and
median nerve
• Etiology
• Injuries
Can be first- to sixth-degree injury
pattern with complete avulsion,
nerve interruption, or nerve
Proximal avulsion injuries
No proximal stump available for
direct repair
Will require some type of
surgery because no return of
function can occur
Distal nerve or tendon
transfers may provide more
timely return of function
For other injury patterns, direct
repair may be possible
Serial exam and
electrodiagnostic studies are
critical to decision making
May or may not require surgical
intervention, depending on
degree of recovery
Stretch injuries can resolve;
degree of recovery depends on
extent of nerve injury
If surgery is indicated, it must be
done in a timely fashion prior to
terminal muscle denervation
• Erb palsy (waiter's tip deformity)
C5 and C6 injury
Unable to abduct and externally
rotate at shoulder, flex elbow, and
extend wrist
• Klumpke palsy
C8 and T1 injury
Combined median and ulnar nerve
Loss of wrist, thumb, and finger
Loss of all intrinsic hand function

Complex Regional Pain

Syndrome (CRPS)
• Etiology
Reflex sympathetic dystrophy
Secondary to trauma (no obvious
associated nerve injury)
Associated with a specific nerve
injury or compressive
Risk factors include injury to brain,
peripheral nerve, spinal cord,
radius fracture, upper extremity
• Symptoms
Spontaneous pain
Allodynia: pain secondary to
nonpainful stimulus
Hyperesthesia: hypersensitivity
Vasospasm skin changes, swelling,
stiffness, increased sweat
• Diagnosis
Thermography detects increased
baseline temperature
X-ray: detects Sudeck bone
atrophy within 3 to 5 weeks
Bone scan: detects increased
vasomotor and periarticular
Stellate ganglion block (diagnostic
• Treatment
Nonoperative (medical)
management: therapy, pain
management (i.e., stellate ganglion
block), edema management,
medications (gabapentin,
pregabalin, amitriptyline)
Surgical management: nerve
decompression or repair (CRPS2)

Acute Compartment
• Increased compartment pressure
results in muscle and nerve ischemia
(irreversible damage occurs after 4
to 8 hours and can lead to Volk-mann
• Etiology
Trauma, crush injury, burn,
reperfusion after arterial
repair/thrombectomy or
extravasation agent (intravenous
contrast, chemotherapeutic agent,
• Symptoms and findings
Pain, numbness, pain with passive
range of motion of involved
muscle, decreased range of
motion, loss of pulses (late
Compartment pressure > 30 mm Hg
and/or compartment pressure
within 20 mm Hg of diastolic
blood pressure (e.g., hypotensive
patients require a lower threshold
for compartment release due to
their decreased perfusion
• Treatment
Emergent fasciotomy and nerve
• Hand compartment release
Decompress the following muscles
Four dorsal interossei
Three volar interossei
Adductor pollicis compartment
Thenar compartment (ABP, FPB,
Hypothenar compartment (ADM,
Hand muscle release typically
done using four fasciotomy
Two dorsal incisions over
second and fourth metacarpals
Two volar incisions over thenar
and hypothenar compartments
Decompress the median nerve
within the carpal tunnel, the ulnar
nerve within the Guyon canal, and
the deep motor branch of the ulnar
• Forearm compartment release
Decompress the following muscles
Mobile wad proximally: consists
of brachioradialis, ECRB, and
Dorsal muscles (EDC, EIP, EPL,
Superficial volar muscles (FCR,
Deep volar muscles (FPL, FDP,
pronator quadratus)
Decompress the median nerve
within the carpal tunnel, the ulnar
nerve within the Guyon canal, and
the deep motor branch of the ulnar

Suggested Reading
Cheng J, Ellison CR. Hand: Peripheral
Nerves and Tendon Transfers.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2010:1–76.
Selected Readings in Plastic
Surgery; vol 10, issue 27
Effron CR, Beasley RW. Compression
neuropathies in the upper limb and
electrophysiologic studies. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:830–834
Fox IK, Mackinnon SE. Adult peripheral
nerve disorders: nerve entrapment,
repair, transfer, and brachial plexus
disorders. Plast Reconstr Surg
Hentz VR, Lalonde DH. MOC-PS (SM)
CME article: self-assessment and
performance in practice: the carpal
tunnel. Plast Reconstr Surg
2008;121(4, Suppl):1–10
Mackinnon SE, Novak CB. Operative
findings in reoperation of patients
with cubital tunnel syndrome. Hand
(NY) 2007;2(3):137–143
Rodriguez-Niedenführ M, Vazquez T,
Parkin I, Logan B, Sañudo JR.
Martin-Gruber anastomosis
revisited. Clin Anat
Shores JT, Lee WP. An evidence-based
approach to carpal tunnel syndrome.
Plast Reconstr Surg
Trumble TE. Brachial plexus injuries.
In: Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:297–312
Trumble TE. Compartment syndrome
and Volkmann's contracture. In:
Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:324–341
Trumble TE. Compressive neuropathies.
In: Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:324–341
Trumble TE, McCallister WV.
Physiology and repair of peripheral
nerves. In: Trumble Principles of
Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
45 Tendons
Reviewed by Warren C. Hammert

Tendon Anatomy
• Extensor tendon compartments
(Table 45.1)
• Flexor tendons
Flexor digitorum profundus (FDP):
inserts on distal phalanx to flex
proximal interphalangeal (PIP) and
distal interphalangeal (DIP) joints
Flexor digitorum superficialis
Splits into two slips (Camper
chiasm) to allow passage of
FDP tendon
Rotates 180 degrees to insert on
middle phalanx to flex the PIP
Flexor pollicis longus (FPL):
inserts on thumb distal phalanx to
flex interphalangeal (IP) joint
• Annular and cruciate pulleys
Five annular pulleys
Three cruciate pulleys
A2 pulley (proximal proximal
phalanx) and A4 pulley (middle of
middle phalanx) are the most
important to repair after injury to
prevent bowstringing
• Lumbricals
Intrinsic muscle originates from
radial aspect of tendon and inserts
on lateral bands of the extensor
Function: metacarpophalangeal
(MCP) flexion, PIP extension
• Anatomical snuffbox
Volar border: first dorsal
compartment (abductor pollicis
longus/extensor pollicis brevis
Dorsal border: third dorsal
compartment (extensor pollicis
longus [EPL])
• Vincula: vascular supply to flexor
• Total active range of motion (TAM)
Sum of TAM of MCP, PIP, and DIP,
minus extensor lag
Table 45.1 Extensor tendon compartments
Compartment Extensor tendons

Abductor pollicis
1 (APL)/extensor
pollicis brevis

Extensor carpi
radialis brevis
2 (ECRB)/extensor
carpi radialis longus

Extensor pollicis
3 longus (EPL): lifts
thumb off tabletop

Extensor digitorum
4 (EDC)/extensor
indicis proprius

Extensor digitorum
minimi (EDM)

Extensor carpi
ulnaris (ECU)

Normal TAM: MCP 90 degrees +

PIP 110 degrees, + DIP 70 degrees
= 270 degrees

Flexor Tendon Injury

• Flexor tendon injury exam (Table
45.2; Fig. 45.1)
Loss of normal digital cascade:
injured finger rests in extended
Table 45.2 Flexor tendon injury zones

Zone Description

Distal to FDS
insertion, FDP only

No man's land, from

proximal aspect of
A-1 pulley to FDS
II insertion, most
difficult zone of
injury to repair,
worst outcomes
Distal aspect of
III transverse carpal
ligament (TCL) to
proximal aspect of
A-1 pulley

IV Under TCL

Proximal to TCL,
although good
outcomes are
possible, it is
V difficult to gain
independent tendon
gliding because
adhesions are
Fig. 45.1 Flexor tendon injury zones.

FDP injury
Patient unable to flex DIP joint
while examiner holds middle
phalanx to block FDS
contribution to PIP flexion
FDS injury
Patient unable to flex PIP joint
without simultaneous DIP
Examiner isolates FDS by
holding uninjured fingers in
extension and blocking FDP
• Repair
Single-stage repair
Direct repair
Tendon graft
Release pulley or debride cut
edges of flexor tendon if
triggering from cut edges
catching on pulley
Staged reconstruction
Required with insufficient
quantity of flexor tendon sheath
First-stage: silicone forms a new
tendon sheath and pulley
Delayed tendon graft
Palmaris longus (PL) tendon
Toe extensors or flexors
Plantaris tendon graft
Incision anterior to medial
margin of Achilles tendon
Oblique course between
soleus and gastrocnemius
Third stage often used to
improve motion with tenolysis
• Rehabilitation
Dorsal extension blocking splint
Best outcomes are from early
active range of motion without
resistance to prevent adhesions for
patients with four-strand repair
and who are compliant and under
supervision of a certified hand
therapist (level I evidence)
Passive protocol for those who are
noncompliant or who have two-
strand repair
Rupture after tendon injury repair:
immediate return to the operating
room for direct repair
Arthrodesis: last resort if flexor
tendon injury cannot be repaired or

Extensor Tendon Injury

(Table 45.3; Fig. 45.2)
• Extensor tendon injury exam
May have slight flexed posture of
digit distal to laceration
May be able to extend distal to
injury due to interconnection
through juncturae tendinum
• Repair
Direct suture repair of injured
extensor tendon if > 60% cross
section extensor tendon ruptured
Table 45.3 Extensor tendon injury zones

Description (odd
numbers over
Zone joints and even
numbers over

DIP, terminal
extensor tendon
I insertion on base of
distal phalanx,
mallet injury

Middle phalanx
(P2), lateral bands
PIP, central slip
insertion on base of
P2, can result in

IV Proximal phalanx

V MCP, fight bite

VI Dorsum of hand

Wrist, extensor

VIII Distal forearm

Proximal forearm,
junction, difficult to
Fig. 45.2 Extensor tendon injury zones.

• Complications
Swan neck deformity: see Chapter
43, Fractures and Dislocations,
and Chapter 49, Rheumatology, for
more information
Boutonniere deformity: see
Chapter 49, Rheumatology, for
more information

• Trigger finger
Stenosis of A1 pulley resulting in
pain, triggering, or locking of digit
with PIP joint flexion in fingers
Tender palpable nodule at level of
A1 pulley
Conservative management
Splinting in extension
Steroid injection
A1 pulley release indications
Failed conservative treatment
Recurrence or incomplete
resolution after steroid
Digit locked in flexion
• De Quervain disease
Tenosynovitis of first dorsal
Tenderness to palpation of first
dorsal compartment
Positive Finkelstein maneuver:
clasped thumb ulnarly deviated
causes pain
Conservative management
Nonsteroidal anti-
inflammatory drugs (NSAIDs)
Steroid injections
Surgical management
Release of first dorsal
Decompression of
subcompartment for EPB
APL will have multiple slips
Avoid injury to dorsal sensory
branch of radial nerve
• Intersection syndrome
Tenosynovitis of second dorsal
Inflammation due to tendon friction
at intersection between first and
second dorsal compartments 4 cm
proximal to wrist
Diagnosis: crepitus and tenderness
Conservative management: rest,
NSAIDs, extension splint,
steroid injections
Surgical: second compartment
release and synovectomy at
intersection point
• Wartenberg syndrome (cheiralgia
Dorsal sensory branch of radial
nerve entrapped between
brachioradialis and extensor carpi
radialis longus
Associated with jewelry and wrist
Diagnosis: pain, numbness,
positive Tinel sign, aggravated
with pronation
Treatment: conservative
management or surgical release
Do not confuse with Wartenberg
sign: ulnar nerve injury leads to
extensor digiti minimi (EDM)
abduction of small finger
secondary to paralysis and lack of
adduction by third palmar
• Contractures can be due to intrinsic
joint problems or extrinsic causes
Contracture or loss of motion is
due to problem outside the joint
(i.e., tendon adhesions,
Dupuytren disease)
Tendon adhesions
Passive motion is better than
active motion
Treatment: tenolysis; surgically
excise adhesions if stiffness
persists following adequate
therapy program and soft
tissues are supple
Passive range of motion is equal
to active range of motion
Treatment: joint release
• Ischemic forearm contracture
Injury to forearm soft tissue leads
to poor joint range of motion
Deepest forearm structures
affected most
FDP, FPL, and median nerve
are deep and most affected
FDS, flexor carpi ulnaris
(FCU), and flexor carpi
radialis (FCR) are more
superficial and less affected
Holden classification
Holden I
Arterial ischemia proximal to
forearm (i.e.,
thromboembolism to upper
Holden II
Direct trauma to forearm
Tsuge classification (based on
extent of muscle involvement)
Initial management: Botox
injections (Allergan, Irvine,
CA), splinting, physical therapy
Holden I or II mild: tendon
Holden I moderate: muscle slide
Holden II moderate: tendon
Holden I or II severe: innervated
free muscle transfer (i.e.,
• Volkmann contracture
Ischemic contracture of forearm
Most common cause:
supracondylar fracture
Most common finding: forearm
flexor fibrosis
Contracture prevention:
compartment release if pressure >
30 mm Hg for > 4 to 6 hours
• PIP contracture (flexion) management
Initial treatment is nonoperative,
with therapy directed at
contracture reversal
Dynamic extension splinting
Serial casting
If contracture remains, can
consider surgical options, but
maintenance of correction can be
Surgical release involves
sequential release of affected
structures until full extension
Release checkrein ligaments
(proximal extension of volar plate)
Collateral ligament release: true
collateral ligament followed by
accessory collateral ligaments
Release oblique retinacular
ligament of Landsmeer (courses
volar to PIP and dorsal to DIP) if
PIP contracture after checkrein
ligament release (conceptual, but
true identification of this structure
and surgical release is not done
Soft tissue coverage of resultant
defect is possible, but rarely
required after release: full
thickness skin graft or cross finger

Tendon Transfers
• Indications
Reconstruction after nerve injury
when repair, grafting and nerve
transfers are not an option
Tendon ruptures: rheumatoid
arthritis, and EPL rupture
following distal radius fracture
Restores motor function only
• Requirements
Joints must be supple with good
passive motion
Adequate muscle strength (a
transferred muscle will lose one
grade of strength)
Adequate excursion (3, 5, 7 rule:
tendons attaching at wrist have 3
cm excursion, digital extensors
have 5 cm excursion, and FDS
tendons have 7 cm excursion)
Must have expendable donor (must
preserve one wrist/digital flexor,
Straight line of pull
Good soft-tissue coverage:
minimal scar and supple tissues
One tendon should restore one
Synergistic transfers easier to
Tenodesis can be used to augment
motion when donor tendon has less
excursion than recipient tendon
• Classification of nerve injuries
Proximal to mid forearm
Reconstruction at this level will
use same procedures as for low
nerve palsy, plus reconstruction
for the proximal deficit
Distal to mid forearm
After innervation of extrinsic
flexors and wrist extensors
• High radial nerve palsy
Goal is to restore wrist, finger, and
thumb extension
Wrist extension: pronator teres
(PT) to ECRB
Finger extension: FCR or FCU or
Thumb extension: PL to EPL
• EPL laceration late reconstruction
• Low median nerve palsy
Goal: restore thumb opposition
PL to abductor pollicis brevis
Adductor digiti minimi (ADM)
to APB (for congenital thumb
• High median nerve palsy
Goal: restore thumb, index, and
middle flexion and thumb
Side-to-side transfer of FDP index
and middle to ring and small
Brachioradialis to FPL
Opponensplasty as described
• Low ulnar nerve palsy
Goal: restore pinch, MP flexion,
small-finger adduction
Treat claw-hand deformity
Dynamic transfers: allow active
MP flexion
Split FDS to ring and small
finger into radial lateral band of
intrinsics to flex MCP and
extend PIP
Split ECRL with graft to radial
lateral bands to prevent MP
Static transfers: block MP
Loop FDS around SF and RF A1
pulleys and suture back onto
Power pinch transfers to adductor
pollicis (AP) and first dorsal
ECRB with tendon graft to AP
and first dorsal interosseous
FDS4 to AP
• High ulnar nerve palsy
Must have function of extrinsic
flexors to develop a claw
Claw hand not present, because no
imbalance between intrinsic and
extrinsic muscles
Power pinch transfers to AP (see
FDP2 and 3 side-to-side to FDP4
and 5
• Combined low ulnar and median
nerve palsy
ECRB and tendon graft to FDP 1 to
Static transfers of MCP
hyperextension occurs
• Quadriplegia
C5 tetraplegia
Loss of elbow extension
Reconstructive goal: wheelchair
Deltoid-to-triceps tendon
Biceps-to-triceps tendon transfer
Low-level tetraplegia
Loss of finger flexion and
Reconstructive goal: key pinch
• Cerebral palsy
Spasticity of flexors overpowers
extensors and can result in
pronation contracture of forearm,
flexion contracture of wrist, and
adduction contracture of thumb
into palm
Initial treatment is splinting and
Goal of tendon transfers are to
improve supination and wrist,
finger extension
Fractional lengthening effective on
flexor side, particularly when
passive wrist extension past
neutral and limited active
• Stroke
Repair based on level of function
and use of hand, as well as IQ
If normal IQ: contracture release
for function
If low IQ: contracture release for
Tendon transfer: FDS to FDP to
lengthen and allow finger
extension (this will substantially
weaken the hand and typically is
only used in nonfunctional hands
following stroke)

Suggested Reading
Bates SJ, Chang J. Repair of the
extensor tendon system. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Beasley RW. Tendon transfers. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:847–855
Bidic SM, Schaub T. Hand: Extensor
Tendons, Dupuytren Disease, and
Rheumatoid Arthritis. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2009:1–60. Selected
Readings in Plastic Surgery; vol
10, issue 26
Cheng J, Ellison CR. Hand: Peripheral
Nerves and Tendon Transfers.
Dallas, TX: Selected Readings in
Plastic Surgery, Inc.; 2010:1–76.
Selected Readings in Plastic
Surgery; vol 10, issue 27
Lalonde DH. An evidence-based
approach to flexor tendon laceration
repair. Plast Reconstr Surg
Lalonde DH, Kozin S. Tendon disorders
of the hand. Plast Reconstr Surg
Lehfeldt M, Ray E, Sherman R. MOC-
PS (SM) CME article: treatment of
flexor tendon laceration. Plast
Reconstr Surg 2008;121(4,
Rockwell WB, Butler PN, Byrne BA.
Extensor tendon: anatomy, injury,
and reconstruction. Plast Reconstr
Surg 2000;106(7):1592–1603, quiz
1604, 1673
Soltanian H. Tenosynovitis. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Trumble TE. Extensor tendon injuries.
In: Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:263–278
Trumble TE. Tendon transfers. In:
Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:343–360
Trumble TE, Sailer SM. Flexor tendon
injuries. In: Trumble Principles of
Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
Zidel P. Tendon healing and flexor
tendon surgery. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:803–809
46 Hand Tumors
Reviewed by Andrew Chen

Hand Tumors
• Evaluation
History and physical exam
Radiological examination
Ultrasound: detects cystic
Magnetic resonance imaging
(MRI): defines soft tissue
tumors and vascular anomalies
X-ray and computed tomographic
(CT) scan: define the bony
tumors and calcified tumors in
the soft tissue
Incisional: via longitudinal
incision within definitive
• Operating room preparation
Do not exsanguinate with Esmarch
prior to placement of tourniquet (if
Can compress brachial artery,
elevate arm for 1 minute, then
apply tourniquet

Benign Soft Tissue Tumors

• Giant cell tumor
Most common benign soft tissue
hand tumor
Usually arise from flexor tendon
Treatment: excision
High recurrence rate: 5 to 50%
• Glomus tumor
Subungual tumor
Digital pulp less common
Symptoms: pain, sensitivity to
Blue-purple mass observed
Love sign: pain on direct contact
Hildreth sign: ablation of pain
with tourniquet
Ice bath immersion provocative
Treatment: excision
Recurrence: 6 to 32%
• Hemangiopericytoma
Benign tumor composed of
vascular Zimmermann pericytes
Diagnosis: biopsy
Treatment: wide local resection
Potential for malignant
• Pyogenic granuloma
Nodules that grow rapidly and
bleed easily
Occurs in young patients after
trauma or during pregnancy
Histology: inflammatory
granulation tissue
Treatment: excisional biopsy;
silver nitrate
• Keratoacanthoma
Benign round, smooth nodule
around a keratinous plug
Appears in sun-exposed skin and
immunosuppressed patients
Rapidly grows over weeks
Observe for potential spontaneous
regression over months
Excise in immunosuppressed
patients because can grow and
5.7% develop into small cell
carcinoma (SCC)
• Digital infantile fibromatosis
Rapidly growing broad nodule on
dorsal lateral finger
Occurs in children, usually < 1
year old
Intracytoplasmic inclusion
Interlacing fibroblasts
Wide excision
Skin grafting
Local flaps
• Schwannoma
Most common benign nerve
Location: nerve sheath
Painless proximal to wrist,
painful in fingers
Tinel positive
Marginal excision: easy to shell
Do not need biopsy
Recurrence rate: 4%
• Neurofibroma
Benign nerve sheath tumor
Grows from within the nerve itself:
not easy to shell out
May require nerve graft
See Chapter 10, Skin Lesions and
Soft Tissue Tumors, for additional
• Verruca vulgaris
Associated with human
papillomavirus infection (types 1
to 4, 7, 10)
Treatment: topical agents,

Malignant Soft Tissue

• Squamous cell carcinoma
Most common primary hand cancer
Excision with 1 cm margins
Mohs surgery if involves nail
Amputate distal phalanx if
involves bone
• Basal cell carcinoma
Slow growing, telangiectasias,
ulceration with pearly border
Excision with 4 mm margins
Mohs surgery if large (> 2 cm)
or morpheaform
• Kaposi sarcoma
Bluish-reddish macule or papule
Indolent 10 to 15 years
Predisposing factors
Human immunodeficiency virus
Human herpesvirus 8 (HHV-8)
Elderly males
Radiation therapy
• Malignant melanoma
Most deadly skin cancer
Acral lentiginous: on palms and
soles; most common melanoma in
skin of color
Subungual melanoma: arises in nail
Full thickness biopsy/excision to
evaluate depth
Wide local excision
Sentinal node biopsy if
intermediate or thick
Amputation one joint proximal to
closest joint in subungual
• Epithelioid sarcoma
Malignant tumor of mesenchymal
Occurs during third and fourth
decades of life
Diagnosis: biopsy
Neoadjuvant radiation therapy to
shrink tumor
Neoadjuvant chemotherapy if
tumor > 10 cm diameter,
involves lymph nodes, or
Wide local resection
• Synovial sarcoma
High grade malignant tumor of
mesenchymal origin
Arises in proximity to joints,
tendons, or bursae
Diagnosis: biopsy
X-rays: soft tissue calcifications in
20 to 30%
Wide local resection

Bone Tumors
• Enchondroma
Most common benign solitary
primary bone tumor
Occurs during second to fourth
decades of life
Most common location: proximal
Pathological fracture
X-ray: lucency
Histology: cartilaginous
Immobilize for fracture healing:
closed reduction, fixation
Surgery: open biopsy, curettage,
bone grafting
Recurrence rate: 10%
Follow-up: surveillance X-rays at
6 months, 1 year, and 2 years
• Enchondromatosis
Ollier disease: multiple
enchondromas under 10 years of
Maffucci syndrome: multiple
enchondromas and hemangiomas
Metachondromatosis: multiple
enchondromas and
• Giant cell tumor of bone
Rare in hand
Usually occurs in early fourth
decade of life
Locally aggressive: high rate of
recurrence; metastatic potential
X-ray: lytic lesion with no matrix
and indistinct borders
Treatment: wide local excision or
• Aneurysmal bone cyst
Rare in hand
Usually occurs in second decade of
Locally aggressive: high rate of
recurrence; no metastatic potential
X-ray: lytic lesion with thin rim of
surrounding bone
Treatment: curettage and
cryosurgery, or wide local
• Osteochondroma
Most common pediatric benign
bone tumor
Arises near growth plate
Composed of bony stalk and
cartilage cap
Observe if small
Excise if large and symptomatic
causing mass effect
Potential for malignant
• Osteoid osteoma
Benign tumor composed of
osteoblasts occurring in long
Occurs during third and fourth
decades of life
Symptoms: nocturnal pain
X-ray: < 1 cm diameter sclerotic
nidus with surrounding halo
Nonsteroidal anti-inflammatory
Curettage and bone grafting if
refractory to medications
• Osteosarcoma
Rare in hand
Usually occurs around the knee
during first and second decades of
Treatment: wide local excision and

• Ganglion
Most common hand mass
Occurs during second to fourth
decades of life
Transilluminates on exam
Scapholunate joint: most
Radiocarpal joint
Excision of cyst, stalk, and
osteophytes if present
Nonsurgical (steroid, aspiration,
rupture) have higher recurrence
• Mucous cyst
Nontender degenerative ganglion
cyst found in distal interphalangeal
Occurs during fifth and sixth
decades of life
X-ray detects degenerative joint
Treatment: excision if
symptomatic; remove any
associated osteophytes
• Epidermal inclusion cyst
Traumatic implantation of
epithelial cells into underlying
dermis or bone
Treatment: soft tissue excision or
curettage from bone
Suggested Reading
Angelides AC, Wallace PF. The dorsal
ganglion of the wrist: its
pathogenesis, gross and microscopic
anatomy, and surgical treatment. J
Hand Surg Am 1976;1(3):228–235
Archer IA, Brown RB, Fitton JM.
Epithelioid sarcoma in the hand. J
Hand Surg [Br] 1984;9(2):207–209
Athanasian EA. Bone and Soft Tissue
Tumors. In: Wolfe Green's
Operative Hand Surgery. 6th ed.
Elsevier; 2011: 2141–2195
Bednar MS, Weiland AJ, Light TR.
Osteoid osteoma of the upper
extremity. Hand Clin
Colon F, Upton J. Pediatric hand tumors.
A review of 349 cases. Hand Clin
Dodge LD, Brown RL, Niebauer JJ,
McCarroll HR Jr. The treatment of
mucous cysts: long-term follow-up
in sixty-two cases. J Hand Surg Am
Dolan M, Saint-Cyr M. Hand:
Fingernails, Infections, Tumors, and
Soft-Tissue Reconstruction. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2009:1–54. Selected
Readings in Plastic Surgery; vol
10, issue 25
Feldman F. Primary bone tumors of the
hand and carpus. Hand Clin
Gandon F, Legaillard P, Brueton R, Le
Viet D, Foucher G. Forty-eight
glomus tumours of the hand:
retrospective study and four-year
follow-up. Ann Chir Main Memb
Super 1992;11(5):401–405
Idler RS. Benign and malignant nerve
tumors. Hand Clin 1995;11(2):203–
Keith JE Jr, Wilgis EF. Kaposi's
sarcoma in the hand of an AIDS
patient. J Hand Surg Am
Mankin HJ. Principles of diagnosis and
management of tumors of the hand.
Hand Clin 1987;3(2):185–195
Noble J, Lamb DW. Enchondromata of
bones of the hand. A review of 40
cases. Hand 1974;6(3):275–284
Okada K, Wold LE, Beabout JW, Shives
TC. Osteosarcoma of the hand. A
clinicopathologic study of 12 cases.
Cancer 1993;72(3):719–725
Phalen GS, McCormack LJ, Gazale WJ.
Giant-cell tumor of tendon sheath
(benign synovioma) in the hand:
evaluation of 56 cases. Clin Orthop
Trumble TE. Ganglion, mucous cyst, and
carpal boss. In: Trumble Principles
of Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
Trumble TE, Berg D, Bruckner J, et al.
Benign and malignant neoplasms of
the upper extremity. In: Trumble
Principles of Hand Surgery and
Therapy. Philadelphia, PA:
Saunders; 2000:529–578
47 Hand Infections
Reviewed by Devra Becker

Flexor Tenosynovitis
• Description
Infection of the flexor tendon
• Kanavel's four signs
Fusiform swelling
Partially flexed posturing
Tenderness over flexor tendon
Pain with passive extension of
• Treatment
Intravenous (IV) antibiotics
Irrigation and drainage of flexor
digital sheath
Open drainage through Brunner
incision exposing A1 to A5
Closed irrigation through
separate counter incisions made
over A1 and A5 pulleys
If only one or two signs, do needle
aspiration to detect presence of

Fingertip Infections
• Paronychia
Nail fold infection
Infectious etiology
Acute disease: Staphylococcus
Chronic disease: Candida
Treatment: soaks, incision,
drainage, removal of nail,
antibiotics (antifungal if chronic),
marsupialize if abscess forms
If fails treatment (after several
weeks or months): biopsy, X-ray,
and rule out cancer
• Felon
Fingertip pulp infection
Treatment: incision, drainage,
• Herpetic whitlow
Etiology: herpes simplex virus
(HSV) infection
Vesicular lesions can be confused
with paronychia and felon
Diagnosis: Tzanck smear of
vesicular fluid reveals giant cells
Rest, elevation, dry dressing,
anti-inflammatory agents
Resolves within a few weeks
with conservative treatment (dry
Incision and drainage should be
avoided, because can cause
secondary bacterial
IV acyclovir if
Specific Pathogens
• Staphylococcus aureus
Gram-positive cocci
Most common pathogen for hand
infections, septic arthritis, and IV
drug abusers
Treatment: first-generation
• Neisseria gonorrhoeae
Gram-negative diplococci
Septic arthritis in young patients
with sexually transmitted diseases,
no history of trauma
Treatment: third-generation
• Bacillus anthracis
Cutaneous or inhalational spread
Results in ulcerative lesions
Treatment: penicillin,
ciprofloxacin, or doxycycline
• Pseudomonas aeruginosa
Most common gram-negative rod
found in diabetic wounds (diabetic
patients with renal failure have
high rates of amputation)
Ecthyma gangrenosum: cutaneous
infection in patients with P.
aeruginosa bacteremia
Rapid progression, fatal in patients
with febrile neutropenia,
complication of chemotherapy
Treatment: antipseudomonal
antibiotics (piperacillin,
gentamicin, ciprofloxacin, and
• Candida albicans
Causes chronic paronychia
Diagnosis: potassium hydroxide
(KOH) preparation
Treatment: see above
• Mycobacterium marinum
Most common mycobacterial hand
Lab tests
Ziehl–Neelsen stain: detects
acid-fast mycobacteria
Culture on Löwenstein–Jensen
agar plate at 30°C
Rice bodies: infected villous
bodies on synovial surface
break off and are trapped within
an inflammatory mass
• HIV needle stick
0.3% conversion risk
80% conversion risk reduction
with zidovudine (AZT)
prophylaxis 2 hours postinjury and
4 week therapy

• Cat and dog bites
Pathogens: Streptococcus,
Pasteurella multocida (gram-
negative facultative anaerobic
bacteria), and Staphylococcus
Augmentin (amoxicillin and
clavulanic acid)
Incision/drainage if abscess
If have penicillin allergy, need to
treat with broad spectrum
antibiotics that cover anaerobes
Cat bites
Seal in infection because cats
have long, thin teeth, compared
to dog bites, which lacerate and
All cat bites should be
considered for incision and
• Human (fight bite)
Tooth penetrates metacarpal skin,
tendon, joint capsule, and bone
Layers of injury separate when
extend hand from clenched fist
Pathogens: Staphylococcus aureus
(most common) and Eikenella
corrodens (gram-negative
anaerobic rod)
Treatment: wound exploration,
drainage, irrigation of joint space,
• Deer tick bite (Lyme disease)
Pathogen: bacterium Borrelia
Erythema chronicum migrans:
expanding rash resembling a
bull's eye
On differential for
monoarthropathy because can
spread to joints
Neurological and cardiac

Palmar Space Infections

• Collar button
Located between dorsal and volar
hand, fingers found in abducted
Treatment: incision and drainage
from dorsal and volar approaches,
• Horseshoe
Between ulnar bursa, Parona
space, and radial bursa
Involves flexor tendon sheaths of
small finger and thumb
• Parona space
Distal volar forearm between
pronator quadratus and flexor
digitorum profundus
Treatment: incision and drainage
via extended carpal tunnel release
• Thenar space
Between thumb metacarpal, index
metacarpal, and adductor pollicis
• Midpalmar space
Between long finger metacarpal,
small finger metacarpal,
interossei, and flexor tendons
• Posterior adductor space
Between adductor pollicis and first
dorsal interosseous

Necrotizing Soft Tissue

• Pathogens
Type 1
Anaerobic (i.e., Clostridium)
and facultative bacteria
Type 2
Single pathogen
Group A Streptococcus (most
• Initial presentation
Dishwater purulence: gray, watery
• Progresses to
Blisters and necrotic skin
Systemic disease: septic shock,
liver failure, kidney failure,
disseminated intravascular
• Labs
• Predisposing factors
Diabetes: most common
Systemic infection
• Treatment
Immediate debridement
IV antibiotics
Repeat debridement in 12 to 24

Hand Infection Mimickers

• Sweet syndrome
Skin lesion: acute febrile
neutrophilic dermatosis
Histology: epidermal and dermal
neutrophils without infection or
Treatment: steroid taper
(unresponsive to antibiotics)
• Crystalline arthropathy (gout and
Joints appear infected (swelling,
redness, tenderness)
No history of trauma
See Chapter 49, Rheumatology, for
additional information
• Amyloidosis
Can cause carpal tunnel syndrome
and tenosynovitis
Diagnosis: amyloid sampling

Suggested Reading
Chao JJ, Morrison BA. Infections of the
upper limb. In: Thorne CH, Beasley
RW, Aston SJ, et al, eds. Grabb and
Smith's Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:817–825
Headley AJ. Necrotizing soft tissue
infections: a primary care review.
Am Fam Physician 2003;68(2):323–
Kozin SH, Bishop AT. Atypical
Mycobacterium infections of the
upper extremity. J Hand Surg Am
Lavery LA, Walker SC, Harkless LB,
Felder-Johnson K. Infected puncture
wounds in diabetic and nondiabetic
adults. Diabetes Care
Monstrey SJ, van der Werken C, Kauer
JM, Goris RJ. Tendon sheath
infections of the hand. Neth J Surg
Ong YS, Levin LS. Hand infections.
Plast Reconstr Surg
Patzakis MJ, Wilkins J, Bassett RL.
Surgical findings in clenched-fist
injuries. Clin Orthop Relat Res
1987; (220):237–240
Trumble TE, Hashisaki P. Hand
infections. In: Trumble Principles
of Hand Surgery and Therapy.
Philadelphia, PA: Saunders;
Watt AJ, Shin AY, Vedder NB, Chang J.
Joint arthritis and soft-tissue
problems of the hand. Plast Reconstr
Surg 2010;126(6):288e–300e
48 Wrist
Reviewed by Anthony Perrone

Wrist Anatomy
• Carpal bones
Mnemonic: Scared lovers try
positions that they can't handle
• Wrist ligaments
Scapholunate interosseous ligament
Primary scaphoid-stabilizing
Injury results in dorsal
intercalated segment instability
(DISI) deformity
Lunotriquetral interosseous
Injury results in volar
intercalated segment instability
(VISI) deformity
Dorsal ligament complex
Primary thumb carpometacarpal
(CMC) stabilizing ligament
Dorsal intercarpal ligament:
between triquetrum and scaphoid
Volar beak ligament: between
thumb metacarpal and trapezium
Volar ligament of Testut:
neurovascular conduit between
radius, scaphoid, and lunate (not a
true extrinsic ligament)
Triangular fibrocartilage complex
Primary distal radioulnar joint
(DRUJ) stabilizer
TFCC injury
Pain on ulnar aspect of wrist
Arthrogram can document
TFCC tear
Distal radioulnar shuck test:
pain with movement of radius
and ulna in opposite directions
Treatment: debridement or

Scapholunate Advanced
Collapse (SLAC)
• Degenerative arthritis of the wrist
caused by
Scapholunate injury
Scaphoid nonunion advanced
collapse (SNAC) wrist
Kienböck disease: avascular
necrosis of the lunate
Rotary subluxation of scaphoid
Preiser disease: avascular necrosis
of the scaphoid
Crystalline arthritis
• Diagnosis
Scaphoid (Watson) shift test
Apply pressure over the
scaphoid tubercle as wrist
deviates from ulnar to radial
Palpable “clunk,” pain, and
laxity preventing vertical
repositioning of the scaphoid
If scapholunate ligament intact,
the scaphoid will reposition
Tenderness distal to the Lister
Diastasis > 2 mm of
scapholunate joint (Terry
Thomas sign)
Scaphoid ring sign due to palmar
rotation of the distal scaphoid
Capitate proximal migration
between scaphoid and lunate
• Four stages of SLAC wrist arthrosis
Stage 1: arthritis between the
radial styloid and the distal
scaphoid (radoscaphoid)
Stage 2: radial midcarpal
Stage 3: ulnar midcarpal
Stage 4: diffuse carpal arthritis
involving the entire wrist
• Treatment
Acute scapholunate ligament tear
(within 3 months)
Dorsal approach
Reduce carpal collapse with
Kirschner wires
Repair scapholunate ligament
directly or with suture anchors
Flexor carpi radialis tendon or
AlloDerm (LifeCell Corp.,
Bridgewater, NJ) reconstruction
Chronic injury
Proximal row carpectomy (PRC)
Effective if disease limited to
radioscaphoid joint
Resurface capitate if diseased
Less range of motion compared
with PRC
Scaphoid excision and four-
corner arthrodesis
Arthrodesis between lunate,
capitate, hamate, and
Radioscapholunate arthrodesis
Effective for disease limited
to radioscaphoid disease
Complete wrist fusion

DISI and VISI Deformities

(Fig. 48.1)
• DISI deformity
Results from scapholunate
interosseous ligament injury
Fig. 48.1 Normal, dorsal intercalated segment
instability (DISI), and volar intercalated
segment instability (VISI) scapholunate angles.

Scaphoid (Watson) shift test

Radiolunate angle is 0
Scapholunate angle is 45
degrees (range: 30 to 60
Lunate tilted with the cup
facing dorsally (remember:
dorsal, DISI)
Increased radiolunate angle
(> 15 degrees of extension)
Increased scapholunate angle
(> 60 degrees)
• VISI deformity
Results from lunotriquetral
interosseous ligament injury
Lunate tilted with the cup
facing volarly (remember:
volar, VISI)
Increased radioluante angle (>
15 degrees of flexion)
Decreased scapholunate angle
(< 30 degrees)

Basal Joint Arthritis

• Joints affected
Thumb CMC joint: most common
• Diagnosis
Attrition of volar oblique ligament
(beak ligament)
Loss of thumb abduction
Osteophyte migration between first
and second metacarpal
Subluxation of first metacarpal on
CMC grind test: axial compression
and rotation of thumb metacarpal
against trapezium causes pain and
X-rays: anteroposterior, oblique,
lateral, and Robert views
• Treatment
Nonsteroidal anti-inflammatory
drugs (NSAIDs)
Trapeziometacarpal arthrodesis
For young manual laborer
Provides strong grip and pinch
Less range of motion compared
with arthroplasty
Ligament reconstruction tendon
interposition (LRTI)
Volar beak ligament
reconstruction and tendon
interposition with palmaris
longus, flexor carpi radialis,
or abductor pollicis longus
Trapeziectomy (hematoma
Polyurethane urea (Artelon)
implant joint reconstruction
Degradable and more
biocompatible than silicone
Silicone implant joint
• Displacement
• Synovitis
• Giant cell reaction

Scaphoid Fracture
• Scaphoid fracture (Fig. 48.2)
Most common carpal bone
Triquetrum is second most common
carpal bone fractured
Scaphoid fracture locations
Tubercle (distal)
Proximal pole: avascular
necrosis results from interrupted
retrograde blood flow
Fig. 48.2 Scaphoid tubercle, waist, and
proximal pole fractures.

• Diagnosis
Pain in anatomical snuffbox
Plain X-rays and computed
tomographic scan
Magnetic resonance imaging scan
can be positive for avascular
necrosis of proximal pole within
24 hours of injury
Reevaluate in 1 to 2 weeks if
initial X-rays are negative
• Treatment
Nondisplaced fracture
Cast immobilization 6 to 12
Long arm thumb spica cast for 4
to 6 weeks, followed by short
arm thumb spica cast until union
is radiologically confirmed
Displaced fracture
Open reduction internal fixation
Compression screw fixation
3 to 6 weeks of cast
Vascularized bone graft: 1,2
supraretinacular artery (1,2
ICSRA) and 2,3 ICSRA graft

Perilunate Instability
• Mayfield progressive perilunate
instability classification
Describes progression of
perilunate ligamentous injury
Stage I: scapholunate separation
Stage II: capitolunate separation
Stage III: lunotriquetral separation
Stage IV: perilunate dislocation
• Diagnosis
Radiographs show disruption of
Gilula's lines, bone fractures, and
carpal gapping
Greater arc injury: involves
fractures of radial styloid,
scaphoid (most common bone
fractured), capitate, triquetrum,
and/or ulna styloid
Lesser arc injury: involves
ligamentous injury of
scapholunate, lunocapitate, and/or
lunotriquetral joints
• Treatment
Repair ligaments
Open reduction and internal

Suggested Reading
Desai HJ, Bidic SM. Hand: Fractures
and Dislocations, the Wrist, and
Congenital Anomalies. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2011:1–68. Selected
Readings in Plastic Surgery; vol
10, issue 29
Mayfield JK, Johnson RP, Kilcoyne RK.
Carpal dislocations:
pathomechanics and progressive
perilunar instability. J Hand Surg
Am 1980;5(3):226–241
Mullett H, Hausman M. Fractures and
ligamentous injuries of the wrist. In:
Thorne CH, Beasley RW, Aston SJ,
et al, eds. Grabb and Smith's
Plastic Surgery. 6th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:781–789
Nilsson A, Liljensten E, Bergström C,
Sollerman C. Results from a
degradable TMC joint Spacer
(Artelon) compared with tendon
arthroplasty. J Hand Surg Am
Sammer DM, Shin AY. Wrist surgery:
management of chronic scapholunate
and lunotriquetral ligament injuries.
Plast Reconstr Surg
Tomaino MM, Pellegrini VD Jr, Burton
RI. Arthroplasty of the basal joint of
the thumb. Long-term follow-up
after ligament reconstruction with
tendon interposition. J Bone Joint
Surg Am 1995;77(3):346–355
Trumble TE. Fractures and dislocation
of the carpus. In: Trumble
Principles of Hand Surgery and
Therapy. Philadelphia, PA:
Saunders; 2000:90–125
Trumble TE, Rafijah G, Gilbert M,
Allan CH, North E, McCallister
WV. Thumb trapeziometacarpal joint
arthritis: partial trapeziectomy with
ligament reconstruction and
interposition costochondral
allograft. J Hand Surg Am
Trumble T, Verheyden J. Treatment of
isolated perilunate and lunate
dislocations with combined dorsal
and volar approach and intraosseous
cerclage wire. J Hand Surg Am
Watson HK, Ballet FL. The SLAC wrist:
scapholunate advanced collapse
pattern of degenerative arthritis. J
Hand Surg Am 1984;9(3):358–365
49 Rheumatology
Reviewed by Jennifer F. Waljee

Rheumatoid Arthritis
• Patient demographics
1% population
Female to male ratio is 3:1
Onset 25 to 50 years old
• Rheumatoid arthritis diagnostic
criteria (Table 49.1)
• Arthritis Impact Measurement Scale:
documents baseline disease
• Exam
Cervical spine involvement (in 25
to 30% of patients)
Swan neck deformity: see below
Boutonniere deformity: see below
Metacarpal bones angle radially
Ulnar drift and subluxation of MCP
• Labwork
Anemia (in 80% of patients)
Elevated erythrocyte sedimentation
rate (in 90% of patients)
Joint fluid aspiration to prove no
infection or crystals
Table 49.1 Rheumatoid arthritis diagnostic

Need 4 of 7 criteria to establish

1. Morning stiffness > 1 hour for > 6

2. 3 or more joints affected

3. Wrist, metacarpophalangeal (MCP)

joints, or proximal interphalangeal (PIP)
joints affected for > 6 weeks

4. Bilateral joint involvement

5. Serum rheumatoid factor (RF) elevation

(in 70% of patients)

6. Rheumatoid nodules present

7. Radiographic evidence

Serum rheumatoid factor elevation

Rheumatoid factor is an
immunoglobulin M (IgM)
autoantibody directed against
IgG antibody
Deposition of antibody–antigen
complexes cause pathology
Also elevated systemic lupus
erythematosus and scleroderma
• Radiography
Bony erosions
• Conservative early treatment
Disease-modifying antirheumatic
drugs (DMARDs)
Nonbiologics (i.e., methotrexate)
Biologics (i.e., infliximab)
Early initiation of these agents is
considered standard of care,
most patients who see surgeons
will be on these medications
• Perioperative management
Collaborate with rheumatologist to
manage immunosuppressive
medications in the perioperative
Stop biologics according to
length of time of their half life
Potential need for stress dose
Communicate with anesthesiologist
regarding airway management
because these patients may have
cervical spine disease (check c-
spine X-ray)
• Surgical treatment for progression of
Procedures should be driven by
patient symptomatology and
request, the presence of deformity
alone is not an indication for
operation (i.e., can manage
nonoperatively if patient is not
having pain and not bothered by
Treat proximal before distal joints
May require management of the
soft tissues (synovectomy, tendon
rebalancing, tendon repair)
Elbow arthroplasty (synovectomy
can play a role in some patients in
early stages of disease)
Wrist arthrodesis
MCP arthroplasty
• Extensor digitorum communis (EDC)
ulnar sublimation
Treatment: tendon rebalancing
(centralize extensor tendons at the
level of the MCP joint)
• Intrinsic tightness
Caused by intrinsic rheumatoid
Results in: swan neck deformity,
MCP flexion, PIP extension
Treatment: intrinsic release
• Swan neck deformity
Description: PIP extension, distal
interphalangeal (DIP) joint flexion
Loss of function is variable
Need to distinguish flexible from
fixed deformities
Terminal tendon rupture (mallet
PIP volar plate laxity
Intrinsic tightness (decreased PIP
flexion with MCP in
Lateral bands displaced dorsally
at PIP
Address any MCP deformity first
before undertaking
reconstruction of swan neck
If mallet: fix mallet, splint DIP,
allow PIP to be free
If PIP volar plate laxity: flexor
digitorum superficialis (FDS)
slip transferred to volar plate to
pull the PIP from extension to
If intrinsic tightness: intrinsic
Oblique retinacular ligament
(ORL) reconstruction (not
commonly done)
Lateral band mobilization if
flexible deformity
Arthroplasty or DIP fusion for
more advanced disease
• Boutonniere deformity
Description: PIP flexion, DIP
extension, MCP hyperextension
Most patients do not have
functional difficulties until late
Central tendon rupture due to
synovial proliferation
Lateral bands displace volarly at
ORL shortens
Determine if fixed or flexible
As with swan neck deformity,
ensure there is no proximal
deformity at level of MCP or
wrist to correct first
Dynamic splinting: PIP in
extension and leave DIP free
Centralize lateral bands
Extensor tenotomy at the DIP
Silicone arthroplasty
PIP fusion (last resort)
• Rheumatoid arthritis and trigger
Steroid injection: first-line
Tenosynovectomy and resection
of slip of superficialis tendon
Excision of flexor tendon nodule
Release of A1 pulley:
controversial because some
surgeons believe that ulnar drift
may worsen
• Flexor tendon adhesions
PIP and DIP joint passive motion
better than active motion
Treatment: tenolysis
• Extensor tendon rupture
Secondary to inflammatory
weakening or attrition from
underlying bony irregularity
Caput ulnae syndrome: ulna is
dorsal to carpal bones, leading to
erosions and risk for extensor
tendon rupture over prominent ulna
Vaughan–Jackson progression:
extensors rupture over damaged
distal radius ulna joint starting on
the ulnar side (extensor digiti
minimi) and progressing radially
(EDC to small finger, ring finger,
then long finger)
Loss of tenodesis effect where
normally flexion wrist allows
extension of MCP if tendon intact
Most common tendons ruptured
EDC: most common
Extensor pollicis longus and
extensor digiti minimi
Flexor pollicis longus rarely
ruptured by scaphoid spur
(Mannerfelt lesion)
Repair needs to include
tenosynovectomy, and must
smooth over bony irregularities
if possible (ulnar head
resection, relocate the
Repair directly: if tendon ends
are close together (uncommon to
be able to do this)
Tendon graft: if tendon ends are
far apart and muscle is not
Tendon transfer: if muscle
Transfer extensor indicis
proprius to small single small
or index finger
Can also recruit a slip of FDS
through the interosseous if
Darrach procedure: distal ulna
resection to eliminate
prominence eroding tendons
• Differential diagnosis for inability to
extend fingers
Extensor tendon rupture
MCP dislocation
Posterior interosseous nerve
Weak finger extension
Due to elbow joint swelling and
compression of arcade of Fröhse
Treatment: steroid injection,
surgical decompression

Additional Inflammatory
Arthritis Conditions
• Juvenile rheumatoid arthritis
Loss of wrist extension
Ulnar angulation of metacarpal
bones, and radial deviation of
MCP joint (opposite in rheumatoid
Loss of flexion at interphalangeal
Swan neck and boutonniere
deformities rare
Tendon rupture rare
Order of repair: surgically correct
deformities from proximal (elbow)
to distal (fingers)
• Gout
Uric acid joint fluid and serum
Podagra: big toe pain
Crystals have negative
birefringence on slit lamp
Medical treatment: colchicine,
allopurinol, nonsteroidal anti-
inflammatory drugs (NSAIDs),
May require joint aspiration to
discern from other pathologies
• Pseudogout (chondrocalcinosis)
Calcium pyrophosphate crystals
present in joint fluid
Crystals have positive
birefringence on slit lamp
• Septic arthritis
Painful joint infection caused by
bacterial, viral, or fungal
Staphylococcus aureus is most
common cause
Leukocytosis and pathogens
present in joint fluid
Can begin with broad spectrum
antibiotics, elevation, splinting
May require operative washout
if fails to improve
Consider arthroscopic washout if
occurs in the wrist
• Psoriatic arthritis
Psoriatic skin lesions, arthritis,
nail pitting
Can present with dactylitis
Can progress to significant erosive
arthritis and joint loss
Pencil-in-cup appearance of joint
Opera glass hand
Most common deformity in the DIP
• Reiter arthritis
Triad: reactive arthritis,
conjunctivitis, uveitis
Precipitated by infection
• Human immunodeficiency virus
(HIV) infection–related arthritis
Explosive onset
May lead to psoriatic arthritis or
reactive arthritis
• Scleroderma
See Chapter 42, Dupuytren and
Vascular Disease, for more
information on scleroderma
• Systemic lupus erythematosus (SLE)
Autoimmune disorder
Soft tissue laxity only without bony
erosions (unless there is
concomitant osteoarthritis)
Also present with findings similar
to rheumatoid arthritis, including
MP subluxation, swan neck
deformity but without bony
May have concomitant Raynaud
phenomena (see Chapter 42,
Dupuytren and Vascular Disease,
for more information on Raynaud
Associated with malar rash,
arthritis, kidney, and pulmonary
• Palmar fasciitis and polyarthritis
syndrome (PFPAS)
Associated palmar fibromatosis,
arthritis, and neoplasm
Computed tomographic scan
abdomen: evaluate for ovarian
cancer in women with palmar
fibromatosis and arthritis

• Description
Idiopathic or traumatic arthritis
Causes pain and stiffness
Most common joints affected: DIP
joint followed by carpometacarpal
(CMC) joint
Women > men (particularly in the
CMC joint, likely mediated by
postmenopausal hormonal
Fifth decade
• Presentation
Morning stiffness < 1 hour
Worsens with activity
Heberden nodules: DIP joint
osteophytes (can present with
mucoid cysts and nail plate
Bouchard nodules: PIP joint
Basal joint arthritis: for additional
information see Chapter 48, Wrist
Radiographic evidence of
osteophytes and sclerotic changes
• Treatment
Nonsurgical management
NSAIDs (topical or oral)
Physical therapy
Steroid injections
CMC joint hyaluronic acid
Activity modification
Surgical options
DIP joint: mucoid cyst excision,
DIP fusion (K wires,
interosseous wires, headless
compression screw)
PIP joint arthroplasty:
pyrocarbon vs. silicone; fusion
last resort
MCP joint arthroplasty:
pyrocarbon vs. silicone (much
less common); fusion last resort
CMC: trapeziectomy with or
without interposition
arthroplasty and resuspension of
the joint (associated variations
with abductor pollicis longus,
flexor pollicis longus); implant-
based reconstruction more

Suggested Reading
Bidic SM, Schaub T. Hand: Extensor
Tendons, Dupuytren Disease, and
Rheumatoid Arthritis. Dallas, TX:
Selected Readings in Plastic
Surgery, Inc.; 2009:1–60. Selected
Readings in Plastic Surgery; vol
10, issue 26
Cook GS, Lalonde DH. MOC-PSSM
CME article: Management of thumb
carpometacarpal joint arthritis. Plast
Reconstr Surg 2008;121(1,
Haase SC, Chung KC. An evidence-
based approach to treating thumb
carpometacarpal joint arthritis. Plast
Reconstr Surg 2011;127(2):918–
Isani A. Upper limb arthritis. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Krause ML, Matteson EL. Perioperative
management of the patient with
rheumatoid arthritis. World J.
Orthop. 5(3): 283–291, 2014
Qureshi AA, Saavedra A. Palmar
fasciitis and polyarthritis syndrome
in patients with ovarian cancer-a
case report and review of the
literature. Hand (NY)
Trumble TE, Gardner GC. Arthritis. In:
Trumble Principles of Hand
Surgery and Therapy. Philadelphia,
PA: Saunders; 2000:401–435
Watt AJ, Shin AY, Vedder NB, Chang J.
Joint arthritis and soft-tissue
problems of the hand. Plast Reconstr
Surg 2010;126(6):288e–300e
Wolf JM, Scher DL, Etchill EW, et al.
Relationship of relaxin hormone and
thumb carpometacarpal joint
arthritis. Clin. Orthop. Relat. Res.
472(4): 1130–1137, 2014
50 Lower Extremity
Reviewed by Hani Sbitany

Lower Extremity Nerves

• Tibial nerve
Branch of sciatic nerve, passes
through popliteal fossa, branches
to gastrocnemius, soleus, tibialis
posterior, and flexor digitorum
longus muscles, branches to the
sural and plantar nerves
Deficit: loss of plantar flexion,
absent plantar foot sensation
• Sural nerve
Located 1 cm posterior to lateral
malleolus in subcutaneous tissue
Composed of tibial nerve (medial
sural branch) and peroneal nerve
(lateral sural branch)
Supplies sensation to lateral foot
and ankle
Ideal nerve graft up to 30 cm long
and 3.6 mm wide
• Plantar nerves: branches of tibial
Medial plantar nerve: provides
sensation to medial sole; supplies
flexor digitorum brevis (flexes
proximal and middle phalanges
toes), flexor hallucis brevis, and
Lateral plantar nerve: provides
sensation to lateral plantar aspect;
supplies flexor digiti minimi
brevis, interossei, lumbricals, and
quadratus plantae (flexes lateral
four toes through flexor digitorum
longus, which is innervated by
tibial nerve and not involved in
tarsal tunnel)
• Tarsal tunnel syndrome
Nerve compression: medial and
lateral plantar nerves
Symptoms: tingling, numbness of
plantar toes and feet, worse with
• Deep peroneal nerve
Arises from: common peroneal
Supplies anterior leg compartment:
tibialis anterior, extensor hallucis
longus, extensor digitorum longus
and brevis, peroneus tertius
Supplies sensation: to the first web
Deficit: weakness of dorsiflexion
(foot drop)
• Superficial peroneal nerve
Arises from: common peroneal
Supplies lateral leg compartment:
peroneus longus and brevis
Supplies sensation: to the lateral
Deficit: weakness eversion, plantar
flexion, and decreased sensation of
lateral leg and middle of dorsum
of foot
• Peroneal nerve palsy
Secondary to: distal femur and
proximal tibia fracture
Symptoms: decreased sensation
and dorsiflexion
Diagnosis: nerve conduction
Treatment: nerve decompression,
nerve repair, or tendon transfer
• Thigh nerves
Obturator nerve: supplies medial
thigh adductors (adductor brevis,
longus, and magnus, gracilis, and
obturator externis), and sensation
to the medial thigh
Femoral nerve: supplies anterior
thigh muscles, iliacus, sartorius
Preoperative Workup
• Clinical exam
Palpable pulses: dorsalis pedis (on
dorsal foot) and posterior tibialis
(between medial malleolus and
Achilles tendon)
Handheld Doppler: if pulses not
Ankle brachial index (ABI): assess
for peripheral vascular disease
(PVD), < 0.5 to 0.6 needs
Toe brachial index: assess for PVD
in patients with diabetes,
atherosclerosis with calcified or
noncompressible vessels; < 30 mm
Hg needs revascularization
• Angiography or computed
tomographic angiography (CTA)
If renal problems, can perform
duplex ultrasonography
Peroneus magnus: anatomic single
vessel supplying distal lower
extremity; check vascularity of leg
with angiography or CTA to avoid
inducing ischemia with removal of
dominant peroneal artery
(peroneus magnus)
• Revascularization options
Bypass graft

Proximal Third
• Gastrocnemius flap
Muscle flap: type 1
Pedicle: sural artery (medial and
lateral branches supply medial and
lateral muscle heads, respectively)
off the popliteal artery, in the
popliteal fossa
Medial muscle head: longer than
lateral head, for extended flap
divide origin from the medial
condyle of femur
Lateral muscle head: beware of
common peroneal nerve, which
crosses superficial to origin
• Do not use: thigh muscle flaps
because their proximally based
pedicles do not rotate distally

Middle Third
• Soleus flap
Muscle flap: type II
Dominant pedicles: multiple
perforators from popliteal artery,
posterior tibial artery, and
peroneal artery
Minor pedicle: posterior tibial
artery, can base reverse soleus off
these perforators

Lower Third Reconstruction

• Reconstructive options
Free flap
Local fasciocutaneous flap
• Reverse sural artery fasciocutaneous
Type A: based on peroneal artery
Largest perforator and pivot point
is 5 cm proximal to lateral
Use a 2 cm wide base
Thin, easier than free flap
Most common complication:
partial flap necrosis, likely due to
venous congestion
• Dorsalis pedis fasciocutaneous flap
Type B septocutaneous flap: based
on dorsalis pedis artery
Donor site morbidity: leave
paratenon on donor site to skin
• Lateral calcaneal fasciocutaneous
Type B septocutaneous flap: based
on peroneal artery
Coverage: lateral lower extremity
• Radial forearm free flap: thin and
pliable with long pedicle
• Do not use
Tissue expansion (high
infection/extrusion rate)
Large bulky free flaps: rectus
abdominis, latissimus dorsi
Local flaps for athletes: use free
flap instead to preserve lower
extremity function
Foot Reconstruction
• Medial plantar flap
Sensate flap for plantar weight
bearing portion of calcaneus
Supplied by medial plantar artery
and nerve
• Abductor hallucis brevis: for small
medial malleolus and heel flaps
• Radial forearm free flap
Sensate free flap for plantar
Supplied by radial artery and
medial or lateral antebrachial
cutaneous nerves
Trauma Reconstruction
• Open tibial fractures (Table 50.1)
Low-energy injury: due to falls,
collisions from ice skating
High-energy injury: due to gunshot
wounds, crush injuries, motor
vehicle crashes
Infection risk: farm injury (most
common cause of infection), injury
severity, increased length of time
from injury, comorbidities
Factors for persistent infection:
dead space, no soft tissue
coverage, nonviable muscle,
devitalized bone
• Contaminated Gustilo IIIB defects
Initially wash out, debride,
antibiotic spacers, and placement
of external fixator for stabilization
Delay definitive reconstruction
once clean after approximately 6
weeks to prevent possible
contamination of plates or free flap
Negative pressure wound therapy
can be used in the interim to keep
the field clean and free of
• Tibial defect management algorithm
Defects > 6 cm: use vascularized
free fibula flap (greater osteocyte
viability because vascularized)
Defects < 6 cm: do not need free
fibula flap, can use
nonvascularized cancellous bone
graft (heal by creeping
substitution, vascular ingrowth)
Avoid using ipsilateral fibula to
reconstruct tibia: ipsilateral side
already weak from tibia, do not
use peroneal artery in traumatized
• Amputation of traumatic lower
extremity Gustilo injury
Stabilize patient first: ABCs
(airway, breathing, circulation)
before amputation
Indications: tibial nerve avulsion
with absent plantar flexion and
sensation, severe soft tissue loss,
warm ischemia time > 6 hours
Filet-of-foot free flap: use part of
amputated lower leg to cover
distal stump
• Risk factors for infection
Farm injury: most common
Length of time from injury
Severity of injury
• Intramedullary free fibula flap
Free fibula flap placed inside
medullary canal of allogeneic bone
Used for large segmental defects of
the tibia or femur in children and
adolescents who need strong long-
term construct
Allogeneic bone graft heals more
quickly by osteoinduction of free
fibula graft

• Venous stasis ulcer
Chronic wound, brown red
discoloration, edema, serous
Treatment: Unna boot
• Diabetic ulcer
Secondary to diabetic neuropathy
Loss of protective sensation and
microvascular thrombosis leads to
• Peripheral vascular disease ulcer
Requires vascular workup
Claudication and decreased ankle
brachial index
May need revascularization prior
to reconstruction
• Recurrent ulceration of a below-the-
knee amputation stump
Treatment: sensate free flap
Keep length: maintain at least 15
cm (5 cm in young patient) for best
function, do not amputate shorter
or do above-the-knee amputation

• Congenital talipes equinovarus
Internally rotated foot: clubfoot
Initial conservative treatment:
conservative with casting, splints
Surgical correction: need preop
tissue expansion for coverage after
release contracted skin

Suggested Reading
Dibbell DG, Edstrom LE. The
gastrocnemius myocutaneous flap.
Clin Plast Surg 1980;7(1):45–50
Ducic I, Attinger CE. Foot and ankle
reconstruction. In: Thorne CH,
Beasley RW, Aston SJ, et al, eds.
Grabb and Smith's Plastic Surgery.
6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:689–706
Griffin JR, Thornton JF. Lower
Extremity Reconstruction. Dallas,
TX: Selected Readings in Plastic
Surgery, Inc.; 2005:1057. Selected
Readings in Plastic Surgery; vol
10, issue 5
Hollenbeck ST, Toranto JD, Taylor BJ,
et al. Perineal and lower extremity
reconstruction. Plast Reconstr Surg
Kasabian AK, Karp NS. Lower-
extremity reconstruction. In: Thorne
CH, Beasley RW, Aston SJ, et al,
eds. Grabb and Smith's Plastic
Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins;
Moran SL, Shin AY, Bishop AT. The use
of massive bone allograft with
intramedullary free fibular flap for
limb salvage in a pediatric and
adolescent population. Plast
Reconstr Surg 2006;118(2):413–
McCraw JB, Furlow LT Jr. The dorsalis
pedis arterialized flap. A clinical
study. Plast Reconstr Surg
Medina ND, Kovach SJ III, Levin LS.
An evidence-based approach to
lower extremity acute trauma. Plast
Reconstr Surg 2011;127(2):926–
Pers M, Medgyesi S. Pedicle muscle
flaps and their applications in the
surgery of repair. Br J Plast Surg
Reddy V, Stevenson TR. MOC-PS (SM)
CME article: lower extremity
reconstruction. Plast Reconstr Surg
2008;121(4, Suppl):1–7
Note: Page numbers followed by f and t
indicate figures and tables, respectively.

Abbe flap, 118f
Abdominally based free flaps for breast
reconstruction, 177
Abdominal wall
– anatomy of, 34, 34f
– reconstruction of, 34–35
Abdominal wall transplant, 34
Abdominoplasty, 183–185
– arterial supply to flap in, 184
– coding for, 61
– complications of, 184
– indications for, 183–184
– mini-, 184
Abductor hallucis brevis flap, 319
ABI (ankle brachial index), 318
Abobotulinumtoxin A (Dysport), 219
Accessory mammary tissue, 167
Accessory nerve injury from neck
dissection, 112
Acellular dermal matrix in breast
reconstruction, 176
Acellularized allograft in nerve repair,
Achrocordon, 51
Acinic cell carcinoma, 114t
Acne, ice pick, 229
Acral lentiginous melanoma, 46, 295
Acrocephalosyndactyly, 241
Acrocephaly, 97t
Actinic cheilitis, 113
Actinic keratosis, 49
Acute compartment syndrome, 281
Adaptive immunity, 58
Adenoid cystic carcinoma, 114, 114t
Adenoma, pleomorphic, 114t
Adipofascial turndown flap for fingertip
amputation, 250t
Adult teeth, 71, 72f
Advancement flap, 6–7, 7f
Advancing age rhinoplasty, 197
AER (apical ectodermal ridge), 237
Aesthetic cases, 61
Afferent pupillary defect, 123
A fiber, 274
AIN (anterior interosseous nerve), 273
AIN (anterior interosseous nerve)
syndrome, 278
ALA (5-aminolevulinic acid) prior to
skin resurfacing, 230
Alar batten graft, 197
Alar countour graft, 197
Alar defects
– partial nasal reconstruction for, 146
– rhinoplasty for, 197
Alar retraction/collapse, 197
Alar rim graft, 197
Aldara (imiquimod) for actinic (solar)
keratosis, 49
Allen test, 21
AlloDerm, 27
– for abdominal wall reconstruction, 35
Allodynia, 282
Allograft, 57
Alloplastic implants, 26
Alopecia. See also Baldness
– androgenic, 223–224
– areata, 224
– female, 223, 223f
– traction, 224
Alveolar bone, 72f
Alveolar bone grafting, 81
Alveolar cleft, 81
Amastia, 166t
Amazia, 166t
Ambient temperature in operating room,
Ameloblastoma of mandible, 135
5-Aminolevulinic acid (ALA) prior to
resurfacing, 230
Amniotic band syndrome, 240
– of finger, 253–254
– of fingertip, 249–250t, 249–251
– of thumb, 255, 256f, 256t
– of traumatic lower extremity Gustilo
injury, 320
Amputation stump, recurrent ulceration
of below-the-knee, 321
Amyloidosis, 303
Anaplastic large-cell lymphoma, breast
augmentation and, 170
Anastomotic coupler devices for
improved flap perfusion, 23
Anatomical snuffbox, 283
ANB angle, 91f, 91t, 92
Androgenic alopecia, 223–224
Anesthesia, 161–165
– general, 163
– local, 161–162, 161t, 162t
– regional, 162–163
Aneurysmal bone cyst, 296
Angle of divergence, 195, 196f
Angular artery, 192, 192f
Animation test, 155
Ankle brachial index (ABI), 318
Annular pulleys, 283
Anosmia, malingering for, 62
Anterior compartment of neck, 110t,
Anterior ethmoid foramen, 69t
Anterior ethmoid nerve, 202
Anterior fontanelle, 96, 96f
Anterior interosseous nerve (AIN), 273
Anterior interosseous nerve (AIN)
syndrome, 278
Anterior lamella of eyelid, 201
Anterior lateral thigh flap, 18, 19t
Anterior thoracic hypoplasia, 36
Anterior tibial vessels and nerve, 138f
Antia–Buch flap, 131, 132f
Antibodies, common side effects of, 59t
Anti-CD3 (OKT3), common side effects
of, 59t
Anti-CD25, common side effects of, 59t
Antigen, 57
Antihelix, 127, 127f
Anti-inflammatory agents for improved
perfusion, 23
Antilymphocytes, common side effects
of, 59t
Antimetabolites, common side effects of,
Antimicrobials for burns, 30, 30t
Antitragus, 127, 127f
Antivenom administration for snake
bites, 54, 54t
Antiviral prophylaxis
– prior to chemical peels, 215
– prior to skin resurfacing, 230
Antley-Bixler syndrome, 98t
Apert syndrome
– craniosynostosis in, 98t
– hand anomalies in, 241
Apex of root of tooth, 72f
Apical ectodermal ridge (AER), 237
Apical foramen, 72f
Aplasia cutis congenita, 118
Apligraf, 27
Arcuate line, 34
Argon-pumped tunable dye laser for
vascular anomalies, 232t
Arnold nerve, 128
Arrector pili muscle, 221f
Arrhythmias due to burns, 31
Artefill, 217
Arteriovenous malformations (AVMs),
– of hand, 262
– HIV-related, 314
– osteo-, 315
– psoriatic, 314
– Reiter, 314
– rheumatoid, 310–313, 310f
– septic, 314
Arthrodesis for SLAC wrist, 305
Arthrogryposis, 241
Arthroplasty for basal joint arthritis, 307
Ascending palatine artery, 92, 93f
Asian eyelid blepharoplasty, 205
Asian rhinoplasty, 197
Atasoy–Kleinert single V-Y flap for
fingertip amputation, 249t
Athelia, 166t
Aural atresia repair, 129
Auricle, 127
Auricular composite graft, 143
Auriculotemporal nerve, 128
Autograft, 57
Autologous breast reconstruction,
Autologous ear reconstruction, 129, 129t
Autologous tissue implants, 26
AVMs (arteriovenous malformations),
– of hand, 262
Axillary dissection, nerves in, 174
Axillary nerve, 274
Axonotmesis, 275t
Azathioprine (Imuran), common side
effects of, 59t

Baboon ear, 130–131
Babysitter procedure for facial
paralysis, 107
Baby teeth, 71, 72f
Bacillus anthracis, hand infections due
to, 300
BAHAs (bone anchored hearing aids),
Baker classification of capsular
contracture, 167–168, 167t
Baker-Gordon formula for chemical
peel, 215
Baldness, 221–226. See also Alopecia
– causes of, 223–224
– female, 223, 223f
– hair anatomy and, 221–222, 221f
– hair transplantation techniques for, 223
– male pattern, 222, 222f
– scalp flaps for, 224–225, 224–226f
Banner flap for constricted ear, 130,
Basal cell carcinoma (BCC), 49–50
– of hand, 295
Basal joint arthritis, 307
Basiliximab, common side effects of,
BAT (bilateral advancement
transposition) flap for baldness, 145,
225, 225f
Bazex syndrome, 50
BDD (body dysmorphic disorder), 62
Becker nevus, 51
Bell palsy, 105
Below-the-knee amputation stump,
recurrent ulceration of, 321
Belt lipectomy, 182
Benign breast disease, 176
Benign premature thelarche, 167
Benign soft tissue hand tumors, 293–294
Bennett fracture, 266–267
“Bent finger,” 243–244
Benzodiazepine half-lives, 163
Bernard–Burow flap (Webster
modification), 116f
Biceps femoris
muscle/musculocutaneous flap,
innervation of, 16t
Bilateral advancement transposition
(BAT) flap for baldness, 225, 225f
Bilateral neck exploration, 110
Bilobed flap, 9, 9f
– for nasal reconstruction, 144
Binder syndrome, 100
Biobrane, 27
Biologic mesh for abdominal wall
reconstruction, 35
Biomaterials, 27
– punch, 45
– sentinel lymph node, 47
Bisphosphonate-related osteonecrosis of
the jaw (BRONJ), 136, 137t
– cat and dog, 300–301
– deer tick, 301
– hand infections due to, 300–301
– human, 301
– snake, 54, 54t
– spider, 55
Black widow spider bites, 55
Blauth classification of thumb
hypoplasia, 244, 245t
Bleeding, preoperative cessation of
drugs that cause, 163
Blepharochalasis, 152
Blepharoplasty, 204–206
– Asian eyelid, 205
– complications of, 205–206
– lower eyelid, 204–205
– patient assessment for, 204
– prominent eye, 205
– upper eyelid, 204
– from blepharoplasty, 206
– due to filler, 218
Blue nevus, 48
Blue rubber bleb nevus syndrome, 103
BMP (bone morphogenetic protein), 12
Body contouring, 181–183, 183t
Body dysmorphic disorder (BDD), 62
Bone anchored hearing aids (BAHAs),
Bone conduction hearing aids, 129
Bone cyst, aneurysmal, 296
Bone dust, 12
Bone formation, 12
Bone grafts, 12
Bone morphogenetic protein (BMP), 12
Bone shortening in nerve repair, 276
Bone tumors of hand, 296–297
Borrelia burgdorferi, 301
Botulinum toxin (BOTOX,
onabotulinumtoxin A), 219
– for brow lift, 208
Bouchard nodules, 315
Boutonniere deformity, 287, 312
Bowen disease, 49
“Boxer's fracture,” 265
Boxy tip, 195
Brachial arches, 74, 74t
Brachial plexus, 280–281
– anatomy of, 280–281
– injuries of, 281
– palsies of, 281
Brachial plexus block, 162
Brachioplasty, 181
Brachycephaly, 97t
Brachydactyly, 243
BRCA, 174
– anatomy of, 166, 174
– burn contracture of, 176
– congenital anomalies of, 166–167,
– ectopic, 167
– gynecomastia of, 171–172
– supernumerary, 167
– tuberous deformity of (constricted),
Breast augmentation, 167–170, 167t
– after massive weight loss, 182
– mastopexy with, 170
Breast cancer
– BRCA and, 174
– and breast reduction, 171
– diagnosis of, 175
– incidence of, 174
– lymphedema due to, 41t
– prognostic factors for, 175, 175t
– risk factors for, 174
– staging of, 175t
– treatment for, 175
Breast disease, benign, 176
Breast expansion, 39–40
Breastfeeding after breast reduction, 171
Breast hypertrophy, juvenile, 171, 176
Breast implants, 167–170
– in breast reconstruction, 176
– and capsular contracture, 167–168,
– complications of, 168–170
– pocket irrigation for, 169
– pocket selection for, 167
– saline, 168
– silicone, 167t, 168–170
– textured, 168
Breast mastopexy, 170, 170t
Breast reconstruction, 176–180
– autologous, 176–178
– coding for, 60
– complications of, 178–179
– free flap options for, 177–178
– with implant, 176
– pedicled flap options for, 176–177
– principles of, 176
– radiation therapy and, 178
– serratus branch of thoracodorsal artery
in, 179
– tissue expander for, 176, 178
Breast reduction, 171
Brent technique for autologous ear
reconstruction, 129, 129t
Breslow scale for melanoma, 46
Bronchoscopy for inhalational injury, 30
BRONJ (bisphosphonate-related
osteonecrosis of the jaw), 136, 137t
Brow anatomy, 201f, 206–207, 207f
Brow lift, 206–209
– anatomy for, 206–207, 207f
– complications of, 209
– fixation techniques for, 209
– nonsurgical intervention for, 208
– patient assessment for, 207
– surgical techniques for, 208–209, 208t
Brown recluse spider bites, 55
Brow paralysis, static reconstruction for,
Brow ptosis, 207
Buccal nerve injury due to facelift, 189
Buccal surface of tooth, 71
Buerger disease, 261
Bupivacaine (Marcaine) for anesthesia,
Burn(s), 28–33
– antimicrobials for, 30, 30t
– chemical, 32, 32t
– complications of, 31
– contracture due to, 30
– – of breast, 176
– criteria for transfer to burn center for,
– degrees of, 28, 28t
– of ear, 130
– electric, 31
– fluid management for, 29
– frostbite as, 31
– hypermetabolic response to, 30
– immunology of, 28
– inhalational injury due to, 30–31
– nutrition for, 29
– silver and other wound dressings for,
30, 30t
– thermal, 28–31, 28t, 29f, 30t
– total body surface area of, 28, 29f
Burn care, dermatologic conditions
requiring, 32
Burn center, criteria for transfer to, 28
Burn shock, 31
Butterfly graft, 193

Cadaveric appearance after
blepharoplasty, 206
Café au lait spots, 51
Calcineurin inhibitors, common side
effects of, 59t
Calcium bone substitutes, 26
Calvarial bone graft, 12
Camptodactyly, 243–244
Canaliculodacryocystorhinostomy, 157
Canaliculus, 157f
Cancellous bone grafts, 12
Candida albicans, hand infections due
to, 300
Canthal tendons, 202, 202f
Canthal tilt, 202
Canthoplasty, 154, 155
Capillary malformations (CMs), 103
Capsular contracture, Baker
classification of, 167–168, 167t
Capsulopalpebral fascia, 203
Caput ulnae syndrome, 313
Carbon dioxide (CO2) laser, 227t, 228t
– for skin resurfacing, 228, 229
– for vascular anomalies, 232t
Carboxyhemoglobin (COHb) in
inhalational injury, 30
Carotid artery blowout, 112
Carotid bifurcation region, 110t, 111f
Carotid canal, 70f
Carpal bone(s)
– anatomy of, 304
– development of, 237
Carpal tunnel syndrome (CTS), 277–278
Carpenter syndrome, craniosynostosis
in, 98t
Carpometacarpal (CMC) grind test, 307
Carpometacarpal (CMC) joint
osteoarthritis, 315
Cartilage grafts, 12–13
Cat bites, 300–301
CATCH-22 syndrome, 77
Cathopexy, 154, 155
Cauliflower ear, 130
Causalgia, 282
Cavum concha, 127
Cementum, 71, 72f
Central incisors, 71
Centric occlusion, 90
Centric relation, 90
Cephalic tip rotation, 196
Cephaloauricular angle, 210
Cephalometric analysis, 90–92, 91f, 91t
Cerebral palsy, 291
Cerebrospinal fluid (CSF) leakage,
Cervical nerve injury due to facelift, 189
C fiber, 274
Champy principle, 124
CHARGE syndrome, 100
Charles procedure for lymphedema, 42
Checkrein ligament, 260, 270, 289
Cheilitis, actinic, 113
Cheiralgia paresthetica, 288
Chemical burns, 32, 32t
Chemical peels, 213–215
– classification of, 213–215, 213t
– deep, 213t, 214–215
– medium, 213t, 214
– pretreatment for, 215
– superficial, 213, 213t
Chemosis after blepharoplasty, 206
Chest anomalies, 36
Chest reconstruction, 36, 36t
Chimerism, 59
Chin disorders, 94–95
Chondritis after otoplasty, 211
Chondrocalcinosis, 302, 314
Chondrocutaneous composite conchal
transposition flap, 131, 132f
Chondrodermatitis nodularis helicis,
Chromophores, 228, 228t
Chylous leak from neck dissection,
Cicatricial ectropion, 154–155
Cigarette smoking, impaired wound
healing due to, 4
Clark's mnemonic for melanoma, 46
Clasped thumb, 240
Clavipectoral fascia, 181
Claw-hand deformity, 290
Cleft hand, 242, 243t
Cleft lip, 77–79
– prenatal diagnosis of, 77
– repair of, 77–79, 78f
Cleft lip and palate (CLP), 75–82
– alveolar cleft in, 81
– classification of, 75, 75f, 75t
– embryology of, 75–76
– epidemiology of, 76, 78t
– orthognathic surgery for, 81, 88
– syndromes associated with, 76–77
– velopharyngeal insufficiency in, 81
Cleft palate, 79–80
– palatal anatomy and, 79, 80f
– primary vs. secondary, 79
– submucous, 80
– surgical repair of, 80
– terminology for, 79
Cleft rhinoplasty, 79
Cleland ligament in Dupuytren disease,
Clinodactyly, 244
CLP. See Cleft lip and palate
Clubfoot, 321
CM(s) (capillary malformations), 103
CMC (carpometacarpal) grind test, 307
CMC (carpometacarpal) joint
osteoarthritis, 315
CMN (congenital melanocytic nevi),
giant, 40, 47–48
CO2 laser. See Carbon dioxide laser
Cobb syndrome, 104
Cocaine for anesthesia, 161, 161t
Coding, 60–61, 60t
COHb (carboxyhemoglobin) in
inhalational injury, 30
Collagen in wound healing, 3–4, 3t
Collar button infection, 301
Colles fascia, 181–182
Columella, hanging, 196
Columellar artery, 202f
Columellar strut graft, 196
Columellolabial angle, 196
Combined low ulnar and median nerve
palsy, 291
Compartment syndrome, acute, 280
Complex regional pain syndrome
(CRPS), 282
Complications, medicolegal aspects of,
Composite tissue allotransplantation, 57
Compound nevus, 48
Comprehensive plastic surgery, 1–62
– burns in, 28–33
– flaps and microsurgery in, 14–25
– immunology and transplantation in,
– implants and biomaterials in, 26–27
– local tissue rearrangement in, 6–10
– lymphedema and pressure sores in,
– skin, bone, and cartilage grafts in,
– skin lesions and soft tissue tumors in,
– soft tissue infection in, 54–56
– tissue expansion in, 39–40
– trunk reconstruction in, 34–37
– wound healing in, 3–5
Computer simulation surgery in
mandible reconstruction, 139–140
Concha, 127, 127f
Conchal depth, 210
Conchoscaphoid angle, 210
Condylar neck fracture, bilateral, 124
Congenital melanocytic nevi (CMN),
giant, 40, 47–48
Congenital midline nasal lesions, 86–87
Congenital talipes equinovarus (CTEV),
Conjunctiva, 201
Conjunctivodacryocystorhinostomy, 157
Conotruncal anomaly face syndrome, 77
Consent, informed, 62
Constricted breast syndrome, 166–167
Constricted ear, 130, 131f
Constriction band syndrome, 240
Contractures, 288–289
– due to burns, 30
Cooper ligaments, 166
Copper vapor laser for vascular
anomalies, 232t
Coronal suture, 96, 96f
Corrugator supercilii muscle, 207t
Cortical bone grafts, 12
Cosmetic surgery, 181–233
– abdominoplasty as, 183–185
– blepharoplasty as, 204–206
– body contouring as, 181–183, 183t
– brow lift as, 206–209, 207t, 208t
– chemical peels as, 213–216
– facelift as, 187–190, 187t, 188t
– fat grafting as, 218
– fillers as, 217, 217t, 218–219
– hair transplantation as, 221–226
– injectables as, 219
– lasers for, 227–233
– liposuction as, 185–186, 185t
– neck rejuvenation as, 190–191, 191t
– otoplasty as, 210–212
– rhinoplasty as, 192–200
Cottle maneuver, 193
Cranial bones and sutures in newborn,
96–97, 96f
Cranial fossa, 69
Cranialization, 124
Cranial nerve, free flap to ipsilateral,
for facial paralysis, 106
Cranial nerve transfers for facial
paralysis, 107
Cranial shapes, 97t
Craniofacial anomaly, orthognathic
surgery for, 88
Craniofacial microsomia, 99
– orthognathic surgery for, 88–89
Craniofacial syndrome, 99–101
Craniomaxillofacial surgery, 65–154
– for cleft lip and palate, 75–82
– for craniosynostosis and craniofacial
syndromes, 96–101
– for ear reconstruction, 127–133
– for eyelid and lacrimal system
reconstruction, 150–158
– for facial paralysis, 105–107
– head and neck anatomy for, 67–74
– for head and neck tumors, salivary
gland tumors, lip and scalp, 108–119
– for hemangiomas and vascular
malformations, 102–104
– for mandible reconstruction, 136–139
– for maxillofacial trauma, 120–126
– for nasal reconstruction, 142–149
– orthognathic, temporomandibular joint
and chin, 88–95
– for Tessier clefts, 83–87
Cranioplasty, pediatric, 12
Craniosynostosis, 96–99
– defined, 96
– diagnosis of, 97–98, 97t
– normal anatomy and, 96–97, 96f
– orthognathic surgery for, 88
– principles for treatment of, 98–99
– syndromic, 98, 98t
– unilateral coronal, 98
Creeping substitution, 12
Cribriform plate, 69t, 70f
Cross-face nerve graft for facial
paralysis, 106
Cross finger flap for fingertip
amputation, 249t
Crouzon syndrome, craniosynostosis in,
Crown of tooth, 71, 72f
CRPS (complex regional pain
syndrome), 282
Cruciate pulleys, 283
Crura of antihelix, 127f
Cryptotia, 130
Crystalline arthropathy, 302
CSF (cerebrospinal fluid) leakage,
CTEV (congenital talipes equinovarus),
CTS (carpal tunnel syndrome), 277–278
Cubital tunnel syndrome, 278–279
Cup ear, 130, 131f
Cusp of tooth, 72f
Cutaneous groin flap, vascular supply to,
Cutaneous horn, 49
Cuticle of hair, 221
Cutis laxa, facelift for, 190
Cyclosporine, common side effects of,
Cylindroma, 52
Cymba concha, 127, 127f
– aneurysmal bone, 296
– epidermal inclusion, 51, 297
– ganglion, 297
– of hand, 297
– mucous, 297
– nasal dermoid, 86

Dacryocystorhinostomy, 157
Dacryon, 84
Dapsone for brown recluse spider bites,
Deciduous teeth, 71, 72f
Deep inferior epigastric artery
perforator (DIEP) flap for breast
reconstruction, 177
Deep peels, 213t, 214–215
Deep peroneal nerve, 317
Deep vein thrombosis (DVT), 163–164,
Deer tick bite, 301
Delta phalanx, 244
Deltopectoral flap, 18, 19t
Dental anatomy, 71–73, 72f
Dentin(e), 71, 72f
Dentofacial imbalance, orthognathic
surgery for, 89
Depressor septi nasi muscle, 203
Depressor supercilii muscle, 207t
De Quervain disease, 287
Dermabrasion, 216
– for tattoo removal, 231t
Dermatochalasis, 152
Dermatofibroma, 52
Dermatofibrosarcoma protuberans, 52
Dermatologic conditions requiring burn
care, 32
Dermatosis papulosa nigra, 50–51
Dermoid cyst, nasal, 86
Descending palatine artery, 92, 93f
Dextran for improved flap perfusion, 23
Diabetic ulcer, 321
DIEP (deep inferior epigastric artery
perforator) flap for breast
reconstruction, 177
DiGeorge syndrome, 77
Digit(s). See Finger(s)
Digital infantile fibromatosis, 294
Diode laser, 227t
Direct fasciocutaneous flaps, 19t, 20f
Disease-modifying antirheumatic drugs
(DMARDs), 311
DISI (dorsal intercalated segment
instability), 304, 305–306, 306f
Distal interphalangeal (DIP) joint
– fractures and dislocations of,
267–268, 268t
– osteoarthritis of, 315
Distally based radial forearm pedicled
flap, 22, 22f
Distal palm injuries, 255
Distal surface of tooth, 73
Distant flap, 10
– for fingertip amputation, 249
Distraction osteogenesis, 92
Distraction test, 154
DMARDs (disease-modifying
antirheumatic drugs), 311
Doctor-patient relationship, 61
Dog bites, 300–301
Dorsal grafts, 195
Dorsal intercalated segment instability
(DISI), 304, 305–306, 306f
Dorsal intercarpal ligament, 304
Dorsalis pedis fasciocutaneous flap, 19t,
Dorsal ligament complex of wrist, 304
Dorsal nasal artery, 202f
Dorsal nasal flap, 145, 146f
Dorsal onlay grafts, 195
Dorsal sidewall onlay grafts, 195
Double bubble with breast implant, 169
Down syndrome, 100
Dry eye management, 157–158
Dupuytren disease, 259–260, 259t
DVT (deep vein thrombosis), 163–164,
Dysport (abobotulinumtoxin A), 219

– anatomy of, 127–128, 128f
– burned, 130
– cauliflower, 130
– constricted (lop, cup), 130, 131f
– prominent, 210–212
– Stahl (Spock, baboon, Vulcan, satyr),
– telephone, 212
Ear avulsion, 130
Ear keloid, 5
Earlobe, 127f
Ear reconstruction, 127–133
– Antia–Buch flap for, 131, 132f
– autologous, 129, 129t
– chondrocutaneous composite conchal
transposition flap for, 131, 132f
– for chondrodermatitis nodularis
helicis, 131
– for congenital deformities, 130–131,
– ear anatomy and, 127–128, 127f
– for microtia, 128–129
– for middle third helical rim defect,
– for traumatic deformities, 130
– for upper third helical rim defect, 131
Ear width, 210
Ecthyma gangrenosum, 300
Ectopic banking for replantation, 254
Ectopic breast, 167
Ectrodactyly, 242, 243t
Ectropion, 154–155
– during blepharoplasty, 206
EDC (extensor digitorum communis)
ulnar sublimation, 311
Ehlers-Danlos syndrome, facelift for,
Eisler fat pocket, 203
Eklund displacement or compression
mammograms, 169
Elastoderma, facelift for, 190
Elderly, rhinoplasty in, 197
Electric burns, 31
EM (erythema multiforme), 32
Embolism, pulmonary, 163–164, 164t
EMLA (eutectic mixture of local
anesthetic) cream, 162
Enamel, 71, 72f
Encephalocele, 86
Encephalopathy, postoperative, 164
Enchondral bone formation, 12
Enchondroma, 296
Enchondromatosis, 296
Endoneurium, 274
Endoscopic approach for brow lift,
Enophthalmos, 122
Entropion, 155
– due to snake bites, 54, 54t
– due to spider bites, 55
Ephelis, 51
Epiblepharon, 155
Epidermal inclusion cyst, 51, 297
Epidermis, layers of, 45
– finger blocks with, 162–163
– lidocaine with, 161t
Epineurium, 274
Epiphora, 157
– after blepharoplasty, 206
Epithelioid sarcoma, 295
Epitope, 57
Eponychium, 247, 247f
Equine antivenom, 54, 54t
laser, 227t, 228t
– for skin resurfacing, 228
– for vascular anomalies, 232t
Erb palsy, 281
Erythema chronicum migrans, 301
Erythema multiforme (EM), 32
Erythroplasia of Queyrat, 49
Estlander flap, 115f
Ethmoid bone, 67, 67f
Eutectic mixture of local anesthetic
(EMLA) cream, 162
Excisions, 6
Extensor digitorum communis (EDC)
ulnar sublimation, 311
Extensor digitorum longus muscle, 138f
Extensor hallucis longus muscle, 138f
Extensor tendon compartments, 283,
Extensor tendon injury, 285–287, 286f,
Extensor tendon rupture, 312–313
External auditory canal, 127f
External carotid artery
– in blood supply to external nasal
pyramid, 192, 192f
– in blood supply to maxilla, 92, 93f
– injury from neck dissection of, 112
External ear
– anatomy of, 127, 127f
– arteries of, 127
– embryology of, 128
– nerves of, 127–128
External oblique
muscle/musculocutaneous flap, 16t
– vascular supply to, 18f
External valve obstruction, 194
Extra-octave fracture, 269
Extraocular muscle(s), 67, 68t
– injury from blepharoplasty of, 206
Extravasation injury, 257–258
– anatomy of, 201f, 206–207, 207f
– ideal position of, 207
Eyebrow lift. See Brow lift
– anatomy of, 201–203, 201f, 202f
– malposition after blepharoplasty of,
Eyelid defect
– ectropion as, 154–155
– entropion as, 155
– evaluation of, 150
– lagophthalmos as, 155–156
– of lateral canthus, 151
– lower, 151
– lower lid malposition as, 154–156,
– of medial canthus, 151
– periocular, 151
– ptosis as, 152–153, 153t
– reconstructive algorithm for, 150–151,
– upper, 150–151

– anatomy of, 187–188, 187t, 188t
– blood supply to, 187–188
– retaining ligaments of, 188, 188t
– youthful vs. aging, 188
Facelift, 187–190
– anatomy for, 187–188, 187t, 188t
– complications of, 188–190
– male, 190
– patient assessment for, 188
– for skin diseases, 190
– subcutaneous, 188
– subperiosteal, 188
– sub-SMAS (deep-plane), 188
– techniques for, 188
Facial artery, 92, 93f, 202f
Facial clefts, rare, 83, 84f
Facial fractures. See Maxillofacial
Facial height, 120
Facial nerve, 187
– injury due to facelift of, 189
Facial paralysis, 105–107
– dynamic reconstruction (facial
reanimation) for, 106–107
– etiology of, 105–106
– principles of, 105
– static reconstruction for, 107
Facial reanimation, 106–107
Facial width, 120
Factor V Leiden, 164
Fanconi anemia, hand anomalies in, 245t
Fasanella–Servat procedure, 153
Fascial bands in Dupuytren disease,
259, 259t
Fasciocutaneous flaps, 18–22, 19t,
Fasciotomy for snake bites, 54
Fat grafting, 218
– for breast implant, 169–170
Fat necrosis with breast reconstruction,
FDMA (first dorsal metacarpal artery)
flap for fingertip amputation, 250t
FDP tendon. See Flexor digitorum
profundus tendon
FDS (flexor digitorum superficialis)
– anatomy of, 283
– injury of, 285
Felon, 299
Female alopecia, 223, 223f
Femoral nerve, 318
FH line, 91f, 91t, 92
Fibroadenoma, 176
Fibromatosis, digital infantile, 294
Fibrous dysplasia, 101
Fibula muscle/musculocutaneous flap,
Fibula osteoseptocutaneous flap,
Fight bite, 301
Filariasis, lymphedema due to, 41t
– classification of, 217, 217t
– complications of, 218–219
– medicolegal aspects of, 61
Finasteride (Propecia)
– for androgenic alopecia, 224
– for male pattern baldness, 222
– amputation of, 253–254
– “bent,” 243–244
– conjoined, 239–240, 239f
– duplication of, 237–239, 238f, 238t
– Jersey, 268, 268t
– overgrowth of, 243
– short, 243
– transposition of, 254
– trigger, 287
– – rheumatoid arthritis and, 312
Finger blocks with epinephrine,
– anatomy of, 247, 247f
– infections of, 299
– nailbed injuries of, 248
– reconstruction for amputated,
249–250t, 249–251
First-degree burns, 28, 28t
First dorsal metacarpal artery (FDMA)
flap for fingertip amputation, 250t
First molars, 71
Fitzpatrick skin classification, 229, 229t
FK-506 (tacrolimus), common side
effects of, 59t
Flag flap for constricted ear, 130, 131f
– advancement, 6–7, 7f
– bilobed, 9, 9f
– distant, 10
– failure of, 22–23
– fasciocutaneous, 18–22, 19t, 20–22f
– improving perfusion of, 23–24
– interposition, 9
– island, 10
– monitoring of, 22
– muscle/musculocutaneous, 14, 14–16t,
17f, 18f, 19t, 20f
– random cutaneous, 6
– rhomboid (Limberg), 8, 8f
– rotation, 6, 6f
– transposition, 7–9, 8f, 8t, 9f
– venous flow through, 24
– vomer, 80
– v-Y, 7, 7f
Flaring ala, 197
Flexor digitorum longus muscle, 138f
Flexor digitorum profundus (FDP)
– anatomy of, 283
– avulsion of, 268, 268t
– injury of, 285
Flexor digitorum superficialis (FDS)
– anatomy of, 283
– injury of, 285
Flexor hallucis longus muscle, 138f
Flexor pollicis longus (FPL) tendon, 283
Flexor tendon(s)
– adhesions of, 312
– anatomy of, 283
– injury of, 284–285, 284f, 284t
Flexor tenosynovitis, 299
Floor of orbit, 67
Fluid management
– for burns, 29
– with suction lipectomy, 185
5-Fluorouracil (5-FU) for actinic (solar)
keratosis, 49
Follicle papilla of hair, 221f
Follicular unit extraction (FUE), 223
Foot reconstruction, 319
Foramen cecum, 69t
Foramen lacerum, 69t, 70f
Foramen magnum, 69t, 70f
Foramen ovale, 69t, 70f
Foramen rotundum, 69t, 70f
Foramen spinosum, 70f
– injuries of, 255
– ischemic contracture of, 288–289
– median nerve compression at, 278
– radial nerve compression at, 279
Forearm compartment release, 280
Forehead expansion, 39
Forehead flap for nasal reconstruction,
144–145, 144f, 145f
Forehead muscles, 206, 207t
FPL (flexor pollicis longus) tendon, 283
Fractional CO2 laser skin resurfacing,
Franceschetti–Klein syndrome, 100
Fred technique for hanging columella,
Free fibula flap for mandible
reconstruction, 138–139, 138f
Free flaps
– for abdominal wall reconstruction, 34
– for breast reconstruction, 177–178
– coding for, 60
– failure of, 22–23
– for fingertip amputation, 249
– monitoring of, 22
Frey syndrome, 114
Froment sign, 278
Frontal bone
– anatomy of, 67, 67f
– pediatric fractures of, 125
Frontalis muscle, 207t
Frontalis sling, 153
Frontal nerve injury due to facelift, 189
Frontal sinus fractures, 123–124
Frostbite, 31
FUE (follicular unit extraction), 223
5-FU (5-fluorouracil) for actinic (solar)
keratosis, 49
Full-thickness burns, 28, 28t
Full-thickness skin graft (FTSG), 11–12
– for nasal reconstruction, 143
Furlow palatoplasty, 80, 81
Furnas sutures, 211

Galactorrhea after breast augmentation,
Gamekeeper's thumb, 271–272, 271f
GAN (greater auricular nerve)
– anatomy of, 127
– injury due to facelift of, 189
Ganglion, 297
Gastric bypass procedures, 182
Gastrocnemius muscle, 138f
muscle/musculocutaneous flap, 15t,
Gender reassignment, 62
General anesthesia, 163
Genioplasty, 94
Germinal matrix
– anatomy of, 247, 247f
– injury of, 248
Giant cell tumor
– of bone, 296
– of hand, 293
– of mandible, 135–136
Giant congenital melanocytic nevi, 40,
Gillies approach to zygoma fractures,
Gillies fan flap, unilateral, 117f
Gingival margin, 72f
Gingivoperiosteoplasty for alveolar
cleft, 81
Glioma, 86
Global period, 61
Glomus tumor, 293
Gluteal autoaugmentation, 182
Gluteus maximus
muscle/musculocutaneous flap, 16t
Glycolic acid
– for chemical peel, 213
– prior to skin resurfacing, 230
Gnathion, 91f, 91t
Goldenhar syndrome, 99–100
Gonion, 91f, 91t
Gore-Tex (polytetrafluoroethylene) mesh
for abdominal wall reconstruction, 35
Gorlin syndrome, 50
Gosain earlobe technique, 211
Gout, 302, 314
Gracilis muscle/musculocutaneous flap,
– for abdominal wall reconstruction, 34
– innervation of, 16t
– vascular supply to, 17f
– alar, 197
– allo-, 57
– auricular composite, 143
– auto-, 57
– bone, 12
– – alveolar, 81
– butterfly, 194
– cartilage, 12–13
– columellar strut, 196
– dorsal, 195
– fat, 169–170, 218
– iso-, 57
– lateral crus, 197
– micro-, 223
– nerve, 276
– – cross-face, 106
– punch, 223
– skin, 11–12, 11t
– splay, 194
– spreader, 193, 195
– tip, 196
– xeno-, 57
Graham and Gault technique, 211
– pyogenic, 52, 294
– silicone, 168
Graves thyroid ophthalmopathy, 205
Grayson ligament in Dupuytren disease,
Greater auricular nerve (GAN)
– anatomy of, 127
– injury due to facelift of, 189
Greater palatine artery, 80f
Greater palatine foramen, 70f
Groin flap, 19t
Growth plate fractures, 269, 270f, 270t
Gustatory rhinorrhea after rhinoplasty,
Gustilo classification of open tibial
fractures, 319–320, 320t
Guyon canal syndrome, 279
Gynecomastia, 171–172
– pseudo-, 183, 183t
Hair anatomy, 221–222, 221f
Hair follicle, 221
Hairline distortion due to facelift, 190
Hair regrowth time, 223
Hair removal, laser, 232–233
Hair shaft, 221, 221f
Hair shape, 221f, 222
Hair sheath, 221f, 222
Hair transplantation, 221–226
– causes of baldness and, 223–224
– for female alopecia, 223, 223f
– hair anatomy and, 221–222, 221f
– for male pattern baldness, 222, 222f
– scalp flaps for, 224–225, 224–226f
– techniques for, 223
Halo nevus, 48
Hamulus, 80f
– claw, 290
– cleft, 242, 243t
– embryology of, 237
– hoof (rosebud), 241
– “lobster claw,” 242
– overgrowth of, 243
– spade (obstetrician's), 241
– spoon (mitten), 241
Hand anomalies, 237–246
– acrocephalosyndactyly (Apert
syndrome) as, 241
– arthrogryposis as, 241
– brachydactyly as, 243
– camptodactyly as, 243–244
– classification of, 237
– cleft hand (ectrodactyly) as, 242, 243t
– clinodactyly as, 244
– constriction (amniotic) band
syndrome, 240
– Kirner deformity as, 246
– macrodactyly as, 243
– Madelung deformity as, 241, 242f
– in Möbius syndrome, 246
– most common, 237–240
– other, 241–246
– in Poland syndrome, 241
– polydactyly as, 237–239, 238f, 238t
– radial limb syndromes as, 244, 245t
– symphalangism as, 246
– syndactyly as, 239–240, 239f
– thumb hypoplasia as, 244–246, 245t
– thumb in palm deformity as, 241–242
– trigger thumb as, 240
Hand compartment release, 280
Hand dislocations
– complete, 264
– distal interphalangeal (DIP) joint,
267–268, 268t
– dorsal vs. volar, 264
– MCP dorsal, 272
– phalangeal, 267
– principles of management of, 264–265,
– proximal interphalangeal (PIP), 269
– simple, 264
Hand fractures, 264–270
– complications of, 270
– distal interphalangeal (DIP) joint,
267–268, 268t
– metacarpal, 265–266
– pediatric, 269–270, 270f, 270t
– phalangeal, 267
– principles of management of, 264–265,
– proximal interphalangeal (PIP), 269
– site of, 264, 264f
– thumb, 266–267
Hand infections, 299–303
– due to bites, 300–301
– of fingertips, 299
– flexor tenosynovitis as, 299
– mimickers of, 302–303
– necrotizing soft tissue, 302
– of palmar space, 301
– specific pathogens in, 300
Hand injuries, 253–258
– of distal palm, 255
– of forearm, 255
– infiltration injury as, 257–258
– reconstructive goals for, 253
– replantation for, 253–254
– ring avulsion injury as, 257
– techniques for improving function
with, 254
– thumb reconstruction for, 255, 256f,
Hand ligament injuries
– gamekeeper's/skier's thumb as,
271–272, 271f
– of index finger MCP radial collateral
ligament, 272
Hand surgery, 235–316
– for congenital anomalies, 237–246
– for Dupuytren disease, 259–260, 259t
– for finger amputations, 247–252
– for fractures and dislocations,
– for infections, 299–303
– for mutilating hand injuries, 253–258
– for nerve disorders and compartment
syndrome, 273–282
– for rheumatologic disorders, 310–316
– for tendon disorders, 283–292
– for tumors, 293–298
– for vascular disease, 261–262
– for wrist disorders, 304–309
Hand tendons, 283–292
– anatomy of, 283–284, 283t
– contractures of, 288–289
– extensor tendon injury of, 285–287,
286f, 286t
– flexor tendon injury of, 284–285, 284f,
– nerve injuries affecting, 290–291
– tendonitis of, 287–288
– tendon transfers of, 289–290
Hand tumors, 293–298
– benign soft tissue, 293–294
– of bone, 296–297
– cysts as, 297
– evaluation of, 293
– malignant soft tissue, 295–296
– operating room preparation for, 293
Hanging columella, 196
Harlequin deformity, 98
Head anatomy, 67–74
– brachial arches in, 74, 74t
– dental, 71–73, 72f
– mandible in, 69, 71t
– orbital, 67, 67f, 68t
– scalp, 68
– sinus, 68
– skull base in, 69, 69t, 70f
– tongue in, 73, 73f
Head and neck reconstruction, 112–113
Head and neck tumors
– classification and staging of, 108, 109t
– neck dissection for, 109–112, 110t,
– pediatric, 118
– reconstruction for, 112–113
Health Insurance Portability and
Accountability Act (HIPAA), 62
Hearing aids for microtia, 129
Hearing in microtia, 129
Heberden nodules, 315
Helical advancement flaps, bilateral,
Helical rim defect
– middle third, 131
– upper third, 131
Helical rim height, 210
Helical rim protrusion, 210
Helix, 127, 127f
Hemangiomas, 102
Hemangiopericytoma, 293
– due to facelift, 188–189
– of nailbed, 248
– after otoplasty, 211
– retrobulbar, 206
– septal, 122
Hemifacial microsomia, 99
– orthognathic surgery for, 88–89
Heparin for improved flap perfusion, 23
Hering's law of equal innervation, 153
Hering test, 153
Herpes outbreak prior to skin
resurfacing, 230
Herpetic whitlow, 299
Hertel exophthalmometry, 154
Heterotopic replantation, 254
High median nerve palsy, 290
High-pressure injection injury, 258
High radial nerve palsy, 290
High ulnar nerve palsy, 291
Hildreth sign, 293
HIPAA (Health Insurance Portability and
Accountability Act), 62
Hirudo medicinalis for improved flap
perfusion, 23
Histocompatibility, 58
HIV (human immunodeficiency virus)
needle stick, 300
HIV (human immunodeficiency virus)-
related arthritis, 314
HLAs (human leukocyte antigens), 58
Holden classification of ischemic
forearm contractures, 288
Hollowed out appearance after
blepharoplasty, 206
Holoprosencephaly, 100
Holt–Oram syndrome, 245t
Hoof hand, 241
Hook nail deformity, 251
Horner syndrome, ptosis due to, 152
Horseshoe infection, 301
Human bites, 301
Human immunodeficiency virus (HIV)
needle stick, 300
Human immunodeficiency virus (HIV)-
related arthritis, 314
Human leukocyte antigens (HLAs), 58
Hurley staging of hydradenitis
suppurativa, 55t
Hutchinson–Gilford syndrome, facelift
for, 190
Hutchinson sign, 47
Hyaluronic acid fillers, 217
Hydradenitis suppurativa, 55–56, 55t
Hydrofluoric acid burns, 32t
– as skin lightener, 215
– prior to skin resurfacing, 230
Hyperesthesia, 282
Hypermetabolic response to burns, 30
Hypertelorbitism, 84–86, 85f
Hyperthermia, malignant, 163
Hypertrophic inferior turbinate, 193
Hypertrophic scars, 5
Hypoglossal canal, 69t, 70f
Hypoglossal nerve injury, 112
Hyponychium, 247, 247f
Hypothenar hammer syndrome, 261
Ice pick acne, 229
IFSSH (International Federation of
Societies for Surgery of the Hand)
Classification of Congenital Hand
Anomalies, 237
Iliac osseomusculocutaneous flap, 15t
– vascular supply to, 17f
Iliohypogastric nerve during
abdominoplasty, 184
Ilioinguinal nerve during
abdominoplasty, 184
Imiquimod (Aldara) for actinic (solar)
keratosis, 49
Immunity, innate vs. adaptive, 58
– of burns, 28
– of transplantation, 57–59, 58t, 59t
Immunosuppressive agents, 58, 58t
– common side effects of, 58, 59t
– impaired wound healing due to, 4
Implants, 26
– breast, 167–170
– Medpor mandibular angle, 92
– osseointegrated dental, 137
Imuran (azathioprine), common side
effects of, 59t
Incisive canal, 70f
Incisive foramen, 80f
Incisors, 71
Incobotulinumtoxin A (Xeomin), 219
Index finger MCP radial collateral
ligament injury, 272
– of breast implant, 169
– with breast reconstruction, 179
– with burns, 31
– due to facelift, 190
– hand, 299–303
– impaired wound healing due to, 4
– of open tibial fractures, 319–320
– soft tissue, 54–56, 54t, 55t
Inferior alveolar nerve, 69
Inferior crus, 127
Inferior meatus, 157f
Inferior oblique muscle, 68t
Inferior orbital fissure, 67, 67f, 69t
Inferior rectus muscle, 68t
Inferior turbinate, hypertrophic, 193
Infiltration injury, 257–258
Inflammatory phase of wound healing, 3t
Informed consent, 62
Infraorbital artery, 202f
Infraorbital nerve, 203
Infratrochlear nerve, 202
Infundibulum of hair, 221f, 222
Inhalational injury, 30–31
Injectables, 219
– medicolegal aspects of, 61
Injection injury, high-pressure, 258
Innate immunity, 58
Inner root sheath of hair, 222
Inosculation stage of skin graft healing,
Insurance cases, 61
Integra Dermal Regeneration Template,
Intense pulsed dye laser, 227t, 228t
Interdomal suture, 196
Internal acoustic meatus, 69t, 70f
Internal carotid artery, 202f
Internal oblique
muscle/musculocutaneous flap, 16t
Internal valve obstruction, 193
International Federation of Societies for
Surgery of the Hand (IFSSH)
Classification of Congenital Hand
Anomalies, 237
Interorbital distance (IOD), 84
Interposition flap, 9
Intersection syndrome, 287–288
Intertragic incisure, 127f
Intertragic notch, 127
Intradermal nevus, 48
Intramedullary free fibula flap, 320–321
Intravenous fluid (IVF) for burns, 29
Intravenous (IV) infiltration injury, 257
Intrinsic tightness due to rheumatoid
arthritis, 311–312
Inverted V deformity after rhinoplasty,
IOD (interorbital distance), 84
Ischemia due to filler, 218
Ischemic forearm contracture, 288–289
Ischial sores, 42, 43t
Island flap, 10
Isograft, 57
IVF (intravenous fluid) for burns, 29
IV (intravenous) infiltration injury, 257

Jaw, bisphosphonate-related
osteonecrosis of, 136, 137t
Jersey finger, 268, 268t
Jessner solution for chemical peel, 213
Jeune syndrome, 167
Job hiring, medicolegal aspects of, 61
Jones tests, 157
Jugular foramen, 69t, 70f
Junctional nevus, 48
Juri flap for baldness, 225, 226f
Juvenile breast hypertrophy, 171, 176
Juvenile melanoma, 48
Juvenile rheumatoid arthritis, 313

Kanavel's four signs of flexor
tenosynovitis, 299
Kaposi sarcoma, 295
Karapandzic repair of lower lip, 116f
Kasabach–Merritt syndrome, 103
Keloids, 4–5
Kenalog steroid injections for alopecia
areata, 224
Keratoacanthoma, 49, 294
Keratocystic odontogenic tumor, 134
– actinic (solar), 49
– seborrheic, 50
Kernahan and Stark's Striped Y
classification of cleft lip and palate,
75, 75f
Ketamine for anesthesia, 162
Kienböck disease, 304
Kirner deformity, 246
Kleeblattschädel, 97t
Klinefelter syndrome, gynecomastia in,
Klippel–Feil syndrome, 100–101
Klippel–Trenaunay syndrome, 104
Klumpke palsy, 281
Kojic acid
– for chemical peel, 213
– as skin lightener, 216
KTP laser, 227t, 228t
– for vascular anomalies, 232t
Kuhnt–Szymanowski procedure, 154
Kutler bilateral V-Y advancement flap
for fingertip amputation, 249t

Labial surface of tooth, 73
Labiaplasty, 182
Lacrimal bone, 67, 67f
Lacrimal sac, 157f
Lacrimal system
– anatomy of, 156, 157f
– reconstruction of, 157–158
Lactrodectus mactans bites, 55
Lagophthalmos, 155–156
Lambdoid suture, 96f
Laryngectomy, 113
Laser(s), 227–233
– defined, 227
– for hair removal, 232–233
– mechanism of action of, 227–228
– for skin resurfacing, 228–230, 229t
– for tattoo removal, 230–231, 231t
– types of, 227–228, 227t, 228t
– for vascular anomalies, 231, 232t
Lateral arm flap, 19t, 20
Lateral aspect of nose, partial nasal
reconstruction for, 146
Lateral brow elevation, 208
Lateral calcaneal artery flap, 18, 20f
Lateral calcaneal fasciocutaneous flap,
Lateral canthal tendon, 202, 202f
Lateral canthus defect, 151
Lateral crus graft, 197
Lateral femoral cutaneous nerve during
abdominoplasty, 184
Lateral incisors, 71
Lateral plantar nerve, 317
Lateral pterygoid muscle, 71t
Lateral rectus muscle, 68t
Lateral retinaculum, 203
Latissimus dorsi
muscle/musculocutaneous flap, 16t
– for abdominal wall reconstruction, 34
– for breast reconstruction, 177
– for chest reconstruction, 36
Lawsuits, 61
Leddy classification of Jersey finger,
268, 268t
Leeches for improved flap perfusion, 23
Le Fort fractures, 120–121, 120f
Le Fort I osteotomy, 92
Lentigo, 51
Lentigo maligna melanoma, 46
Lesser occipital nerve, 128
Lesser palatine foramina, 70f
Levator advancement, 153
Levator aponeurosis, 203
Levator function, grades of, 153
Levator labii superior alaeque nasi
muscle, 203
Levator palpebral muscle, 203
Levator plication, 153
Levator veli palatini (LVP) muscle, 79,
Lidocaine, 161, 161t, 162t
Lid retractors, 203
Limb development, 237
Limberg flap, 8, 8f
Lingual nerve in head and neck
reconstruction, 113
Lingual surface of tooth, 71
Lip cancer, 113
Lipectomy, suction, 185–186
Lipoma, 87
Liposuction, 185–186, 185t
– upper arm, 181
Lip reconstruction, 115, 115–117f, 115t
Lisch nodules, 51
Littler flap for fingertip amputation, 250t
LMs (lymphatic malformations), 103
“Lobster claw hand,” 242
Lobule of ear, 127
Lobule to nostril ratio, 195, 195f
Local anesthesia, 161–162, 161t, 162t
Local flaps for fingertip amputation,
249, 249–250t
Local muscle transposition for facial
paralysis, 106
Local tissue rearrangement, 6–10
– advancement flap as, 6–7, 7f
– bilobed flap as, 9, 9f
– distant flap as, 10
– excisions as, 6
– interposition flap as, 9
– island flap as, 10
– random cutaneous flap as, 6
– rhomboid (Limberg) flap as, 8, 8f
– rotation flap as, 6, 6f
– transposition flap as, 7–9, 8f, 8t, 9f
– V-Y flap as, 7, 7f
– Z-plasty as, 8, 8t, 9f
Lockwood ligament, 203
Lop ear, 130, 131f
Love sign, 293
Lower back wound, 37
Lower body lift, 182
Lower extremity, 317–322
– congenital anomalies of, 321
– foot reconstruction of, 319
– lower third reconstruction of, 319
– middle third reconstruction of,
– nerves and nerve disorders of,
– preoperative workup for, 318
– proximal third reconstruction of, 318
– trauma reconstruction of, 319–321,
– ulcers of, 321
Lower eyelid
– blepharoplasty of, 204–205
– – malposition after, 205
– defect of, 151
– lid retractors of, 203
– malposition of, 154–156, 157f
– periorbital fat of, 203
Lower jugular region, 110t, 111f
Lower leg, transverse cross-section
anatomy of, 138f
Lower lip
– Karapandzic repair of, 116f
– static reconstruction for asymmetry of,
Low median nerve palsy, 290
Low radial nerve palsy, 290
Low ulnar nerve palsy, 290–291
Loxosceles reclusa bites, 55
Luckett procedure, 211
Ludwig classification of female
alopecia, 223, 223f
Lumbrical(s), 283
Lumbrical plus after fingertip
amputation, 251
Lunotriquetral interosseous ligament,
Lunula, 247, 247f
LVP (levator veli palatini) muscle, 79,
Lyme disease, 301
Lymphangioma circumscriptum, 52, 103
Lymphatic drainage patterns of head and
neck, 111
Lymphatic malformations (LMs), 103
Lymphedema, 41–42, 41t
Lymph node biopsy, sentinel, 47

Mackinnon classification of nerve
injuries, 275, 275t
Macrodactyly, 243
Macrostomia, 76
Madelung deformity, 241, 242f
Mafenide acetate (Sulfamylon) for
burns, 30, 30t
Maffucci syndrome, 104, 296
Major histocompatibility complex
(MHC), 58
Malar support, 154
Male facelift, 190
Male pattern baldness, 222, 222f
Male rhinoplasty, 197
Malignant hyperthermia, 163
Malignant melanoma. See Melanoma
Malignant soft tissue hand tumors,
Malingering for anosmia, 62
Mallet injury, 267, 268t
Malocclusion, 88, 88t
Mammary tissue, accessory, 167
Mammograms, Eklund displacement or
compression, 169
– anatomy of, 69, 71t
– computer simulation surgery in
mandible reconstruction, 139–140
– defect classification, 134
– deformities of, 92
– fibula osteoseptocutaneous flap,
– fractures of, 124
– – pediatric, 125
– osteonecrosis of, 136, 137t
– reconstruction of, 136–139, 137t, 138f
– tumors of, 134–137
Mandibular ligaments, 188t
Mandibulectomy, 136
Mandibulofacial dysostosis, 100
Marcaine (bupivacaine) for anesthesia,
Marcus Gunn pupil, 123
Marfan syndrome, chest anomalies in, 36
Marginal mandibular nerve injury
– due to facelift, 189
– due to neck dissection, 112
Marjolin ulcers, 43
Marlex (polypropylene) mesh for
abdominal wall reconstruction, 35
Martin–Gruber connection, 274
Masseteric ligaments, 188, 188t
Masseter muscle, 71t
Massive localized lymphedema (MLL),
41t, 42
Massive weight loss
– body contouring complications with,
– gastric bypass procedures for, 182
– mastopexy and autoaugmentation of
breasts after, 182
– nutrition with, 182–183
– pseudogynecomastia after, 183, 183t
Mastectomy, 175
Mastication muscles, 69, 71t
Mastoid foramen, 70f
Mastopexy, 170, 170t
– after massive weight loss, 182
Mathes–Nahai classification
– of fasciocutaneous flaps, 19t, 20f
– of free fibular flap, 138
– of muscle/musculocutaneous flaps, 14t
Matrix cells of hair, 221f
Maxilla, 67, 67f
– blood supply to, 92, 93f
– hypoplasia of, 92
– vertical deficiency of, 92
– vertical excess of, 92
Maxilla-mandibular fixation (MMF),
Maxillary artery, 92, 93f
Maxillectomy, midface reconstruction
after, 113
Maxillofacial trauma, 120–126
– coding for, 61
– frontal sinus fractures as, 123–124
– general information on, 120
– indications to extract teeth in line of
fracture with, 124–125
– Le Fort fractures as, 120–121, 120f
– mandibular fractures as, 124
– nasal fractures as, 121–122
– nasoorbitoethmoid (NOE) fractures as,
123, 123t
– orbital fractures as, 122–123
– pediatric, 125
– zygoma fractures as, 121
Maxillonasal dysplasia, 100
Mayfield progressive perilunate
instability classification, 308
McCash procedure for Dupuytren
disease, 260
McCune–Albright syndrome, 101
MCP joint. See Metacarpophalangeal
Medial arm flap, 19t
Medial brow elevation, 208
Medial canthal tendon, 202, 202f
Medial canthus defect, 151
Medial plantar flap, 319
Medial plantar nerve, 317
Medial pterygoid muscle, 71t
Medial rectus muscle, 68t
Medial thigh lift, 181–182
Medial wall of orbit
– anatomy of, 67
– fractures of, 122
Median forehead flap, 19t
Median nerve, 273
Median nerve block, 162
Median nerve compression at forearm,
Median nerve palsy, 290
Medicinal leeches for improved flap
perfusion, 23
Medicolegal aspects, 61–62
Medium peels, 213t, 214
Medpor (porous polyethylene) implants,
– mandibular angle, 92
Meissner corpuscles, 274
Melanocytic nevi, 48
– giant congenital, 40, 47–48
Melanoma, 45–47
– acral lentiginous, 46, 295
– diagnosis of, 45
– and giant congenital melanocytic nevi,
– of hand, 295
– juvenile, 48
– malignant, 295
– metastasis of, 46
– of nail bed (subungual), 47, 295
– nodal involvement in, 46
– sentinel lymph node biopsy for, 47
– staging of, 46
– surgical margins for, 46–47
– tumor depth of, 46
– types of, 46
Melasma, 52
Membranous bone formation, 12
Mental foramen, 69
Mental nerve, 94
Menton, 91f, 91t
Merkel cell(s), 274
Merkel cell carcinoma, 52
Mesial surface of tooth, 73
Mesotherapy, 183
Metacarpal fractures, 264, 264f,
Metacarpophalangeal (MCP) joint
– dorsal dislocation of, 272
– osteoarthritis of, 315
– radial collateral ligament injury of
index finger at, 272
Metachondromatosis, 296
Metal implants, 26
– of melanoma, 46
– unknown primary presenting in neck
as, 108
Methemoglobinemia from local
anesthesia, 162
Metopic suture, 96f, 97
Meurmann classification of microtia,
MHC (major histocompatibility
complex), 58
Micrografting for hair transplantation,
Microsomia, craniofacial (hemifacial),
88–89, 99
Microsurgery, 22–24
Microtia, 128–129
Middle third helical rim defect, 131
Midface reconstruction after
total/subtotal maxillectomy, 113
Midjugular region, 110t, 111f
Midline nasal lesions, congenital, 86–87
Midpalmar space infection, 301
Milroy disease, 41t
Miniabdominoplasty, 184
Minoxidil (Rogaine) for androgenic
alopecia, 224
Mitten hand, 241
Mixed dentition, 71
MLL (massive localized lymphedema),
41t, 42
MMF (maxilla-mandibular fixation),
Moberg flap for fingertip amputation,
Möbius syndrome
– craniofacial anomalies in, 100
– hand anomalies in, 246
Mohs surgery, 50
Molars, 71
Molluscum contagiosum, 52
Mongolian spot, 48
Monsplasty, 182
Mucocele, 123
Mucoepidermoid carcinoma, 114t
Mucous cyst, 297
Muenke syndrome, craniosynostosis in,
Müller muscle, 203
Munro classification of
hypertelorbitism, 85, 85f
Muscle flaps, 14, 14–16t, 17f, 18f
Muscle transposition, local, for facial
paralysis, 106
Musculocutaneous flaps, 14, 14–16t,
17f, 18f, 19t, 20f
Musculocutaneous nerve, 274
Mustarde sutures, 210–211
Mutton chop flap for abdominal wall
reconstruction, 35
Myasthenia gravis, ptosis due to, 152
Mycobacterium marinum, hand
due to, 300
Mycophenolate mofetil, common side
effects of, 59t
Myelomeningocele, 37
Myoglobinuria due to electric burns, 31
Nagata technique for autologous ear
reconstruction, 129, 129t
Nager syndrome, 100
– anatomy of, 247, 247f
– hematoma of, 248
– injuries of, 248
– melanoma of, 47, 295
Nail fold infection, 299
Nail plate
– anatomy of, 247, 247f
– deformities of, 251
NAM (nasoalveolar molding)
– for alveolar cleft, 81
– for cleft lip repair, 77
Nasal airway obstruction, 203–204
Nasal alar defects
– partial nasal reconstruction for, 146
– rhinoplasty for, 197
Nasal alar flaring, 197
Nasal alar retraction/collapse, 197
Nasal anatomy, 192–193, 192f
Nasal dermoid cyst, 86
Nasal dorsum defect, partial nasal
reconstruction for, 147
Nasal dorsum deformity, rhinoplasty for,
194–195, 194t
Nasal fractures, 121–122
– pediatric, 125
Nasal hump deformity, rhinoplasty for,
194–195, 194t
Nasal lesions, congenital midline, 86–87
Nasal lining reconstruction, 145–146
Nasal reconstruction, 142–149
– auricular composite graft for, 143
– bilobed flap for, 144
– dorsal nasal (Rieger) flap for, 145,
– forehead flap for, 144–145, 144f, 145f
– full thickness skin graft for, 143
– of nasal lining, 145–146
– of nasal septum, 147
– partial, 146–147
– principles of, 142, 142f, 143t
– for rhinophyma, 143
– for septal perforation, 142, 143t
– total, 147–148, 148f
Nasal septum
– arterial supply of, 192
– defects of, 147
Nasal sidewall defect, partial nasal
reconstruction for, 146
Nasal subunits, 142, 142f
Nasal surgery olfactory dysfunction, 198
Nasal tip defects
– anatomic landmarks for, 195, 195f
– angle of divergence for, 195, 196f
– partial nasal reconstruction for, 146
– rhinoplasty for, 195–196, 195f, 196f
NASHA (nonanimal stabilized
hyaluronic acid) filler, 217
Nasion, 91f, 91t
Nasoalveolar molding (NAM)
– for alveolar cleft, 81
– for cleft lip repair, 77
Nasofrontal duct injury, 123
Nasolabial chin plane (NLCP), 191
Nasolabial flap, 19t
Nasolacrimal duct, 157f
Nasoorbitoethmoid (NOE) fractures,
123, 123t
Nasopalatine artery, 93f
Nasopalatine nerve, 203
Natatory bands in Dupuytren disease,
259, 259t
Nausea, postoperative, 163
NCM (neurocutaneous melanosis),
Nd:YAG (neodymium:yttrium-aluminum-
garnet) laser, 227t, 228t
– for tattoo removal, 231t
– anatomy of, 74, 74t
– bilateral exploration of, 110
– layers of, 187t
– regions of, 110, 110t, 111f
– skin lymphatic drainage patterns of,
– of tooth, 72f
Neck dissection, 109–112
– complications of, 111–112
– principles of, 109–110
– radical, 110
– – modified, 110
– regions of neck for, 110, 110t, 111f
– selective, 110
Neck reconstruction, 112–113
Neck rejuvenation, 190–191, 191t
Neck tumors
– classification and staging of, 108, 109t
– neck dissection for, 109–112, 110t,
– pediatric, 118
– reconstruction for, 112–113
– unknown primary presenting as
metastatic, 108
Necrotizing fasciitis, 56, 302
Necrotizing soft tissue infections, 56,
Neisseria gonorrhoeae, hand infections
due to, 300
(Nd:YAG) laser, 227t, 228t
– for tattoo removal, 231t
– anatomy and physiology of, 273–274
– layers of, 274
Nerve compression, 277–280
– in carpal tunnel syndrome, 277–278
– in cubital tunnel syndrome, 278–279
– in Guyon canal syndrome, 279
– of median nerve at forearm, 278
– pathophysiology of, 277
– of radial nerve at forearm, 279
Nerve conduit, 276
Nerve fibers, 274
Nerve graft, 276
Nerve injury (ies)
– of brachial plexus, 280–281
– classification of, 275, 275t, 290–291
– evaluation and timing of repair of, 275
– due to facelift, 189
– high, 290
– low, 290
– nerve regrowth after, 275
– nerve repair for, 276–277
– postoperative management of, 276
– principles of, 275–276
– and Wallerian degeneration, 275, 275t
Nerve regrowth, 275
Nerve repair, 275–277
Nerve transfer, 276
Neurapraxia, 275t
Neurilemmoma, 294
Neurocutaneous melanosis (NCM),
Neurofibroma, 51, 294
Neurofibromatosis, 51
– after fingertip amputation, 250
– after nerve injury or repair, 276–277
Neuroma-in-continuity, 275t
Neurotmesis, 275t
– Becker, 51
– blue, 48
– blue rubber bleb, 103
– compound, 48
– halo, 48
– intradermal, 48
– of Ito, 48
– junctional, 48
– melanocytic, 48
– – giant congenital, 40, 47–48
– of Ota, 48
– sebaceous of Jadassohn, 50
– spilus, 48
– Spitz, 48
– Sutton, 48
Nifedipine for improved flap perfusion,
Nipple, average male, 166
Nipple sensitivity after breast
augmentation, 169
NLCP (nasolabial chin plane), 191
Nodal involvement in melanoma, 46
Nodular melanoma, 46
Nodules due to filler, 218–219
NOE (nasoorbitoethmoid) fractures,
123, 123t
Nonanimal stabilized hyaluronic acid
(NASHA) filler, 217
Norwood-Hamilton classification of
male pattern baldness, 222, 222f
Nose. See also under Nasal
– aesthetic subunits of, 142, 142f
– anatomy of, 192–193, 192f
Notta nodule, 240
– for burn patients, 29–30
– with massive weight loss patient,

Obstetrician's hand, 241
Obstructive sleep apnea, orthognathic
surgery for, 89
Obturator nerve, 318
Oculoauriculovertebral dysplasia
(OAVD) syndrome, 99–100
Odontogenic tumors, 134
OKT3 (anti-CD3), common side effects
of, 59t
Olfactory dysfunction, nasal surgery, 198
Ollier disease, 296
Omental muscle/musculocutaneous flap,
– for chest reconstruction, 36
Onabotulinumtoxin A (botulinum toxin,
BOTOX), 219
– for brow lift, 208
Open book deformity after rhinoplasty,
Operating room (OR), minimal ambient
temperature in, 163
Opponensplasty, 290
Optic canal, 67, 67f, 70f
Optic foramen, 69t
Optic neuropathy, traumatic, 122–123
Oral cancer, 108
Orbicularis oculi muscle, 201
– anatomy of, 67, 67f, 68t
– pediatric tumors of, 118
Orbital apex syndrome, 123
Orbitale, 91f, 91t
Orbital fractures, 122–123
– pediatric, 125
Orbital septum, 202
Organ transplantation
immunosuppressants, impaired wound
healing due to, 4
Orofacial clefts, rare, 83, 84f
Orthognathic surgery, 88–93
– and blood supply to maxilla, 92, 93f
– for centric occlusion and relation, 90
– cephalometric analysis for, 90–92,
91f, 91t
– for cleft lip and palate, 81, 88
– for craniosynostosis, 99
– distraction osteogenesis in, 92
– indications for, 88–89, 88t
– for mandibular deformities, 92
– for maxillary hypoplasia, 92
– Medpor mandibular angle implants in,
– for overbite, 90, 90f
– for overjet, 90, 90f
– planning for, 89
– timing of, 89
– for vertical maxillary excess, 92
Orticochea flap for baldness, 225
Osler–Weber–Rendu syndrome, 103
Osmotic tissue expander, 40
Osseocutaneous flap, 21
Osseointegrated dental implant, 137
Osseous free flaps for mandible
reconstruction, 136–137, 137t
Osteoarthritis, 315
Osteochondroma, 296–297
Osteoconduction, 12
Osteogenesis, 12
Osteogenic sarcoma, 297
– of mandible, 136
Osteoid osteoma, 297
Osteoinduction, 12
Osteointegrated auricular prosthesis,
Osteomyelitis, 42–43
Osteonecrosis of mandible, 136, 137t
Osteoplastic thumb reconstruction, 255
Osteoradionecrosis of mandible, 136
Osteosarcoma, 297
– of mandible, 134
Otitis externa after otoplasty, 211
Otoplasty, 210–212
– anatomical measurements for, 210
– complications of, 211–212
– techniques for, 210–211
– timing of, 212
Outer root sheath of hair, 222
Overbite, 90, 90f
Overjet, 90, 90f
Over-resuscitation with burns, 31
Oxycephaly, 97t

Pachydermoperiostosis, 152
Palatal surface of tooth, 71
– anatomy of, 79, 80f
– primary vs. secondary, 80f
Palatine bone, 67, 67f
Palatine foramen, 80f
Palatoglossus muscle, 79
Palatopharyngeus muscle, 79
Palatoplasty, 80, 81
Palm, distal injuries of, 255
Palmar fasciitis and polyarthritis
syndrome (PFPAS), 315
Palmar space infections, 301
Parascapular flaps, 19t, 20–21, 21f
Paraspinous musculofascial flaps for
myelomeningocele, 37
Parkes Weber syndrome, 104
Parkland rule for fluid management, 29
Parona space infection, 301
Paronychia, 299
Parotidectomy, 113–114
Parotid ligaments, 188t
Parotid tumors, 114t
– pediatric, 118
Parry–Romberg syndrome, 100
Partial-thickness burns, 28, 28t
Particulate bone, 12
Passavant ridge, 79
PE (pulmonary embolism), 163–164,
Pectoralis major muscle advancement
flap for chest reconstruction, 36
Pectoralis major
muscle/musculocutaneous flap, 16t
Pectoralis major muscle turnover flap
for chest reconstruction, 36
Pectus excavatum due to Marfan
syndrome, 36
Pediatric cranioplasty, 12
Pediatric facial fractures, 125
Pediatric growth plate fractures, 269,
270f, 270t
Pediatric hand fractures, 269–270, 270f,
Pedicled flaps for breast reconstruction,
Peels. See Chemical peels
Penile reconstruction, 24
Penile replantation, 24
Perialar crescentic advancement flaps,
bilateral, 117f
Periareolar mastopexy, 170
Perilunate instability, 308–309
Perineal reconstruction, 24
Perineurium, 274
Periocular defect, 151
Periodontal ligaments, 71, 72f
Periorbital fat, 203
Periostitis after rhinoplasty, 198
Peripheral vascular disease ulcer, 321
Permacol for abdominal wall
reconstruction, 35
Permanent teeth, 71, 72f
Peroneal artery flap, 18, 19t
Peroneal nerve, 138f
Peroneal nerve palsy, 317
Peroneal vessels, 138f
Peroneus brevis muscle, 138f
Peroneus longus muscle, 138f
Petrotympanic fissure, 70f
Pfeiffer syndrome, craniosynostosis in,
PFPAS (palmar fasciitis and
polyarthritis syndrome), 315
Phalangeal fractures and dislocations,
Pharyngoplasty, sphincter, 81
Phenol for chemical peel, 214–215
Photodynamic therapy prior to skin
resurfacing, 230
Phyllodes tumor, 176
Pierre Robin sequence, 76–77
Pilomatricoma, 52
Pincer nail syndrome, 251
Pinna, 127
PIP joint. See Proximal interphalangeal
Pitanguy line, 187, 207
Pit viper bites, 54
Plagiocephaly, 97t
Plantar nerves, 317
Plasmatic imbibition stage of skin graft
healing, 11t
Plating, resorbable, 26
Pleomorphic adenoma, 114t
PMMA (polymethyl methacrylate)
implants, 26
Pneumonia due to burns, 31
Podagra, 314
Pogonion, 91f, 91t
Poland syndrome
– breast anomalies in, 167
– hand anomalies in, 241
Pollicization, 245–246
Polly beak deformity after rhinoplasty,
Polydactyly, 237–239, 238f, 238t
Polymethyl methacrylate (PMMA)
implants, 26
Polypropylene (Marlex, Prolene) mesh
for abdominal wall reconstruction, 35
Polytetrafluoroethylene (Gore-Tex) mesh
for abdominal wall reconstruction, 35
PONV (postoperative nausea and
vomiting), 163
Porion, 91f, 91t
Porous polyethylene (Medpor) implants,
– mandibular angle, 92
Positional molding, 97t
Posterior adductor space infection, 301
Posterior condylar canal, 70f
Posterior fontanelle, 96, 96f
Posterior interosseous flap, 18, 19t
Posterior lamella of eyelid, 201
Posterior pharyngeal flap, 81
Posterior thigh flap, 24
Posterior tibial vessels and nerve, 138f
Posterior triangle of neck, 110t, 111f
Postoperative complications, 163–164,
Postoperative nausea and vomiting
(PONV), 163
Postseptal fat pads, 203
PRC (proximal row carpectomy) for
SLAC wrist, 305
Prednisolone, common side effects of,
Preiser disease, 305
Premaxilla, 79, 80f
Preseptal incision, 204
Pressure sores, 42–43, 42t, 43t
Pretendinous bands in Dupuytren
disease, 259, 259t
Primary palate, 80f
Procerus muscle, 203, 207t
Progeria, facelift for, 190
Prognathia, 92
Prolabium, 79
Prolene (polypropylene) mesh for
abdominal wall reconstruction, 35
Proliferative phase of wound healing, 3t
Prominent eye blepharoplasty, 205
Pronator syndrome, 278
Propecia (finasteride)
– for androgenic alopecia, 224
– for male pattern baldness, 222
Proptosis, 156
Prosthetic mesh for abdominal wall
reconstruction, 35
Proximal interphalangeal (PIP) joint
– contracture of, 289
– fractures and dislocations of, 269
– – complications of, 270
– osteoarthritis of, 315
Proximal row carpectomy (PRC) for
SLAC wrist, 305
Pseudoaneurysm of radial artery, 262
Pseudofolliculitis barbae, 51
Pseudogout, 302, 314
Pseudogynecomastia, 183, 183t
Pseudohypertelorbitism, 86
Pseudomonas aeruginosa, hand
infections due to, 300
Pseudoptosis, 152
Psoriatic arthritis, 314
Psychiatric aspects, 62
Pterygopalatine nerve, 203
Ptosis, 152–153
– assessment of, 152–153, 153t
– brow, 207
– defined, 152
– etiology of, 152
– after mastopexy, 170, 170t
– repair of, 153, 153t
– senescent, 152
Ptyalism, 114–115
Pudendal flap, 19t, 24
Pulmonary embolism (PE), 163–164,
Pulp chamber, 72f
Pulsed dye laser, 227t, 228t
– for tattoo removal, 231t
– for vascular anomalies, 232t
Punch biopsy for melanoma, 45
Punch grafting for hair transplantation,
Punctal occlusion, 158
Punctum, 157f
Pupillary defect, afferent, 123
Purpura fulminans, 32
Pyogenic granuloma, 52, 294

Q-switched alexandrite laser, 227t, 228t
– for tattoo removal, 230–231, 231t
Q-switched ruby laser, 227t, 228t
– for tattoo removal, 230–231, 231t
Quadrangular space, 21
Quadriga after fingertip amputation, 251
Quadriplegia, 291

Radial artery
– anatomical landmarks of, 22f
– pseudoaneurysm of, 262
Radial collateral ligament injury, index
finger MCP, 272
Radial forearm flap, 19t
– distally based pedicled, 22, 22f
– fasciocutaneous free, 21, 319
Radial limb syndromes, 244, 245t
Radial nerve
– anatomy and physiology of, 273–274
– compression at forearm of, 279
Radial nerve palsy, 163, 290
Radial sensory nerve block, 162
Radiation therapy
– and breast reconstruction, 178
– impaired wound healing due to, 4
– after mastectomy, 175
Radiesse, 217
Ramirez, Oscar, 35
Ramus lateralis nasi, 202f
Ramus septi nasi, 202f
Random cutaneous flap, 6
Raynaud disease, 261–262
Rectangular advancement flap, 7, 7f
Rectus abdominis
muscle/musculocutaneous flap, 16t
– for chest reconstruction, 36
– vertical, 24
Rectus femoris
muscle/musculocutaneous flap, 15t
– innervation of, 16t
– vascular supply to, 17f
Rectus sheath, 34, 34f
Reflex sympathetic dystrophy (RSD),
Regional anesthesia, 162–163
Regional flaps for fingertip amputation,
Reidel line, 94
Reiter arthritis, 314
Rejection of transplant, 58, 59t
Remodeling phase of wound healing, 3t
Replantation, 253–254
Resorbable plating, 26
Retaining ligaments of face, 188, 188t
Retin-A (tretinoin)
– for chemical peel, 213, 215
– prior to skin resurfacing, 230
Retrobulbar hematoma after
blepharoplasty, 206
Retrognathia, 92
Retro-orbicularis oculi fat (ROOF), 203
Revascularization stage of skin graft
healing, 11t
Reverse cross finger flap for fingertip
amputation, 249t
Reverse latissimus dorsi flap for lower
back wound, 37
Reverse sural artery fasciocutaneous
flap, 319
Rheumatoid arthritis, 310–313
– boutonniere deformity due to, 312
– caput ulnae syndrome due to, 313
– conservative early treatment of, 311
– demographics of, 310
– diagnostic criteria for, 310, 310t
– differential diagnosis of, 313
– evaluation of, 310–311
– extensor digitorum communis (EDC)
ulnar sublimation due to, 311
– extensor tendon rupture due to,
– flexor tendon adhesions due to, 312
– intrinsic tightness due to, 311–312
– juvenile, 313
– perioperative management of, 311
– surgical treatment for progression of,
– swan neck deformity due to, 311–312
– and trigger finger, 312
Rheumatologic disorders, 310–316
– gout as, 314
– HIV-related arthritis as, 314
– osteoarthritis as, 315
– pseudogout (chondrocalcinosis) as,
– psoriatic arthritis as, 314
– Reiter arthritis as, 314
– rheumatoid arthritis as, 310–313, 310f
– scleroderma as, 314
– septic arthritis as, 314
– systemic lupus erythematosus as,
Rhinitis, seasonal allergic, 194
Rhinophyma, 143
Rhinoplasty, 192–200
– advancing age, 197
– Asian, 197
– cleft, 79
– complications of, 198
– male, 197
– for nasal airway obstruction, 193–194
– of nasal ala, 197
– nasal anatomy for, 192–193, 192f
– of nasal dorsum, 194–195, 194t
– of nasal tip, 195–196, 195f, 196f
– secondary, 197
– thick skin, 197
Rhomboid flap, 8, 8f
Riedel procedure, 124
Rieger flap, 145, 146f
Ring avulsion injury, 257
Roberts syndrome, 245t
Rocker deformity, 195
Rogaine (minoxidil) for androgenic
alopecia, 224
Rolando fracture, 267
ROOF (retro-orbicularis oculi fat), 203
Root of tooth, 71, 72f
Rosebud hand, 241
Rotation flap, 6, 6f
RSD (reflex sympathetic dystrophy), 282
Rule of nines, 28, 29f

Sacral ulcers, 42, 43t
Saddle nose deformity after rhinoplasty,
Saethre-Chotzen syndrome,
craniosynostosis in, 98t
Sagittal suture, 96f
Salabration for tattoo removal, 231t
Salicylic acid for chemical peel, 213
Saline implant, 168
Salivary fistula from neck dissection,
Salivary gland secretion, excessive,
Salivary gland tumors, 113–115, 114t
Salter Harris classification of pediatric
growth plate fractures, 269, 270f,
– epithelioid, 295
– Kaposi, 295
– osteogenic, 297
– – of mandible, 136
– synovial, 296
Sartorius muscle/musculocutaneous flap,
Satyr ear, 130–131
Scalp anatomy, 68
Scalp expansion, 39
Scalp flaps, 19t
– for baldness, 224–225, 224–226f
Scalping flap for nasal reconstruction,
147, 148f
Scalp loss, partial or total, 225
Scalp reconstruction, 118, 118t
Scalp reduction for baldness, 224, 224f
Scapha, 127
Scaphocephaly, 97t
Scaphoid fossa, 127f
Scaphoid fracture, 307–308, 308f
Scaphoid ring sign, 305
Scaphoid shift test, 305
Scapholunate advanced collapse
(SLAC), 304–305
Scapholunate interosseous ligament, 304
Scapular flaps, 19t, 20–21
Scar(s), hypertrophic, 5
Scarpa fascia, 181
SCC. See Squamous cell carcinoma
SCDs (sequential compression devices),
Schirmer test, 153
Schwannoma, 294
Scleral show, 205
Scleroderma, 262, 314
Sculptra, 217
Seasonal allergic rhinitis, 194
Seborrheic keratosis, 50
Secondary palate, 80f
Second-degree burns, 28, 28t12
Second molars, 71
Seddon classification of nerve injuries,
275, 275t
Selective photothermolysis, 228, 228t
– for vascular anomalies, 231, 232t
Sella, 91f, 91t
Sella nasion pogonion (SNPg) angle,
91f, 91t, 92, 94
muscle/musculocutaneous flap,
innervation of, 16t
Semitendinous muscle/musculocutaneous
flap, innervation of, 16t
Senile lentigo, 51
Sensory receptors, 274
Sentinel lymph node biopsy (SLNB), 47
Septal fracture, 122
Septal hematoma, 122
Septal perforation, 142, 143t
Septal pivot flap, 147
Septic arthritis, 314
Septocutaneous flap, 19t, 20, 20f
Sequential compression devices
(SCDs), 164
– from abdominoplasty, 184–185
– from body contouring, 183
– from breast reconstruction, 179
Serratus branch of thoracodorsal artery
with breast reconstruction, 179
Serratus muscle/musculocutaneous flap,
Seymour fracture, 269–270
SGAP (superior gluteal artery
perforator) flap for breast
reconstruction, 177
Sharpey's fibers, 71, 72f
SHFM (split hand/split foot
malformation), 242
Shock, burn, 31
Shprintzen syndrome, 77
Sicca syndrome, 115
Sickle flap for nasal reconstruction,
SIEA (superficial inferior epigastric
artery) flap, 19t
– for breast reconstruction, 177
Silicone granuloma, 168
Silicone implants
– complications of, 168–170
– generations of, 167t
– solid, 26
Silver nitrate for burns, 30
Silver sulfadiazine (Silvadene) for
burns, 30, 30t
SIMON acronym, 62
Simple lentigo, 51
Sinus anatomy, 68
Sjögren syndrome, 115
SJS (Stevens-Johnson syndrome), 32
Skier's thumb, 271–272, 271f
Skin, Fitzpatrick classification of, 229,
Skin avulsion of ear, 130
Skin cancer, 45
– basal cell carcinoma as, 49–50
– classification of, 45
– melanoma as, 45–47
– Merkel cell carcinoma as, 52
– Mohs surgery for, 50
– prevention of, 45
– risk factors for, 45
– sentinel lymph node biopsy for, 47
– squamous cell carcinoma as, 48–49
Skin diseases, facelift for, 190
Skin grafts, 11–12, 11t
Skin lesions, 45–52
– basal cell carcinoma as, 49–50
– melanocytic nevi as, 48
– – giant congenital, 40, 47–48
– melanoma as, 45–47
– miscellaneous, 50–52
– Mohs surgery for, 50
– sentinel lymph node biopsy for, 47
– squamous cell carcinoma as, 48–49
Skin lighteners, 215–216
Skin lymphatic drainage patterns of head
and neck, 111
Skin resurfacing, 228–230, 229t
Skin slough after facelift, 189
Skull base anatomy, 69, 69t, 70f
SLAC (scapholunate advanced
collapse), 304–305
SLE (systemic lupus erythematosus),
Sleep apnea, obstructive, orthognathic
surgery for, 89
SLNB (sentinel lymph node biopsy), 47
Small finger duplication, 238
Smoking, impaired wound healing due
to, 4
SNA angle, 90, 91f, 91t
Snake bites, 54, 54t
Snap-back test, 154
SNB angle, 91, 91f, 91t
SNPg (sella nasion pogonion) angle,
91f, 91t, 92, 94
Soft palate, 80f
Soft tissue infection(s), 54–56
– due to hydradenitis suppurativa,
55–56, 55t
– necrotizing, 56, 302
– due to snake bites, 54, 54t
– due to spider bites, 55
Soft tissue tumors, 50–52
– of hand
– – benign, 293–294
– – malignant, 295–296
Solar keratosis, 49
Solar lentigo, 51
Soleus muscle/musculocutaneous flap,
15t, 318–319
Solid organ transplantation, 57
Solid silicone implants, 26
SOOF (suborbicularis oculi fat), 203
Spade hand, 241
Sphenoid bone, 67, 67f
Sphincter pharyngoplasty, 81
Spider bites, 55
Spina bifida, 37
Spiral bands in Dupuytren disease, 259,
Spitz nevus, 48
Splay graft, 193
Split hand/split foot malformation
(SHFM), 242
Split-thickness skin graft (STSG), 11–12
Spock ear, 130–131
Spoon hand, 241
Spreader grafts
– for internal valve collapse, 193
– for nasal dorsum defects, 195
Squamous cell carcinoma (SCC), 48–49
– of hand, 295
– oral, 108
– of breast cancer, 175t
– of head and neck tumors, 108, 109t
– of hydradenitis suppurativa, 55t
– of melanoma, 46
Stahl ear, 130–131
Staphylococcus aureus, hand infections
due to, 300
Stener lesion, 271, 271f
Stenstrom technique, 211
Sterile matrix
– anatomy of, 247, 247f
– injury of, 248
Sternal cleft, 36
Sternal debridement, 36
Sternal wounds, 36, 36t
Sternocleidomastoid muscle injury from
neck dissection, 112
muscle/musculocutaneous flap, 15t
– common side effects of, 59t
– impaired wound healing due to, 4
Stevens-Johnson syndrome (SJS), 32
Stewart–Treves syndrome, 42
Stickler syndrome, 77
Strattice for abdominal wall
reconstruction, 35
Streptococcus toxic shock syndrome, 56
Streptokinase for improved flap
perfusion, 23
Striped Y classification of cleft lip and
palate, 75, 75f
Stroke, 291
STSG (split-thickness skin graft), 11–12
Sturge–Weber syndrome, 104
Stylomastoid foramen, 70f
Subciliary incision, 204
Subcondylar fractures, 124
Subglandular pocket, 168
Subglottic hemangioma, 102
Sublingual gland tumors, 114t
Submandibular gland tumors, 114t
Submandibular region, 110t, 111f
Submental region, 110t, 111f
Submucous cleft palate, 80
Suborbicularis oculi fat (SOOF), 203
Subpectoral pocket, 168
Subungual melanoma, 47, 295
Suction lipectomy, 185–186
Sulfamylon (mafenide acetate) for burns,
30, 30t
Sunderland classification of nerve
injuries, 275, 275t
Sunscreen prior to skin resurfacing, 230
Superficial inferior epigastric artery
(SIEA) flap, 19t
– for breast reconstruction, 177
Superficial peels, 213, 213t
Superficial peroneal nerve, 317
Superficial spreading melanoma, 46
Superficial temporal artery, 187
Superior crus, 127
Superior gluteal artery perforator
(SGAP) flap for breast reconstruction,
Superior labial artery, 192, 192f
Superior oblique muscle, 68t
Superior orbital fissure, 67, 67f, 69t, 70f
Superior orbital fissure syndrome, 123
Superior pharyngeal constrictors, 79
Superior rectus muscle, 68t
Supernumerary breast, 167
Supraomohyoid dissection, 110
Supraorbital nerve, 202, 207
Supratip deformity after rhinoplasty, 198
Supratrochlear artery, 202f
Supratrochlear nerve, 202, 206–207
Sural artery flap, 19t
Sural nerve, 317
Surgical margins for melanoma, 46–47
Surgisis, 27
– for abdominal wall reconstruction, 35
Sutton nevus, 48
Sutures for tip rhinoplasty, 196
Swan neck deformity, 267, 287,
Sweet syndrome, 302
Symmastia after breast augmentation,
Symphalangism, 246
Syndactyly, 239–240, 239f
– bilateral, 241
Synovial sarcoma, 296
Syringoma, 51
Systemic lupus erythematosus (SLE),

Tacrolimus (FK-506), common side
effects of, 59t
Talipes equinovarus, congenital, 321
TAM (total active range of motion),
Tar burns, 32t
Tarsal conjunctival mullerectomy, 153
Tarsal tunnel syndrome, 317
Tarsoligamentous structures, 202–203,
Tarsus, 202
TAR (thrombocytopenia–absent radii)
syndrome, 245t
– dyes for, 231
– removal of, 230–231, 231t
– types of, 230
TBSA (total body surface area) of burns,
28, 29f
TCA (trichloroacetic acid) for chemical
peel, 214
Tearing, excessive, 157
– anatomy of, 71–73, 72f
– in line of fracture, 124–125
Telephone ear deformity after otoplasty,
Telogen effluvium, 224
Temporalis muscle, 71t
Temporomandibular joint disorders,
Temporomastoid flap for nasal
reconstruction, 148
Temporoparietal fascia flap, 19t
Temporoparieto-occipital flap for
baldness, 225, 226f
TEN (toxic epidermal necrolysis), 32
Tendonitis, 287–288
Tendon transfers, 289–290
Tensor fascia lata
muscle/musculocutaneous flap, 15t
– for abdominal wall reconstruction, 34
– innervation of, 16t
– vascular supply to, 17f
Tensor veli palatini (TVP) muscle, 79,
Terry Thomas sign, 305
Tessier, Paul, 83
Tessier clefts, 83, 84f
Tetrapod fracture, 121
Textured breast implants, 168
TFCC (triangular fibrocartilage
complex), 304
Thelarche, benign premature, 167
Thenar flap for fingertip amputation,
Thenar space infection, 301
Thermal burns, 28–31, 28t, 29f, 30t
Thick skin rhinoplasty, 197
Thigh nerves, 318
Third-degree burns, 28, 28t
Thoracodorsal artery, serratus branch of,
with breast reconstruction, 179
Thrombocytopenia–absent radii (TAR)
syndrome, 245t
Thromboembolism from liposuction,
Thrombosis, deep vein, 163–164, 164t
– amputation and reconstruction of, 255,
256f, 256t
– clasped, 240
– duplication of, 238, 238t
– fractures of, 266–267
– gamekeeper's/skier's, 271–272, 271f
– hypoplasia of, 244, 245t
– trigger, 240
Thumb in palm deformity, 241–242
Thumb position, transfer of index finger
to, 245–246
Tibial fractures, 319–321, 320t
Tibialis anterior muscle, 138f
Tibialis anterior
muscle/musculocutaneous flap, 16t
Tibialis posterior muscle, 138f
Tibial nerve, 317
Tip graft, 196
Tip rhinoplasty, 195–196, 195f, 196f
Tip rotation, cephalic, 196
Tip rotation suture, 196
Tissue expansion, 39–40, 39f
– for baldness, 225
– for breast reconstruction, 176, 178
Tissue plasminogen activator (t-PA) for
improved flap perfusion, 23
TON (traumatic optic neuropathy),
Tongue anatomy, 73, 73f
Torticollis, 99
Total active range of motion (TAM),
Total body surface area (TBSA) of
burns, 28, 29f
Toxic epidermal necrolysis (TEN), 32
Toxic shock syndrome
– after rhinoplasty, 198
– streptococcus, 56
t-PA (tissue plasminogen activator) for
improved flap perfusion, 23
Traction alopecia, 224
Tragus, 127, 127f
TRAM (transverse rectus abdominis
muscle) flap for breast reconstruction,
Transconjunctival incision, 204
TransCyte, 27
Transdomal suture, 196
Transplantation, 57–59
– grafts for, 57
– history of, 57
– immunology of, 57–59, 58t, 59t
– immunosuppressive agents for, 58, 58t
– – common side effects of, 58, 59t
– rejection of, 58, 59t
– solid organ, 57
– types of, 57
Transposition flap, 7–9, 8f, 8t, 9f
Transverse back flap, 19t
Transverse facial artery, 187
Transverse nasalis muscle, 203
Transverse rectus abdominis muscle
(TRAM) flap for breast
reconstruction, 176–177
Transverse upper gracilis (TUG) flap
for breast reconstruction, 177–178
Trapeziometacarpal arthrodesis, 307
Trapezius muscle/musculocutaneous
flap, 15t
Traumatic optic neuropathy (TON),
Treacher Collins syndrome, 100
Tretinoin (Retin-A)
– for chemical peel, 213, 215
– prior to skin resurfacing, 230
Triangular fibrocartilage complex
(TFCC), 304
Triangular fossa, 127, 127f
Triangular space, 20
Trichloroacetic acid (TCA) for chemical
peel, 214
Tricholemmoma, 51
Trichotillomania, 224
Trigger finger, 287
– rheumatoid arthritis and, 312
Trigger thumb, 240
Trigonocephaly, 97t
Trisomy 21, 100
Trochanter sores, 42, 43t
Trunk reconstruction, 34–37
– of abdominal wall, 34–35, 34f
– of chest, 36, 36t
– of lower back, 37
Tsuge classification of ischemic forearm
contractures, 288
Tuberous breast deformity, 166–167
TUG (transverse upper gracilis) flap for
breast reconstruction, 177–178
Tumescence techniques for liposuction,
185, 185t
TVP (tensor veli palatini) muscle, 79,
22 minus syndrome, 77
22q11.2 deletion syndrome, 77
Two-flap palatoplasty, 80

– of below-the-knee amputation stump,
– diabetic, 321
– peripheral vascular disease, 321
– venous stasis, 321
ULC (upper lateral cartilage) fold-in
flap, 193
Ulnar nerve
– anatomy and physiology of, 273
– compression at wrist of, 279
Ulnar nerve palsy, 290–291
Ultrasound-assisted liposuction, 185
Umbilical necrosis with breast
reconstruction, 179
Unilambdoid synostosis, 97t
Upper eyelid
– blepharoplasty of, 204
– – malposition after, 205
– defect of, 150–151
– lid retractors of, 203
– malposition of, 152–153, 153t
– paralysis of, 107
– periorbital fat of, 203
Upper jugular region, 110t, 111f
Upper lateral cartilage (ULC) fold-in
flap, 193
Upper third helical rim defect, 131
Urbaniak classification of ring avulsion
injuries, 257
Urokinase for improved flap perfusion,
Uvula, 79, 80f

VACTERLS syndrome, hand anomalies
in, 245t
Vaginal reconstruction, 24
Van der Woude syndrome, 76
Vascular anomaly (ies), laser treatment
for, 231, 232t
Vascular anomaly syndromes, 103–104
Vascular disease of hand, 261–262
Vascular malformations, 102–103
Vastus lateralis
muscle/musculocutaneous flap, 15t
– for abdominal wall reconstruction, 34
– innervation of, 16t
– vascular supply to, 17f
Vaughan–Jackson progression, 313
Veau classification of cleft lip and
palate, 75, 75f, 75t
Velocardiofacial syndrome, 77
Velopharyngeal insufficiency, 81
Venous congestion due to filler, 218
Venous flow through flap, 24
Venous malformations (VMs), 103
Venous stasis ulcer, 321
Verruca vulgaris, 294
Vertical buttresses of face, 120
Vertical mastopexy, 170
Vertical maxillary deficiency, 92
Vertical maxillary excess (VME), 92
Vertical rectus abdominis myocutaneous
(VRAM) flap, 24
Vincula, 283
Virchow's law, 96
VISI (volar intercalated segment
instability), 304, 306, 306f
Visual loss
– from blepharoplasty, 206
– due to filler, 218
VM(s) (venous malformations), 103
VME (vertical maxillary excess), 92
Volar beak ligament, 304
Volar intercalated segment instability
(VISI), 304, 306, 306f
Volar V-Y cup advancement flap for
fingertip amputation, 249t
Volkmann contracture, 289
Vomer flap, 80
Vomiting, postoperative, 163
von Hippel–Lindau disease, 52
von Recklinghausen disease, 51
VRAM (vertical rectus abdominis
myocutaneous) flap, 24
Vulcan ear, 130–131
V-Y flap, 7, 7f
V-Y hamstring flap, innervation of, 16t

Waardenburg syndrome, 77
Waiter's tip deformity, 281
Wallerian degeneration, 275, 275t
Wartenberg sign, 278, 288
Wartenberg syndrome, 288
Warthin tumor, 114t
Washio flap for nasal reconstruction,
Wassel thumb duplication classification,
238, 238t
Watson shift test, 305
Webster technique, 211
Webster triangle, 195
Wedge resection for abdominoplasty,
Weight loss, massive. See Massive
weight loss
Werner syndrome, facelift for, 190
Wernicke encephalopathy, 164
White phosphorus burns, 32t
Whitnall ligament, 203
Whitnall tubercle, 203
Wound care, 5
Wound closure coding, 60, 60t
Wound dehiscence with body contouring,
Wound dressings for burns, 30, 30t
Wound healing, 3–5
– for burns, 30
– collagen in, 3–4, 3t
– excessive, 4–5
– impaired, 4
– phases of, 3, 3t
– synthesis in, 4
– wound care and, 5
Wrist, 304–309
– anatomy of, 304
– basal joint arthritis of, 307
– DISI and VISI deformities of,
305–306, 306f
– ligaments of, 304
– perilunate instability of, 308–309
– scaphoid fracture of, 307–308, 308f
– scapholunate advanced collapse of,
– ulnar nerve compression at, 279
Wrong site surgery, 62
Wucheria bancrofti, lymphedema due to,

Xanthelasma palpebrarum, 51
Xenograft, 57
Xeomin (incobotulinumtoxin A), 219
Xeroderma pigmentosum, 45

Zone of polarizing activity (ZPA), 237
Z-plasty, 8, 8t, 9f
Zygoma fractures, 121
Zygomatic bone, 67, 67f
Zygomatic ligaments, 188, 188t