Plastic and Reconstructive Surgery

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					CHAPTER 43 - Plastic and Reconstructive
Surgery

 Robert J. Wood
 M.J. Jurkiewicz
INTRODUCTION
Plastic surgery is that aspect of the discipline of surgery in which concentration and
interest are focused on the restoration of form as well as function. The disorders that
the plastic surgeon encounters might be the result of trauma, aging, congenital
defects, cancer, or prior surgical procedures. Deformity and its consequences are
protean, and hence a plastic surgeon must have versatility, a sure spatial sense, and an
appreciation of the profound effects that deformity can have on the human spirit. The
foundation for the study of plastic surgery is a thorough education in surgical
principles and a detailed knowledge of anatomy, surgical technique, and the biology
of wound repair.

The word plastic derives from the Greek plastikos, meaning to mold. The term plastic
surgery appeared sporadically in a number of surgical texts through the eighteenth and
nineteenth centuries. It was firmly established with the publication of Plastic
Surgery—Its Principles and Practice in 1919 by John Staige Davis.

Many modern plastic surgical procedures have their roots in ancient times with early
practitioners. In the Sushruta Samhita, an early text written in the sixth or seventh
century b.c. by the practitioner Sushruta, reconstruction of an amputated nose with a
pedicled forehead flap and reconstruction of auricular defects with cheek flaps are
described. Amputation of the nose remained a common form of punishment in India
through the eighteenth century. When this technique was noted by English physicians
of the seventeenth and eighteenth centuries it became known as the Indian method of
nasal reconstruction. The Roman physician Celsus described operations for the repair
of traumatic injuries to the nose, eyelids, ears, and lips in the first century a.d. Another
Roman physician, Paulus Aegineta, also described operations for the treatment of
facial injuries in the first century a.d.

The Middle Ages produced few known practitioners of reconstructive procedures.
The period of the Renaissance marked a resurgence in attempts at reconstructive
surgery. During the fifteenth century members of the Branca family in Italy practiced
techniques of nasal reconstruction probably derived from Sushruta. Gaspara
Tagliacozzi (1545–1599) published De Curtorum Chirurgia per Insitionem in 1597.
This is believed by many to be the first modern plastic surgery text; it describes the
technique of nasal reconstruction using an arm flap.

Baronio described the successful grafting of skin in sheep in 1804. Techniques for
human skin grafting were described by Revendin in France, as well as by Ollier and
Thiersh in a series of publications during the latter part of the nineteenth century. As
with other surgical specialties, great advances in plastic surgery took place during the
First and Second World Wars. During the period of the First World War the discipline
of plastic surgery became well established by melding techniques of dental surgery,
otolaryngology, ophthalmology, and general surgery. In England Sir Harold Gillies,
an otolaryngologist, established a center for maxillofacial reconstruction of the many
allied military casualties. V. H. Kazanjian is well known for his application of dental
techniques to these injuries. In particular, he pioneered the use of prosthetic devices to
maintain soft tissue as delayed bony reconstructions were performed. Upon entry of
the United States in World War I, Vilray P. Blair of St. Louis became consultant to
the surgeon general of the army and organized units to care for soft tissue wounds and
maxillofacial reconstruction.

In the period between World Wars I and II academic societies of plastic surgeons
were established and the training of plastic surgeons both in the United States and
Europe became more formalized. As in World War I, centers for plastic surgery were
established during World War II, including centers for reconstructive surgery of the
hand. Ever since World War II a unifying theme in the clinical and research work of
plastic surgeons has been the transfer of tissue, both autologous and allogeneic. The
biology of the transplantation and rejection of skin allografts was studied by Gibson
and Medawar, who set the stage for the first successful renal transplantation in
monozygotic twins by Joseph Murray and coworkers in 1954 at the Peter Bent
Brigham Hospital in Boston.

The techniques of moving tissues regionally within a patient were advanced by the
development of axial pattern flaps, including the deltopectoral flap by Bakamjian in
1965 and the groin flap by McGregor and Jackson in 1972. Transferring muscle and
muscle-skin units had been described in the nineteenth century by Tanzini. Lost and
forgotten, the work was rediscovered by McCraw, Orticochea, Ger, Vasconez,
Bostwick, and others. Since 1974 a great number of muscle and muscle-skin flaps
have been developed.

Also during this time the development of microsurgical techniques by Buncke in the
United States, Ackland in the United Kingdom, Harii and Ohmori in Japan, and
Taylor in Australia made possible the transfer of tissues from distant donor sites.
Among the earliest “free flaps” described were transfer of the omentum and groin
flap. By 1990 microsurgical transfer of a great number of muscle as well as skin flaps
was commonplace, and replantation of traumatically amputated extremities and digits
became a standard of care.

In France, Paul Tessier and coworkers in the 1960s pioneered new techniques for
reconstruction of deformities of the craniofacial skeleton. This new discipline of
craniofacial surgery was rapidly adopted in the United States, and multidisciplinary
centers for the treatment of craniofacial disorders were established.

GENERAL PRINCIPLES
Skin Incisions
Perhaps more than in any other surgical specialty the operative results in plastic
surgery are readily apparent, to both the trained and the untrained eye. Although a
patient may not have an opinion about the adequacy of resection after colectomy for
colon carcinoma, the same patient would almost certainly have a strong opinion about
the results of rhinoplasty or the repair of a child's cleft lip. Hence in any plastic
surgery procedure skin incisions are planned to optimize the resultant scar. Langer has
described the skin lines of minimal tension that generally run perpendicular to the
long axis of underlying muscles (Fig. 43-1). Gravitational forces also work to produce
these lines. The lines of minimal tension, or Langer's lines, are very obvious in the
face of an older person, in whom they can be seen as the lines of facial expression
(Fig. 43-2). An incision planned within or parallel to these lines will result in a
narrower and less conspicuous scar than one that runs perpendicular to the lines of
minimal tension. Elective incisions may also be placed in areas less obvious to the
observer, such as the hairline or eyebrow, or within the eyelids, nares, or mouth.

As the scar matures there is an attendant contraction of the wound. If an incision must
cross a joint surface, the direction of the incision should be altered so a linear
contracture does not develop that may restrict joint motion. An incision placed across
a joint in an oblique or transverse fashion will lengthen the overall scar and change
the direction of wound contracture to optimize range of motion.

Excisions of lesions small enough to be closed primarily are frequently performed by
an elliptical excision. The long and short axes should be in a ratio of approximately
4:1. Excisions by an ellipse with a long axis that is too short will often result in excess
tissue at either end of the closure, or a dog ear. Removal of this excess tissue can be
performed with a number of techniques, all of which result in a longer but much more
acceptable scar. A common technique involves extending the incision in longitudinal
fashion and then excising the redundant tissue on one side of the incision (Fig. 43- 3).

Wound Closure
Wound healing is a complex process dependent on local and systemic factors as well
as surgical technique. Before closing any wound, basic preparation includes
debridement of devitalized tissue and removal of foreign bodies and gross wound
contaminants. Debridement of devitalized tissue is considered by many to be the
single most important factor in the management of a contaminated wound. Nonviable
tissue within a wound acts as a culture medium for bacterial growth and also affects
leukocyte function by promoting an anaerobic environment within the wound. Tissue
viability and the extent of debridement required are best judged by thorough
inspection of the wound. In fresh traumatic or surgical wounds skin viability can often
be difficult to assess accurately. In these instances the injection of fluorescein dye can
be helpful in demarcating devitalized skin. In general, however, viable skin edges and
muscle tissue bleed when debrided, and viable muscles contract when stimulated.

Ideally skin should be coapted with minimal or no tension (Fig. 43-4). Excessive
tension across a wound can lead to delayed wound healing and a wide scar. The
tension across a wound closure can be modulated by undermining the surrounding
skin, closing the wound in a layered fashion such that sutures in a deep dermal or
subcutaneous plane reduce the tension at the skin edge, and by transposing additional
skin into the wound in the form of a flap.

Skin and subcutaneous tissues may by coapted with suture material, staples, or
surgical tape. A great variety of suture material, absorbable and nonabsorbable, is
available to the surgeon. Common absorbable sutures include surgical gut, chromic
gut, polyglactin-910 (Vicryl), polydioxanone (PDS), and polyglycolic acid (Dexon).
Plain gut, derived from sheep or beef intestine, loses most of its strength within 7
days. This is commonly used in areas where wound healing is expected to be rapid
and suture removal may be difficult. Fine gut suture (6-0) is commonly used for skin
closure in the periorbital regions and in facial wounds in children. Chromic gut is
treated to resist breakdown by tissue and maintains its tensile strength longer that
plain gut. We frequently use this suture within the mouth and nose, where suture
removal can be difficult. Tissue reaction to chromic gut can be significant. It is rarely
used on the skin of the face. Polyglactin and polydioxanone sutures can be used in
subcutaneous tissues. Polyglactin will have lost approximately 70 percent of its tensile
strength at 3 weeks, and polydioxanone will maintain approximately 50 percent of its
tensile strength at 4 weeks and 25 percent at 6 weeks.

Nonabsorbable sutures include surgical silk, surgical cotton, surgical steel, nylon,
polypropylene, and polyethylene terephthalate. Nylon and polypropylene are
relatively inert within tissue. These sutures are appropriate for skin closure in both
interrupted and running subcuticular “pull-out” fashion, tendon repairs, and
microsurgery. A continuous running polypropylene suture in a subcuticular fashion
allows the accurate coaption of skin edges and can be left in place without creating
suture marks in the skin. A subcuticular polypropylene pull-out suture is our standard
for general skin closure. The point where a suture pierces the epidermis will begin to
epithelialize at 3 days. This process is responsible for the permanent suture marks
sometimes seen after wound repair. To prevent these permanent suture marks, skin
sutures on the face should be removed at 3 to 5 days and the wound stabilized with
sterile tape.

Skin Grafts
Skin grafting is one of the most powerful techniques in plastic surgery. By
transplanting a sheet of epidermis and a variable thickness of dermis a surgeon is able
to close wounds that would otherwise require a more complex flap or free tissue
transfer. The technique of skin grafting also allows large areas to be resurfaced, as in
the treatment of burns. A skin graft is a sheet of skin including epidermis and a
variable thickness of dermis that is completely freed from its native blood supply and
transplanted to a recipient site to be closed. Skin grafts may be either full thickness,
including all epidermis and dermis, or partial (split) thickness, in which the skin is
harvested at some level within the dermis (Fig. 43-5). Partial-thickness grafts are
frequently harvested at a thickness of 1/1200 to 1/2000 of an inch. Harvesting skin at
this level will leave some dermis as well as epidermal appendages such as hair
follicles and sweat glands in the donor site. These epidermal appendages then allow
regeneration of new epidermis to close the donor site.

A full-thickness graft, because it includes the entire epidermis and dermis at the donor
site, requires that the donor site be closed primarily or left open to granulate and
contract. In a full-thickness graft there are no epidermal or dermal remnants to allow
epithelialization as in a partial- thickness graft (Fig. 43-6). As a general rule, split-
thickness grafts have a greater chance of surviving but will contract up to 40 percent
on average. In practice, the type of skin graft is matched to the given clinical situation.
Partial-thickness grafts are usually used to resurface burns, as the donor areas will
rapidly close and can be reharvested. A full-thickness graft is usually selected to
resurface relatively small and critical areas such as an eyelid so that contraction of the
grafted tissue is minimal.
There are a number of commonly used donor sites for full-thickness grafts. In
selecting a donor site, the surgeon must consider which anatomic location provides
the best skin color and texture match to the anatomic area being grafted and the
consequences of a scar in the region of the donor site. In general, donor sites that are
closest anatomically to the site to be grafted will have a closer match in skin color and
texture. Postauricular skin is suitable for grafting the skin of the face. Smaller grafts in
this area may be taken and the donor site closed primarily. If necessary the entire non-
hair-bearing skin of the postauricular and mastoid region can be harvested and grafted
with split-thickness skin, as this area is relatively concealed from a frontal view. The
supraclavicular region is another appropriate donor site for a full-thickness graft for
the face. This skin will often maintain a pinkish tone to match the face. The
antecubital crease and inner aspect of the arm are appropriate donor sites for full-
thickness grafts for the hand or finger. These donor sites are usually already prepared
in the field during hand cases but have the disadvantage of a frequently prominent
scar. Transverse incisions in the area of the wrist flexion crease can be especially
troublesome to patients if mistaken by others as self- inflicted or an apparent suicide
attempt. The hip flexion crease in the inguinal area is an excellent donor site for full-
thickness grafting to the upper extremities and hands. The linear scar usually remains
well hidden in a natural skin fold. A limited split-thickness graft may be harvested
from the hypothenar region, which gives the best match and texture for the hand.
Redundant upper eyelid skin may be harvested with or without underlying orbicularis
muscle for full-thickness grafting of the contralateral lid. This is also a well-concealed
donor site when the donor incision is oriented within the tarsal fold.

When larger areas are to be grafted, split-thickness skin is frequently harvested from
the buttocks, thighs, and abdominal wall. It is desirable whenever possible to keep this
donor site in an area that will eventually be hidden by undergarments and bathing
suits. The scalp and suprapubic areas provide possible donor sites for split-thickness
skin. With the regrowth of hair in the donor site any resultant scar remains well
concealed. Thick grafts should be avoided in these areas to prevent alopecia. Scalp
donor sites reepithelialize rapidly and permit frequent reharvesting. This technique is
useful in treating extensive burns.

Cultured autologous keratinocytes can provide sheets of epithelium that will cover
patients who have massive burns. Promising techniques are being developed to
provide collagen or dermis matrix to enhance the stability of cultured keratinocytes.

For a skin graft to survive it must be revascularized by the recipient bed. Radiation-
damaged tissue and relatively avascular tissue such as tendon or bone are therefore
poor recipient sites for skin grafts. For the first 48 h that a skin graft is in contact with
the recipient bed the graft survives by a process known as plasmatic imbibition.
During this time nutrients diffuse from the underlying bed through the surrounding
extracellular fluid and directly into the capillaries and cells of the skin graft. During
this period fibrin bonds fix the graft to the recipient bed. At 48 h, vascular buds in the
bed have made contact with capillaries within the graft, and circulation is established
by a process known as inosculation. In this process vessels in the graft bed randomly
attach to capillaries in the skin graft or recipient site blood vessels grow into the graft
itself and within some of the preexisting capillaries. It remains controversial whether
neovascular ingrowth or random inosculation of existing vessels is the primary
method of revascularization.
For a graft to be successfully revascularized and survive, a number of conditions must
be satisfied. As discussed above, as a rule the recipient bed must be well vascularized.
An exception to this is the occurrence of the “bridging” phenomenon, in which a
small area of skin graft over avascular tissue is perfused via collateral vessels from
adjacent vascularized skin graft. In this event only several millimeters of vascularity
are bridged and even then may eventually break down.

Wounds containing more than 1 × 105bacteria per gram of tissue will not support a
skin graft. Heavily colonized wounds are also chronic and poorly vascularized. In
these instances simple examination of the wound is often not adequate and
quantitative bacteriology may be helpful. A rapid slide technique to predict the
number of bacteria per gram of tissue homogenate is examined microscopically and
the bacteria per gram of tissue reliably determined.

Contact of the skin graft and the recipient bed must be maintained for the skin graft to
survive. Any shear force between the graft and its bed will disrupt revascularization.
When a skin graft is applied to the extremities, splinting of proximal and distal joints
should be considered to limit motion at the site of the skin graft. Compressive
dressings also serve to firmly fix the skin graft to its bed. Any collection of fluid, such
as serum, blood, or purulent material, between the skin graft and its bed will also
prevent revascularization. Here again a compressive dressing such as a tie-over
dressing can be helpful. Meshing or “pie crusting” the skin graft with a number of
small slits in the graft will permit the egress of fluid beneath the graft into the adjacent
dressing. Unless a tie-over dressing is applied, examination of the graft on the second
postoperative day is recommended. At this point if any fluid collection is noted
beneath the graft, that area can be incised and the fluid evacuated.

Split-thickness skin grafts can be harvested by hand or by using a number of power
instruments. A drum dermatome such as the Reese dermatome employs an adhesive-
coated cylinder that is applied to the skin. As this cylinder is rotated away from the
surface of the skin a blade harvests a sheet of skin in a very controlled manner.

Humby knives and Weck knives use a guarded, disposable blade that harvests skin as
the knife is advanced tangentially across the body surface with a back-and-forth
movement. Power-driven instruments permit the rapid harvesting of large surface
areas. These include the Brown or Zimmer air- driven dermatome (Fig. 43-7) and the
Padgett electric dermatome. Full- thickness grafts are usually harvested with a No. 10
or a No. 15 blade by elliptical excision. Any fat is then trimmed from the dermal
surface to permit dermal contact with the recipient bed. This can be facilitated by
rolling the graft around the surgeon's finger with the dermal side exposed and then
using a Metzenbaum-type scissors to excise subcutaneous fat.

A number of mechanical devices are available to mesh skin grafts. All these devices
produce multiple uniform slits in the graft. When tension is applied perpendicular to
these slits, openings appear in the graft and the effective surface of the area is
increased. These openings will eventually epithelialize. Meshed skin grafts allow
large surface areas to be resurfaced and are particularly useful in large burns. They
contour well and allow the egress of any fluid collection beneath the graft during the
first 24 h. Meshed skin grafts contract more than sheet grafts, however, and the
aesthetic result is often inferior to that with sheet grafts.

Skin grafts can be secured to the recipient bed by staples, sutures, skin tapes, or the
dressing alone. For large burns skin stapling is rapidly done and decreases operating
time. We favor fine chromic sutures in the younger child, in whom staple or suture
removal can be problematic. Skin grafts are usually dressed with a layer of
nonadherent material such as Xeroform or Adaptic next to the graft's surface followed
by a layer of sterile absorbent gauze. The dressing is then secured by an occlusive
circumferential wrapping of an extremity and tape. A tie-over dressing is helpful for
providing compression in areas such as the face where the circumferential wrapping is
not possible (Fig. 43-8). Sutures placed circumferentially at the edge of the skin graft
are left long and then tied over a standard skin graft dressing beneath a layer of cotton
or Dacron fiber. This technique is also used to secure intraoral skin grafts. We
substitute a soft dental compound for the fiber bolus in oral tie-over dressings.

The split-thickness graft donor site heals by reepithelialization from epidermal
appendages in the dermis. Epithelial cells from sweat glands, hair follicles, and
sebaceous glands in the dermis migrate across the surface of the donor area. The
donor site is not unlike a partial-thickness burn wound; a donor site from which a
thick skin graft has been taken will heal more slowly than one from which a thin graft
has been harvested.

The healing process may take from 7 to 21 days, depending on the thickness of the
graft. This process is facilitated by a clean, moist environment. Donor sites may be
dressed with a layer of Xeroform and Adaptic followed by absorbent gauze or pads.
After 24 h the dressing is taken down to the level of nonadherent dressing material.
As healing occurs at the donor site the edges of the nonadherent material separate
from the underlying skin and may be trimmed. The donor site usually dries after it is
left open for 1 or 2 days. We do not favor the use of heat lamps or hair dryers to dry a
donor site because it is painful and impedes reepithelialization. The transparent
semipermeable dressings, such as Op- Site, are also excellent dressings for donor
sites. These have been shown to reduce pain remarkably at the donor site
postoperatively. They can be left in place for 1 to 2 weeks as epithelialization
proceeds. If an excessive amount of fluid collects under a transparent dressing it may
be drawn off with a syringe and the dressing “patched” with another, smaller piece of
transparent dressing using sterile technique.

We prefer to take down the skin graft dressing on the second postoperative day and
examine the graft for any fluid collection or signs of infection. If the likelihood of
these complications is thought to be small the dressing may be left undisturbed for 5
days for a split-thickness graft and 7 to 10 days for a full-thickness graft. Any
unexplained fever, local pain, erythema, or purulent drainage necessitates the
immediate removal of all dressings.

Infection can convert a donor site from a partial-thickness to full-thickness skin
wound. We treat any signs of infection at the donor site or skin graft site aggressively
with frequent dressing changes and topical and appropriate systemic antibiotic
therapy. Patients who are debilitated, immunosuppressed, or elderly are also at risk
for having the donor site convert to a full-thickness injury. When this risk is judged to
be high, the donor site can be grafted with a small amount of widely meshed split-
thickness skin.

When the skin grafts and donor sites are epithelialized, any commercially available
skin lotion containing lanolin or cocoa butter may be used. Compressive garments can
control edema and scar hypertrophy at both the skin graft and the donor site.

Lower-extremity skin grafts are maintained in a nondependent position for 7 days
postoperatively. Subsequently, activity is slowly increased from leg dangling to non-
weight-bearing to full-weight-bearing ambulation over the next 1 to 2 weeks. During
this time frequent examination of the graft is essential and compressive garments or
wraps are used for the first week. Activity is then increased as tolerated, with frequent
monitoring of the graft for any sign of breakdown. Elastic (Ace) bandages are
essential for 4 weeks.

A skin graft undergoes contraction in two phases. Primary contraction occurs as the
skin graft is lifted from its donor site. In this phase contraction is caused by elastic
fibers within the dermis of the skin graft. Thin grafts with less dermis contract less
than thick grafts. The secondary phase of contraction is largely a result of contraction
of the recipient bed. This phase begins after 7 to 10 days and continues for as long as
6 months. A number of factors alter the extent of the secondary contraction. Thin
grafts contract more than thick grafts, and full-thickness grafts undergo little
contraction. Meshed grafts or grafts in which only partial take has occurred contract
more as the open areas heal by contraction and epithelialization. Soft, mobile recipient
beds tend to contract more than fixed, rigid beds. For instance, skin grafts placed on
flexor surfaces often yield troublesome contractures.

Skin grafts, especially those taken below the clavicle, often become darker as they
mature. This is often more pronounced with thinner grafts. To minimize
hyperpigmentation skin grafts should be protected from ultraviolet light by clothing or
sunscreen for a full year postoperatively.

The return of sensation to a skin graft is dependent on the recipient bed and its
anatomic location. Heavily scarred beds or beds with poor native sensibility, such as
granulation tissue over bone or periosteum, allow minimal regeneration of peripheral
nerves into the graft. Two-point discrimination in a skin graft, however, will approach
that of surrounding skin if regenerating nerves are not impeded at the level of the
recipient bed. The return of sensation can be considered maximal at 2 years.

Skin grafts may be effectively banked by immediately replacing them on their donor
site. Grafts stored in this manner may be reharvested easily up to 48 h later. Skin
grafts may also be banked by placing them in saline- soaked gauze sponges and
storing them at 4°C. If sterility is maintained, grafts stored in this manner remain
viable for up to 21 days.

A composite graft is a free graft containing at least two different tissue elements. The
most common composite graft is skin and cartilage transferred to a small wedge taken
from the ear. This composite graft is commonly used to reconstruct alar defects of the
nose (Fig. 43-9). Common composite grafts include skin and cartilage from the
auricular concha, skin and fat from the earlobe, and skin and muscle from the eyelid.
Revascularization of a composite graft is similar to that in a split-thickness skin graft
except that the large ratio of volume to absorptive surface area precludes nourishment
from plasmatic imbibition. The general principles involved in skin graft survival also
apply to composite grafts. A well- vascularized recipient bed and meticulous
technique, including graft immobilization and hemostasis, are imperative for graft
survival. As a general rule, all points within the composite graft should be less than 1
cm from the recipient bed, and grafts with a diameter of less than 1.5 cm are safest.


Flaps
A flap is a tongue of tissue transferred from one anatomic site to another. Vascularity
of the transferred tissue is maintained by nutrient vessels within the flap pedicle. The
pedicle may either remain attached at its origin or be divided during transfer and
reanastomosed to recipient vessels using microsurgical techniques. Microsurgical
transfer of tissue is also known as a free flap. Flaps are useful for closing defects too
large for primary closure and where skin grafting is inadequate. Examples include
exposed structures such as brain, blood vessels, bone and joint surfaces, and wounds
with poor vascularity, where skin grafting would likely fail. Full- thickness defects in
the head and neck are often unacceptable in appearance and function when
reconstructed with skin grafts. In these instances flaps may provide better form and
function. The reconstructive surgeon may transfer functional units of bone, muscle,
and neural tissue for reconstruction of complex defects. Flaps, especially those
containing muscle, have proved useful in clearing infection at the recipient site.
Muscle flaps have proved to be very immunologically active and are a mainstay in the
treatment of problem infections such as osteomyelitis, sternal wound infections, and
infected prosthetic materials.

Flaps are classified according to their blood supply. A random flap receives blood
through the dermal and subdermal plexus (Fig. 43-10). The subdermal plexus receives
its blood supply from vessels extending from underlying muscles to the skin. These
vessels are sometimes referred to as musculocutaneous perforators. Skin flaps that
receive their blood supply from cutaneous arteries and veins longitudinally oriented
within the substance of the flap are known as axial pattern flaps (Fig. 43-11). A
fasciocutaneous flap contains skin and underlying fascia and is supplied by the
vascular plexus within the fascia. A musculocutaneous flap contains skin, fascia, and
muscle and is supplied by perforating vessels from the muscle to the subdermal
plexus (Fig. 43-12). Arterialized flaps have a richer vascular supply and allow for
reliable transfer of a greater amount of tissue.

Random Flaps
Random flaps receive their blood supply from the subdermal plexus via
musculocutaneous perforators at the base of the flap. These flaps are usually
categorized by their type of movement. The advancement flap is moved into a defect
without lateral or rotational movement. To close a rectangular defect, three sides of an
adjoining rectangle of tissue can be incised and undermined with a layer of
subcutaneous fat. The rectangle of skin is then advanced into the defect. Small
rectangles of tissue at the base of the flap, known as Burow's triangles, may be
excised to facilitate advancement. A triangle of tissue may also be advanced as a V-Y
advancement flap (Fig. 43-13). With this technique a rectangular defect is closed by
incising an adjacent triangle of tissue, which is advanced into the defect, closing the
secondary defect as a linear incision behind the flap. Advancement flaps generally
allow limited movement of tissue. This movement is facilitated in anatomic areas
where a relative excess of skin exists or in the elderly patient with loose, mobile skin.

A rotation flap is a semicircular flap rotating about a pivot point to close a triangular
defect (Fig. 43-14). The secondary defect may then be closed primarily or skin
grafted. A small backcut into the base of the flap can facilitate movement of a rotation
flap. A transposition flap is typically a rectangular flap that rotates about its base to
fill an adjacent defect (Fig. 43-15). This allows closure of the defect without undue
tension. Here again, a small backcut into the base of the flap may facilitate movement.
Any backcut into the base carries some risk of compromising the vascular supply of
the flap.

The Z-plasty is a particularly useful type of transposition flap (Fig. 43-16). The Z-
plasty consists of two triangular flaps, each of which is rotated into the defect left by
the other flap. This is frequently used to transfer tissue into a scar or contracture and
lengthen it or to reposition a scar within lines of minimal tension. The sides of the two
triangles must be equal in length, and the angles may vary between 30 and 90 degrees.
For any given angle, longer triangles will transfer more tissue and provide greater
lengthening. Larger angles will also transfer more tissue; however, clinical experience
has shown that 60 degrees provides optimal lengthening.

The rhomboid flap, or Limberg flap, is another common transposition flap design
(Fig. 43-17). To close a rhomboid-shaped defect with internal angles of 60 and 120
degrees, a rhomboid-shaped flap of identical dimensions is designed on the side of the
defect judged to have the most available tissue. A bilobed flap is a series of two
transposition flaps (Fig. 43-18). A properly designed bilobed flap is rotated into the
defect as a primary flap, and a secondary flap, whose diameter is half that of the
primary flap, is rotated into the defect left by the primary flap. The defect left by the
secondary flap is closed primarily. For a bilobed flap to be successful the secondary
flap should come from an area of relative skin laxity. An interpolation flap is similar
to a transposition flap in that a tongue of skin and subcutaneous tissue is rotated about
an axis. An interpolation flap, however, is transposed across an intervening bridge of
tissue. The deltopectoral flap, discussed below, is an example of an interpolation flap.

Axial Flaps
Axial pattern flaps contain cutaneous vessels running in the longitudinal axis of the
flap. They are better vascularized and more reliable than random flaps. The possible
length of an axial pattern flap is determined by the length of the cutaneous artery and
an additional distal area of skin that is randomly supplied by the subdermal plexus.
The midline forehead flap is based on supratrochlear vessels and is commonly used
for nasal reconstruction. The deltopectoral flap receives blood supply from
perforating branches of the internal mammary artery through the second, third, and
fourth intercostal spaces (Fig. 43-19). Historically, this flap has been a mainstay in the
reconstruction of head and neck defects. The groin flap is based on the superficial
circumflex iliac artery and has been used to resurface wounds of the hand and upper
extremity (Fig. 43-20). An axial pattern flap can be designed around the radial artery
to involve skin and subcutaneous tissues of skin and bone. The radial forearm flap can
then be transferred to defects of the upper extremity or transferred with microsurgical
techniques to distant sites. The entire greater omentum may be taken as an axial flap
based on either the right or left gastroepiploic arteries. The omentum is then available
for closing defects of the chest wall and mediastinum (Fig. 43-21). Because of its
large surface area, the omentum is particularly useful for extensive wounds such as
radiation injuries and sternal wound infections. The omentum readily accepts split-
thickness grafts to complete closure.

Fasciocutaneous Flaps
A fasciocutaneous flap consists of skin, subcutaneous tissues, and underlying fascia.
Blood supply is derived at the base of the flap from musculocutaneous perforators or
direct branches of major arteries. Because this flap includes the vascular plexus
immediately superficial to the fascia, it is more reliable than random flaps.
Fasciocutaneous flaps are frequently used in the lower extremity. A fasciocutaneous
flap can be designed to include perforators from the medial head of the gastrocnemius
muscle to close difficult wounds of the middle and proximal thirds of the lower leg.
The posterior thigh fasciocutaneous flap is frequently used for closure of ischial
pressure sores. This flap includes fascia lata, subcutaneous skin, and tissue of the
posterior thigh and includes the descending branch of the inferior gluteal artery. This
vessel runs parallel to the posterior cutaneous nerve of the thigh and accounts for the
reliability of this flap.

Muscle and Musculocutaneous Flaps
Muscles can be transferred into adjacent defects if their native vascular supply is
preserved. The utility of any given muscle flap is limited by the size of the muscle and
the length of its vascular pedicle and hence the distance it can be transferred. The
defect, both functional and cosmetic, created by the muscle transfer must also be
considered. Muscle flaps transfer richly vascularized and very immunologically active
tissue into wounds that are ischemic or infected. The bulk of muscle flaps allows
contour defects to be resurfaced.

Skin can be transferred with the underlying muscle. Vessels extending directly from
the muscle to the overlying skin, known as musculocutaneous perforators, account for
a significant portion of cutaneous circulation. These perforating vessels define
independent vascular territories within the skin that can be transferred as units with
muscle. This principle has been rediscovered several times in the past century.
Manchot, in 1889, noted that the skin received much of its blood supply from the
underlying muscle. Tanzini, in 1906, described the latissimus dorsi myocutaneous
unit for breast reconstruction. The concept was again lost until McCraw and
colleagues described a number of musculocutaneous flaps and their vascular
territories in 1974.

Delay
Partial disruption of the vascular supply to a flap in a preliminary procedure is known
as a delay procedure. The purpose of a delay procedure is to increase the length of the
random portion of the flap that will survive after transfer. In a delay procedure skin
incisions defining the flap partially disrupt the subdermal plexus but maintain the
primary pedicle. The flap is then replaced in its bed. One week later the flap is lifted
out of its native bed and transferred to the recipient site. Clinical experience suggests
that delay procedures can increase the amount of tissue a given pedicle can carry. The
mechanism of the delay phenomenon remains incompletely understood. There are two
general schools of thought. One theory suggests that delay acclimatizes the flap to
ischemia, permitting it to survive with less blood flow than would normally be
required. Another theory suggests that delay improves vascularity by increasing flow
through preexisting vessels, reorganizing the pattern of blood flow to more ischemic
areas. In reality, probably both mechanisms contribute to the delay phenomenon.

Free-Tissue Transfer
The development of microsurgery was one of the great advances in plastic surgery of
this century. Reconstructive surgeons previously were constrained by the arc of
rotation of any given vascular pedicle. Microvascular surgery allows the complete
division of a known vascular pedicle and reanastomosis to recipient vessels at a
distant site.

Replantation of severed upper extremities was reported by Malt and McKhan in 1964.
The first clinical example of free-tissue transfer was reported in 1972, when McLean
and Buncke transferred greater omentum to resurface a large scalp defect. Since that
time microsurgery has become standard in most large medical centers, and successful
reimplantations of severed parts occur on a daily basis. Many series of elective free-
tissue transfers report success rates higher than 95 percent. Free-tissue transfer has
applications in all areas of reconstruction and is the standard for reconstructing large
defects of the head and neck.

In its simplest form microvascular surgery involves the anastomosis of vessels 0.5 to
3.0 mm in diameter in a manner that maintains patency of the anastomosis. This
involves not only surgical technique but also controlling the dynamics of the blood
flow, the coagulation system, and inflammatory mediators.

Flow through a blood vessel can be described by Poiseuille's law, whereby the
volume flow rate through a capillary tube varies directly with the pressure drop and
the fourth power of the radius of the tube, and inversely with the length of the tube
and the coefficient of viscosity. Clinically blood pressure must be adequately
maintained throughout a microvascular procedure. Hypotension or the use of systemic
vasoconstrictors to support blood pressure can be disastrous. Blood viscosity is
another factor that can be manipulated by the microvascular surgeon by altering
hematocrit levels. A hematocrit level between 30 and 35 percent maximizes flow and
oxygen-carrying capacity. Poiseuille's law suggests that vessel radius is the single
most important factor in determining flow rate. For this reason the largest possible
vessels should be selected for anastomosis. When dealing with very small vessels any
problem with technique or vasospasm will likely result in failure of the anastomosis.

The coagulation system is best controlled by avoiding traumatized vessels and by
performing an anastomosis that coapts intact intima to intact intima.
Microanastomoses that expose subendothelial collagen invite platelet aggregation and
activate the coagulation cascade. A traumatized artery responds to mediators of
inflammation by contraction of the smooth muscle within the vessel wall. Some
vasospasm occurs even with careful dissection of vessels. If vasospasm is persistent, it
can be controlled by irrigation of the vessel with a solution of papaverine and
lidocaine. The spasm of severely traumatized vessels is often refractory. For this
reason microsurgeons prefer to operate out of the “zone of injury,” the region near the
defect that, although grossly intact, is undergoing the metabolic changes of injury at a
cellular level. The mediators of inflammation within the zone of injury can lead to
vasoconstriction and platelet aggregation. If a surgeon is unable to perform the
anastomosis out of the zone of injury, a pharmacologic agent to modulate the
coagulation system can be administered. The most commonly used agents are aspirin,
heparin, and dextran. These medications can be given prophylactically before
operation or used selectively intraoperatively.

Aspirin blocks prostaglandin synthesis at the level of cyclooxygenase. At lower doses
this effect appears to be selective for thromboxane synthesis and platelet aggregation.
Aspirin is used in some microsurgical centers as a single preoperative or
intraoperative prophylactic dose. Heparin inhibits thrombin production, the
production of fibrin from fibrinogen, and the second phase of platelet aggregation.
Heparin is usually used selectively in circumstances judged to be unfavorable such as
reoperation for thrombosis of a microvascular anastomosis, anastomoses performed
with an extensive zone of injury, and replantation. Dextran decreases platelet
adhesiveness, alters the structure of fibrin clot to make it more unstable, and enhances
blood flow by reducing viscosity and increasing vascular volume. Dextran is
frequently given routinely by microsurgeons as an intraoperative bolus at the time of
anastomosis, followed by several days of continuous infusion. The role of any agents
used to manipulate the coagulation system nevertheless remains poorly defined in
microsurgery. Although dextran is still widely used, the trend in elective free flap
transfers has been toward less frequent use of anticoagulation therapy. In situations in
which mechanical or metabolic factors are not optimal for microvascular anastomosis,
such as replantation surgery, extensive zones of injury proximal to the area to be
reconstructed, and long periods of ischemia, anticoagulant therapy is commonly used.

Response to Ischemia
Any operation involving free-tissue transfer requires the donor tissue to undergo a
variable period of ischemia. Skin and subcutaneous tissue are relatively tolerant of
ischemia. Skin can tolerate 24 h of anoxia. Muscle, however, is relatively sensitive to
ischemia. Irreversible changes are apparent in muscle tissue after 6 h of warm
ischemia. Peripheral nerves are intermediate in their tolerance to ischemia, with
irreversible changes appearing at 8 h of warm ischemia. In general those tissues with
a low metabolic rate, such as connective tissue, are more resistant to ischemia.
Cooling of tissue prolongs viability during ischemia. Traumatically amputated parts
should be wrapped in saline-moistened gauze and placed in a plastic bag. The bag
should then be packed in ice. When handled in this manner successful digital
replantation has been reported after 36 h.

Vascular endothelium appears to be the tissue most sensitive to hypoxia. Changes can
be seen in the endothelium after only several minutes of warm ischemia. Hypoxic
damage to endothelial cells is thought to be responsible for the “no-reflow
phenomenon,” in which damage to the sodium pump of endothelial cells leads to
cellular swelling of the vascular endothelium and leakage of intravascular fluid to the
interstitium. Adenosine triphosphate- depleted red blood cells are less deformable and
not able to pass through microcirculation. A combination of endothelial swelling,
interstitial edema, and aggregation of rigid red blood cells leads to obstruction of the
microcirculation. There is additional evidence that arachidonic acid release by injured
endothelial cells and aggregation of granulocytes are also part of the mechanism of
the no-reflow phenomenon.
Clinically, the no-reflow phenomenon might be seen in a free muscle flap with an
extended ischemic period. Upon microvascular anastomosis, the flap would show
progressive decrease in arterial inflow because of increasing arterial resistance within
the flap. Finally, despite widely patent anastomoses there would be no arterial inflow
or venous outflow. There is no specific treatment for the no-reflow phenomenon at
this time. Current research revolves around the use of nonsteroidal anti-inflammatory
agents and control of oxygen free radicals.

Microsurgical Technique
Microsurgery involves the use of an operating microscope. This instrument usually
includes foot pedals to control focus, a beam splitter with independent objectives to
allow the surgeon and assistant to assume positions 180 degrees from each other, a
fiberoptic light source, and a solid base to minimize unwanted motion of the
microscope during the procedure. Microsurgical instruments perform the same basic
functions as macrosurgical instruments, but are particularly small and delicate. They
must be handled carefully; simply dropping a microsurgical instrument can damage it
beyond repair. A jeweler's forceps is used almost constantly in the surgeon's
nondominant hand. This instrument is useful for handling perivascular tissue and
sutures. The tips must be precisely aligned, kept free of dried blood and tissue, and
meet evenly or suture cannot be reliably handled by the instrument. There are a
variety of needle holders available. Most have tips that are angled in relation to the
handles. A curved-tip microscissors is useful for dissection. A straight microscissors
is use for trimming adventitia of vessels. A vessel dilator is a modified jeweler's
forceps with a smooth, tapered, blunt tip. This instrument is helpful for dilating vessel
ends for irrigation. Vessel clamps may be either single- or double-approximating
clamps. Double-approximating clamps may have a suture holding frame that permits
stay sutures to be used during the anastomosis. Closing pressures of microvascular
clamps must be below 30 g/mm2 to prevent extensive damage to the endothelium.
Suture material is usually polypropylene or monofilament nylon. The size of the
suture used is dependent on the vessel size and ranges from 8-0 to 11-0. Microneedles
are usually tapered needles ranging from 30 to 100mm in diameter.

Vascular Anastomosis
The end-to-end anastomosis is the most common anastomosis performed by the
microsurgeon. The vessels to be anastomosed are placed in microclamps and
approximated without tension (Fig. 43-22). Adventitia is removed from the vessel
ends using the microscissors. The adventitia may be removed as a sleeve by pulling
the adventitia off the end of the vessel in the long axis of the vessel and trimming it
with straight microscissors. The vessel dilator is then used to dilate the end of the
vessel, and the lumen is irrigated with heparinized saline. Frequently a piece of blue
or green plastic sheeting is placed behind the microclamps and vessel ends. This
prevents adjacent tissue from obstructing the operative field and permits easy
visualization of the suture material.

The needle holder is then used to grasp the needle, which is most stable when held
perpendicularly to the jaws of the needle holder. The needle should be passed
perpendicularly through the vessel wall, released, and regrasped in the vessel lumen.
The needle should be passed through the tissue along the curve of the needle. With
time, it may be difficult to refrain from passing the needle through both vessel ends in
one stroke. This is discouraged, however, as needle placement in the second vessel
wall is less precise. The suture is then drawn through the vessels until approximately
10 mm is apparent from the vessel end. To tie a knot, the longer end of the suture is
grasped with the nondominant-hand forceps approximately 10 mm from the vessel
end. A loop is made by winding the dominant-hand forceps around the suture or
creating a loop with the opposite-hand forceps or a combination of these movements.
The dominant-hand forceps is then passed through the loop, and the free, short end of
the suture is grasped. The free end is pulled back through the loop and the knot
secured. A second throw of the square knot can be completed by making a loop in the
opposite direction. The loop should be formed near the short end so that the distance
traveled by the instruments is small. As the second half knot is made, the
nondominant-hand forceps never releases the suture. For most purposes, three half
knots will be sufficient. The suture is then cut short end first followed by the long end
between forceps and knot. In this manner the suture is always controlled and the
needle can be retrieved easily by pulling the needle into the field with the
nondominant hand.

A second suture may be placed 180 degrees from the first and the anterior wall
completed by placing sutures bisecting the space between each suture. Alternatively
the triangulation technique may be used with the first three sutures.

On completion of the anterior wall the microclamps are rotated 180 degrees and the
anastomosis is inspected. This is an opportunity to note any suture placed in the back
wall and again to irrigate any blood or clot within the lumen. The posterior wall of the
anastomosis is then completed in an identical manner.

If the discrepancy of lumen size in the vessels to be anastomosed is greater than 2:1,
an end-to-side anastomosis should be performed. The same microsurgical techniques
also apply to an end-to-side anastomosis. The adventitia is removed from the area of
the anastomosis using a curved microscissors. The media of the vessel is grasped with
a jeweler's forceps and the arteriotomy or venotomy made with a straight
microscissors. It may be necessary to change the microscissors from the one hand to
the other to create two clean scissors cuts. If placed properly, the two scissors cuts
will make a neat elliptical hole in the vessel wall. The donor vessel should be trimmed
at an angle to reduce turbulence. The end of the donor vessel is often trimmed in a
convex form to increase the lumen size at the area of anastomosis (Fig. 43-23). The
posterior wall is normally completed first. If the anterior wall is completed first it is
often difficult to fully visualize the sutures in the posterior wall. Suturing of
anastomosis can be facilitated if the donor vessel can be moved across the field as
each side of the anastomosis is completed.

Although not universally accepted, continuous-suture techniques can be used in
microsurgery. The principal advantage of a continuous-suture technique is that
anastomosis can be completed in less time; in addition, it may be the preferred
technique in the anastomosis of vessels with different- sized lumens. The usual
disadvantages of continuous-suture techniques include purse-stringing, narrowing of
the anastomosis, and suture breakage requiring repeat anastomosis.

When the distance between recipient and donor vessels is too large to allow direct
coaptation of vessel ends, vein grafts are required. Vein grafts may be used in head
and neck reconstruction, where therapeutic neck dissection or irradiation preclude the
use of vessels adjacent to the defect. Lower-extremity trauma with extensive zones of
injury also may require vein grafts. The vein graft selected should be as close in size
to the recipient vessel as possible. Donor sites for vein grafts include the saphenous
vein in the leg and the superficial veins in the dorsum of the hand and ventral forearm.

Monitoring Free-Tissue Transfers
The success rate for free-tissue transfer, in most series, is greater than 90 percent.
Given the large number of free-tissue transfers performed yearly, this success rate still
yields a sizable number of failed grafts. The purpose of any postoperative monitoring
system is to identify failing grafts early enough that an appropriate intervention might
salvage the graft.

Examination by an experienced physician is the single most reliable test of graft
viability. The flap should be examined for temperature, color, capillary refill, and if
any doubt remains, response to pinprick. A pale, cool flap with delayed or absent
capillary refill indicates arterial obstruction. Flaps that are purplish with rapid
capillary refill and prolonged bleeding of dark blood upon needle stick likely have a
venous obstruction. Although the clinical examination is usually an accurate
assessment of flap viability, it is often not practical to have an experienced physician
observe the flap continuously for the first several days postoperatively. Remote
monitoring systems include percutaneous Doppler flow monitoring, laser Doppler,
temperature probes, transcutaneous measurements of tissue oxygen tension, and
intravenous fluorescein. Clinical experience has not indicated any single monitoring
system to be superior. The inexpensive, reliable, and simple free-flap monitoring
system has yet to be described.

Tissue Expansion
Human tissue has a well-known ability to expand. This is observed during growth and
pregnancy as well as in response to pathologic processes such as tumor growth and
morbid obesity. Neumann in 1957 described the first attempt at controlled clinical
expansion of soft tissue. He successfully resurfaced an ear reconstruction by placing a
subcutaneous balloon in the postauricular area and inflating it over 2 months.
Radovan, in a series of reports beginning in 1976, described tissue expansion with
silicone devices. Tissue expansion has become an increasingly important part of
reconstructive surgery. The technique provides sensate tissue of similar color and
texture to tissue adjacent to the defect.

A wide variety of expansion devices are available to the reconstructive surgeon. In its
simplest form the device consists of a silicone reservoir attached to a self-sealing
injection port via a variable length of silicone tubing. Using a 23-gauge or smaller
needle, saline is injected into the injection port and the reservoir is expanded beneath
skin and subcutaneous tissue. Ports may be placed external to the skin or in a
subcutaneous position. They should be placed in an accessible location and, if
subcutaneous, should be easily palpable. Tissue expanders are also currently available
with the injection port integrated into the wall of the expander. These devices require
accurate localization of the injection port by palpation or a magnetic locator to
prevent inadvertent puncture and deflation of the expander.

The biology of tissue expansion has been extensively studied. When expansion forces
are applied to skin, collagen fibers are noted to orient parallel to the expansion force
and lose their native orientation. In the first week after placement of the tissue
expander epidermal thickening can be noted. This rapidly returns to baseline and
probably represents postoperative edema. An increase in melanocyte activity is noted
during active expansion and may account for the hyperpigmentation sometimes seen
during tissue expansion. A decrease in dermal thickness is noted during and after
expansion. The population of myofibroblast cells increases, and elastic tissues become
more prominent. Elastin fibers serve to align collagen. With excessive expansion
forces elastin fibers are disrupted, leaving collagen in an unnatural orientation.
Disruption of elastin fibers might account for stria formation and the permanence of
expansion when the expander is removed. Skin with a great deal of intact elastin
fibers tends to contract more after expansion.

Tissue expansion increases the vascularity of skin. New vessels are seen in the area
adjacent to the capsule. Skin flaps raised in expanded tissue behave similarly to
delayed flaps. Compared to unexpanded skin, increased survival length of skin flaps
can be expected.

A number of mechanisms account for the new skin formed with tissue expansion.
When serial stress loads are applied to skin, collagen and elastin fibers align
themselves parallel to the stress, as noted above. As this alignment takes place, the
skin stretches. This phenomenon is known as creep. As an expander is inflated,
adjacent skin is recruited into the area of the expander. It is probable that new tissue is
also formed during the expansion process. Increased epidermal mitoses are noted
during expansion, and collagen synthesis increases in the dermis.

Suction Lipectomy
Suction lipectomy is said to be the most frequently performed aesthetic procedure in
the United States. The procedure involves removal of subcutaneous fat via a blunt-
tipped cannula attached to a vacuum pump. The cannula is introduced through small
stab incisions, and radial passes are made across the anatomic region where fat
removal is desired. The ideal patient for suction lipectomy is young, with localized fat
deposits that are unresponsive to diet and exercise.

Suction cannulas range from 1.5 to 10 mm in diameter, and the most popular models
have three openings set back from the tip at 120 degrees around the axis of the
cannula. A vacuum pump able to generate a negative pressure of 1 atm is then
connected to the cannula by flexible tubing. The area to be suctioned is usually
injected with a solution of 0.25% lidocaine and 1:400,000 epinephrine. Hyaluronidase
(Wydase) is sometimes added to improve the diffusion of the injection fluid. A small
stab incision is made along Langer's lines, typically in the groin or suprapubic area for
abdominal suction and within the gluteal fold for hip and buttock suction. With the
vacuum pump on, the cannula is passed in the subcutaneous plane, creating tunnels
radiating from the skin incision. This process is repeated through a second incision
such that the radiating subcutaneous tunnels intersect one another. As the procedure
progresses the area being contoured is constantly palpated. As a general rule the
procedure is terminated when less than 2 cm of skin and subcutaneous tissue can be
pinched between the index finger and thumb in the extremities and trunk. The wounds
are closed with fine absorbable sutures and a compressive garment is worn for 10
days postoperatively.
Suction lipectomy requires close monitoring of the patient's hemodynamic status. For
every 150 mL of fat removed, a 1 percent drop in the patient's hematocrit level can be
expected. Fluid shifts dictate that crystalloid must replace fat removed in a 3:1 fluid-
to-fat ratio. If more than 1500 mL of fat is removed, autologous blood replacement
must be considered. Tumescent technique involves the injection of large volumes of
dilute lidocaine and epinephrine solution into the subcutaneous tissue before
liposuction. This technique decreases transfusion requirements in cases in which large
volumes of fat are removed.

The procedure is generally safe and well tolerated. In 1987 the American Society of
Plastic and Reconstructive Surgeons ad hoc committee on new procedures reported a
5-year experience with more than 100,000 suction lipectomies. Eleven deaths and
nine major complications were reported within this group. Most cases of death or
major morbidity result from hypovolemia, overwhelming sepsis, or embolism,
including fat emboli. Although rare, these complications underscore the need for
appropriate patient selection and intravenous fluid therapy. Most surgeons give
prophylactic antibiotics, but available clinical and laboratory data do not favor any
specific prophylactic agent for the fat emboli syndrome.

HEAD AND NECK
Cleft Lip
Two theories are generally held concerning the embryogenesis of cleft lip. The classic
theory holds that a cleft lip results from failure of the nasomedial and nasolateral
process of the embryo to fuse. The mesodermal penetration theory notes that the
embryo is an epithelial bilayer in the region of the face until mesoderm migrates
between the bilayers, forming the facial processes. Failure of this mesodermal
migration results in clefting. Available evidence favors the mesodermal penetration
theory in the etiology of cleft lip.

The primary palate is considered to include the lip, the alveolus, and the hard palate to
the incisor foramen. The secondary palate includes the hard palate posterior to the
incisor foramen and the soft palate. A cleft lip, then, would also be considered a cleft
of the primary palate.

The incidence of cleft lip varies across races (approximately 1/1000 for whites and
0.41/1000 for blacks in the United States). The etiology of cleft lip is thought to be
multifactorial. Factors that may increase the incidence of cleft lip include increased
parental age, drug use and infections during pregnancy, and smoking during
pregnancy. Parents with a cleft lip have an increased risk of producing a child with a
cleft lip. The chance of producing a cleft-lipped child with one affected parent is
approximately 4 percent. If both parents are unaffected but have a single child with a
cleft lip, the risk of the second child's being affected is also approximately 4 percent.

A cleft lip may be unilateral or bilateral and may or may not be associated with a cleft
palate (Figs. 43-24 and 43-25). Cleft lips are termed complete if the cleft extends into
the nostril floor and incomplete if a bridge of tissue connects the central and lateral
lip. This tissue bridge is sometimes referred to as Simonart's band.

Cleft lips are associated with characteristic nasal deformities. For a unilateral cleft lip
this consists of inferior and posterior displacement of the alar cartilage on the cleft
side. The maxilla and alar base on the cleft side is also deficient, resulting in posterior
displacement of the alar base. In a bilateral cleft lip these nasal deformities are
bilateral and the columella is usually short. The nose tends to be broad and vertically
short.

Before definitive lip repair is carried out the patient may undergo a course of
presurgical oral orthopaedic procedures. In conjunction with an orthodontist, acrylic
splints may be fabricated to better align the alveolar segments and effectively narrow
the cleft. By adding acrylic or removing it in certain areas of the splint, the
orthodontist is able to move the alveolar arches and soft tissues of the lip to facilitate
repair. As an alternative to these passive appliances, pin-retained appliances may be
used. The appliance is fixed to the palate with metal pins and moves the alveolar
segments with a connecting screw that is rotated daily.

Definitive lip repair is carried out when the child's general health and weight permit
the safe induction of general anesthesia. The time-honored “rule of tens” is a useful
guide to the timing of surgery. According to this rule, lip repair is carried out when
the child has attained a weight of 10 lbs, is 10 weeks old, and has a hemoglobin
concentration higher than 10 mg/dL. Cleft lip repair is being considered at even
earlier ages in otherwise healthy babies.

The cleft lip repair is usually performed under general anesthesia. After marking the
proposed flaps, the lip is injected with dilute epinephrine (1:400,000) to facilitate
hemostasis. Many different types of cleft lip repair have been proposed. An effective
repair must realign the vermilion and cupid's bow of the lip, reconstruct the upper lip
and philtrum, and reapproximate the orbicularis oris muscle within the repair. The
rotation- advancement repair as described by Millard is the most popular technique
for unilateral cleft lip repair (Fig. 43-26). This technique uses a medial rotation flap to
realign the vermilion of the lip. The triangular C flap is inset into the defect created by
the rotation flap and is used to lengthen the columella. An advancement flap of the
lateral side closes the upper lip and nostril sill. At the time of primary lip repair some
surgeons will attempt to raise mucoperiosteal flaps within the alveolar cleft. When
these flaps are reapproximated across the cleft, a tunnel of periosteum is formed that
may support bone growth across the cleft. This technique, known as
gingivoperiosteoplasty, is facilitated by the use of presurgical oral orthopaedics.

Bilateral clefts of the lip present a great challenge. No technique yet described
provides consistently satisfying results. The central portion of the upper lip
(prolabium) and maxilla (premaxilla) often project anteriorly away from the lateral lip
elements. Repositioning of the premaxilla is carried out preoperatively with an
intraoral appliance or with external traction from tapes or head gear. Current
techniques for closure of the bilateral cleft lip use the prolabium to form the upper
central lip, closing the cleft with either a straight-line closure or some application of
the Z-plasty principle. The prolabium contains no mature muscle, and orbicularis oris
muscle continuity must be restored.

Attempts have traditionally been made to protect the cleft lip repair postoperatively.
Some surgeons advocate the use of stiff plastic arm cuffs that prevent the child from
touching the lip. Feeding by cups and catheter also avoids possible trauma by
nippling. This view, however, is not universally accepted. Breast feeding has not been
shown to be deleterious to lip repair.

Correction of the cleft lip nasal deformity may accompany primary lip repair.
Proponents of this approach typically mobilize the lower lateral cartilage from the
overlying nasal skin and reapproximate the cartilage medially with a suture. Timing
of the nasal correction remains controversial. Some authors believe that dissecting the
nasal cartilages at the time of lip repair carries the risk of injury to these fragile
structures and possible disturbances in nasal growth. Another approach to the cleft lip
nasal deformity is to perform a rhinoplasty at the age of five or six, before the child
enters school. At this time further revisions in the cleft lip repair are also often
completed.

Cleft Palate
The hard palate develops from the fusion of the two lateral palatine processes that
meet initially in the region of the incisive foramen and then continue to fuse
posteriorly until, by the twelfth week of gestation, the uvula is formed. These
processes are initially on either side of the tongue but swing upward into a more
horizontal position as the tongue migrates down. Clefting results when the fusion of
the two palatal processes is incomplete. Clefts of the lip and palate are more common
on the left side, probably because this palatal process is the last to assume a horizontal
position. The most common cleft is a cleft uvula. This occurs in approximately 2
percent of the population. The second most common type of cleft palate is a left
unilateral cleft palate and left unilateral cleft lip or cleft of both the primary and
secondary palates (Fig. 43-27). The incidence of cleft palate alone in the general
population is approximately 1/2000.

A unilateral cleft of the primary palate extends from the incisive foramen anteriorly
between a canine and an adjacent incisor to the lip. Clefts of the primary palate may
be unilateral or bilateral. A cleft of the secondary palate extends from the incisive
foramen to the uvula. An incomplete cleft palate does not extend entirely to the
incisive foramen, involving mainly the soft palate.

As with cleft lip, the etiology of cleft palate is multifactorial. Animal models have
demonstrated that vitamin A, corticosteroids, and phenytoin produce cleft palate when
given during pregnancy. Cleft palates commonly are associated with other anomalies
at birth.

During speech and swallowing the palate moves both superiorly and posteriorly
against the posterior pharyngeal wall to separate the oral pharynx and nasal pharynx.
This is known as velopharyngeal closure. Effective velopharyngeal closure allows
intraoral pressure to be increased for release with certain sounds during speech. A
cleft palate allows air to escape through the nose during speech; this is known as
hypernasal speech. Because the oral and nasal cavities cannot be effectively
partitioned in the presence of a cleft palate, it is also difficult for the patient to create a
negative intraoral pressure. This results in an ineffective suck and feeding problems in
the infant with cleft palate. Children with cleft palate have an increased incidence of
otitis media. This may be related to abnormal insertions of palate musculature and
ineffective opening of the eustachian tube. The recurrent otitis media in cleft palate
patients can result in hearing loss.
Timing of cleft palate repair remains somewhat controversial. The cleft palate is
usually closed when the patient is between 6 and 18 months of age. The dissection
involved in cleft palate closure may have a negative effect on facial growth. For this
reason many surgeons prefer late closure of the cleft palate. Children who have
undergone early closure of their cleft palate, however, tend to develop more normal
speech.

Cleft palate closure is performed under general anesthesia using endotracheal
intubation. The head is hyperextended, and a retractor such as the Dingman mouthgag
is placed to hold the mouth open and retract the tongue and endotracheal tube. The
palate is injected with 0.25% lidocaine with 1:400,000 epinephrine solution.
Prophylactic intravenous antibiotics are usually administered. A number of techniques
are currently used for cleft palate closure. The von Langenbeck palatoplasty is the
oldest technique for cleft palate closure still in use today. In this procedure, relaxing
incisions are made bilaterally medial to the alveolar ridges, and incisions are made
along the margin of the cleft (Fig. 43-28). Bipedicle mucoperiosteal flaps are then
raised based on the greater palatine vessels. These flaps are then closed in the midline
in two layers. Mucosal flaps may be also raised from the vomer to aid in closure of
the nasal layer. Most surgeons believe that it is also important to reconstitute the sling
of the levator veli palatini muscle during cleft palate closure. In patients with cleft
palate this muscle abnormally inserts along the margins of the cleft. In the normal
palate the levator veli palatini muscle extends from the base of the skull to the middle
of the palate, where it decussates with the opposite paired muscle to form a
continuous sling. This sling moves the palate posteriorly and superiorly during speech
and swallowing (Fig. 43-29). Reconstitution of the levator muscle sling is known as
an intravelar veloplasty. The bare areas of the hard palate are then left for closure by
secondary intention or may be closed primarily in some cases. Critics of the von
Langenbeck technique note that it does nothing to lengthen the palate to aid in
velopharyngeal closure and that fistulas tend to develop anteriorly where a number of
suture lines meet.

The Veau-Wardill-Kilner palatoplasty uses a W-shaped relaxing incision to create
mucoperiosteal flaps that are then advanced in a V-Y fashion to close and lengthen
the palate. This technique also involves a confluence of incisions anteriorly, and many
question whether any permanent lengthening of the palate is achieved.

We prefer Furlow's double-opposing Z-plasty technique for most cleft palates in our
practice (Fig. 43-30). This operation uses a Z-plasty on both the nasal and the oral
side of the palate to lengthen the palate and to realign the levator musculature. With
this technique, relaxing incisions may still be required for closure of the hard palate.

Breakdown of the cleft palate closure will result in a palatal fistula. This allows food
and fluid to escape into the nose. Air may also pass through the palatal fistula,
resulting in speech disturbances. Small fistulas may be closed by raising adjacent
flaps of mucoperiosteum. Large palatal fistulas often require flaps of gingiva or
tongue tissue.

After cleft palate closure the palate may still not be able to achieve velopharyngeal
closure. The incidence of velopharyngeal incompetence varies among studies,
depending on the surgical technique and methods of speech evaluation involved.
Historically, 20 percent of patients exhibit velopharyngeal insufficiency after a cleft
palate closure. The majority of these patients can achieve satisfactory speech with
speech therapy. The remainder require a second procedure to lengthen the palate. The
most popular surgical technique for correction of velopharyngeal insufficiency is a
superiorly based posterior pharyngeal flap inserted into the free edge of the soft
palate. Orticochea has described a pharyngoplasty designed to create a dynamic
velopharyngeal sphincter. In this technique the palatopharyngeus muscles are raised
from the lateral pharynx and joined in the posterior midline with an inferiorly based
flap of mucosa and the superior constrictor muscle.

A well-trained speech pathologist is best able to evaluate velopharyngeal
incompetence and success after corrective surgery. Other useful adjuncts in diagnosis
include radiography and nasal endoscopy.

Craniofacial Surgery
Craniofacial surgery principally involves movements of the craniofacial skeleton for
reconstruction of acquired or congenital defects. Many of the procedures commonly
performed by craniofacial surgeons today were considered too dangerous or the bony
movements too unstable until the pioneering work of Dr. Paul Tessier of Paris. These
advances were in part made possible by parallel advances in the fields of anesthesia
and critical care. In a series of publications during the late 1960s and 1970s Tessier
not only clarified the classification of craniofacial anomalies but also described access
to the entire cranium and facial skeleton through less conspicuous incisions, and the
bony movements necessary to reconstruct craniofacial anomalies.

Craniosynostosis
Craniosynostosis is the premature closure of one or more cranial sutures. This occurs
in approximately 1/1000 births. The etiology of craniosynostosis remains
incompletely defined and is probably multifactorial. Some cases of craniosynostosis,
particularly craniosynostosis as part of a craniofacial syndrome, may be secondary to
an abnormal cranial base. In these cases abnormal forces from the cranial base could
be transmitted to the involved suture through ligamentous structures. Isolated cases of
craniosynostosis may also be secondary to abnormal extrinsic forces in utero, such as
abnormal fetal position, or weak intrinsic growth forces, such as microcephaly.

Premature closure of a cranial suture results in limitation of growth perpendicular to
the line of the suture and compensatory growth parallel to the direction of the suture.
Complications of craniosynostosis follow from the brain growing within a restricted
bony vault. These problems include intracranial hypertension, optic atrophy, and
mental retardation. Hydrocephalus may be secondary to a generalized stenosis of the
cranial base.

Craniosynostosis is often classified according to the shape of the skull (Fig. 43-31). It
is important to remember that these terms refer not to a disease entity but simply to
the morphology of the skull. For instance, a child with plagiocephaly does not
necessarily have premature fusion of the coronal suture. Scaphocephaly refers to
increased length of the skull in the sagittal plane with bitemporal narrowing. This
skull morphology is seen with isolated synostosis of the sagittal suture.
Trigonocephaly describes a midline, keel- like prominence of the forehead that is seen
with premature closure of the metopic suture. Plagiocephaly is an asymmetric
obliquity or flattening of one side of the skull. This may be either anterior or
posterior. Plagiocephaly is seen with synostosis of the coronal or lambdoid sutures.
Brachycephaly is shortening of the skull in the anteroposterior direction. This is seen
with premature fusion of both coronal sutures. Turricephaly presents an excessive
skull height and can be seen in pansynostosis.

Craniofacial Dysostosis
Craniofacial dysostosis refers to a variety of syndromes, most involving some degree
of midface (maxilla, orbits) deficiency and craniosynostosis. These syndromes
involve complex deformities that are a supreme challenge for the craniofacial
surgeon. Reconstruction of these craniofacial syndromes is usually staged, with
several procedures during childhood and early adolescence.

Crouzon's Syndrome
Crouzon's syndrome is characterized by hypoplasia of the orbits, zygomas, and
maxillae and variable craniosynostosis. The coronal suture is more frequently
involved. The syndrome is inherited in an autosomal dominant pattern with variable
penetrance. The incidence in the general population is 1/25,000. Patients with
Crouzon's syndrome can suffer all the complication of craniosynostosis as well as
problems related to exorbitism such as corneal exposure. Midface hypoplasia can lead
to malocclusion, airway disturbances, and significant facial deformity (Fig. 43-32).

Apert's Syndrome
Apert's syndrome involves a morphology similar to Crouzon's syndrome with
syndactyly of the hands. Most cases of Apert's syndrome are sporadic, although
autosomal dominant transmission has been reported. Advanced paternal age is
thought to be a factor in some cases. The deformities of the midface are generally
more severe than in Crouzon's syndrome. There is also a significant incidence of cleft
palate.

Treacher Collins Syndrome
Treacher Collins syndrome, also known as mandibulofacial dysostosis, is
characterized by hypoplasia of structures derived from the first and second branchial
arches. Typically this involves hypoplasia or clefting of the zygomas, external ear
deformities, and hypoplasia of the mandible. The syndrome has an autosomal
dominant inheritance pattern with incomplete penetrance.

Facial Clefts
A number of rare craniofacial clefts have been described. As with cleft lip and palate,
these probably represent failure of mesenchymal migration or incomplete fusion of
facial processes. A number of confusing classification schemes have been proposed.
In 1976 Tessier proposed a classification system that remains in wide use. In Tessier's
system clefts are assigned a number based on their position relative to the sagittal
midline (Fig. 43-33). Within this classification system, the standard cleft lip is part of
clefts 1, 2, and 3, and Treacher Collins syndrome exhibits some expression of clefts 6,
7, and 8.

Craniofacial Techniques
The majority of craniofacial surgery can be performed through a combination of three
well-concealed incisions. A buccal sulcus incision can be made within the mouth to
provide wide subperiosteal exposure of the anterior maxilla, the piriform aperture, and
the anterior zygoma. A subciliary incision placed just beneath the lower eyelashes is
also well concealed and provides access to the orbital floor, the medial and lateral
orbital walls, and the anterior maxilla (Fig. 43-34). A bicoronal incision extended
from ear to ear transversely across the scalp allows the surgeon to expose the entire
cranial vault, and by reflecting the bicoronal flap anteriorly and dissecting in a
subperiosteal plane, the entire bony orbit can be exposed (Fig. 43-35).

Historically, craniosynostosis was treated by strip craniectomy in an attempt to create
a patent cranial suture. Simple craniectomy fails to address other abnormalities in the
cranial vault and has a high rate of reoperation, as the craniectomy site rapidly
reossifies. Tessier pioneered the advancement of the superior orbit and frontal bone in
one piece. This increases intracranial volume to alleviate increased intracranial
pressure and also corrects the brachycephaly commonly seen in craniofacial
syndromes or coronal synostosis. At the time of frontal bone advancement, the
anterior cranial vault might also be remodeled by shaping and repositioning the bone
of the anterior cranium. In a typical patient with coronal synostosis frontal orbital
advancement and cranial vault remodeling would be performed as a single procedure
before the child is 1 year old (Fig. 43-36). Children with more complex cranial
deformities and severe craniosynostosis syndromes may require repeat frontal bone
advancement or further cranial vault remodeling in early childhood. In those patients
with midface hypoplasia such as in Apert's and Crouzon's syndromes, a second phase
of treatment involves advancement of the midface. By performing osteotomies at the
nasofrontal junction, the floor of the orbit, the lateral maxilla, and the
pterygomaxillary fissure, the entire midface may be advanced in an anterior direction.
This is known as a LeFort III midfacial advancement after the facial fracture of the
same name. Advancement of the midface in this manner serves to correct
exophthalmos and improve airway difficulties, and it has a powerful effect on facial
appearance. The timing of the LeFort III midfacial advancement is also controversial
and varies from early childhood to adolescence. Treatment of the patient with a
craniofacial syndrome would typically then be completed by a course of orthodontic
treatment and jaw surgery, if necessary, in adolescence.

Hypertelorism
Orbital hypertelorism refers to increased distance between the bony orbits. This is
seen with midline craniofacial clefts and certain craniofacial syndromes, including
Crouzon's and Apert's syndromes. Significant hypertelorism is best managed by an
intracranial approach as described by Tessier. In this procedure a bicoronal incision
provides exposure for an anterior craniotomy. Osteotomies are then made around the
entire orbit and paramedian bone is removed. The orbits are then mobilized and fixed
in a more medial position (Fig. 43-37).

Distraction Osteogenesis
Distraction osteogenesis hasbecome a standard part of the craniofacial surgeons'
armamentarium. This technique is adapted from the original work of Ilizarov in
orthopaedic reconstruction. For some time the healing callus of a surgically created
cut in the long bones of extremities are stretched slowly by an extended frame to
lengthen the bone. This typically yields 1 mm of lengthening per day of distraction.
After the pioneering work of McCarthy and colleagues, this technique is now widely
applied to the mandible of children with hemifacial microsomia and micrognathia.
This has proved to be a powerful technique for augmenting the facial bones and even
soft tissue of children with severe microsomia.

Orthognathic Surgery
Disproportion of the maxillae and mandible is commonly seen with craniofacial
problems. Maxillary hypoplasia is particularly common with cleft lip and palate and
may in part be related to the dissection and subsequent scarring of repair. Acquired
maxillomandibular disproportion is usually the result of trauma. Maxillomandibular
disproportion can result in malocclusion and ineffective chewing. These patients may
also have a significant aesthetic deformity.

The patient with maxillomandibular disproportion is best evaluated by team approach.
Essential members of this team include a plastic surgeon, an orthodontist, and a
prosthodontist. Evaluation includes dental impressions from which plaster models can
be made. If surgery is planned, these models can then be cut and segments
repositioned during model surgery. This allows the plastic surgeon and the
orthodontist to plan accurately what bony movements are necessary to achieve proper
occlusion. Cephalograms or standardized frontal and lateral radiographs of the face
and skull provide an outline of the skeletal and soft tissue profile. Measurements
between standardized points on the radiograph can then be compared to a database of
normal values for age and sex. Minor problems of maxillomandibular disproportion
and malocclusion can often be handled by orthodontia alone. Significant skeletal
disproportion requires both surgical and orthodontic treatment.

Deformities of the jaws may be classified according to their dental and skeletal
relationships. Dental occlusal relationships are normally described by Angle's
classification. In this classification mesial means close to the dental midline, distal
means away from the dental midline, buccal means toward the outer aspect of the
dental arch, and lingual means toward the inner aspect of the dental arch. In normal
occlusion the mesial buccal cusp of the maxillary first molar lies within the buccal
groove of the mandibular first molar. This is known as class I occlusion. In class II
occlusion the mesial buccal cusp of the maxillary first molar is found mesial to the
buccal groove of the mandibular fist molar, as might be seen with an abnormally
small mandible. In class III occlusion the mesial buccal cusp of the maxillary first
molar is found distal or posterior to its normal position. This relationship may be seen
with an abnormally large mandible or small maxillae.

Micrognathia refers to an abnormally small mandible. Retrognathia refers to a
mandible of normal size located in an abnormally posterior position. Both
retrognathia and micrognathia would typically present with class II occlusion and the
appearance of a weak or recessed chin. Mandibular advancement is normally
performed by creating osteotomies in the sagittal plane through both mandibular rami.
The distal mandible is then advanced into a more favorable position and plates or
screws used to hold the advancement rigidly. This technique carries some risk of
injury to the inferior alveolar nerve. Nerve transection has been reported in
approximately 2 percent of cases, and up to 15 percent of patients may have some
evidence of long-term dysfunction (Fig. 43-38).


Prognathia denotes an abnormally large mandible. These patients will often have class
II occlusion. Surgical treatment of mandibular prognathism may also be by a sagittal
split of the mandibular rami, with posterior repositioning of the distal mandibular
segments. Alternatively a vertical osteotomy can be made from the sigmoid notch to
just anterior to the angle of the mandible. The distal mandibular segment can then be
positioned posteriorly and lingual to the proximal segment of the mandible. This
technique has a lower risk of inferior alveolar nerve injury, but fixation is more
difficult. Most patients will be placed in intermaxillary fixation for 4 to 6 weeks after
vertical osteotomy of the mandible.

The soft-tissue contour of the mandible can be further altered by bony movement of
the symphysis. A genioplasty or horizontal osteotomy of the mandible allows the
anterior projection of the chin to be augmented or reduced. By advancing or recessing
the mentum, the soft-tissue contour of the chin can be significantly altered without
changing dental occlusion. Plates or lag screws are used to rigidly fix the bony
movement. Chin augmentation can also be achieved with the use of a small silicone
prosthesis.

Maxillary deformities of hyperplasia and hypoplasia are also commonly seen by the
craniofacial surgeon. Maxillary hypoplasia commonly presents as maxillary
retrognathia and class II or class III occlusion. This is commonly seen in cleft lip and
palate patients. Maxillary hyperplasia often presents as vertical maxillary excess, also
known as the long face syndrome. These patients have excessive gingival exposure
when smiling and poor lip competence.

Most maxillary deformities can be approached by the LeFort I osteotomy. An incision
is made in the upper buccal sulcus and dissection is carried out in the subperiosteal
plane. The surgeon then performs a horizontal osteotomy just above the level of the
piriform aperture bilaterally. When additional cuts are completed through the base of
the nasal septum, the medial wall of the maxillary sinus, and the pterygomaxillary
fissure, the maxilla is then free to be repositioned in three dimensions. This technique
is usually performed in patients with permanent dentition. Horizontal osteotomy of
the maxilla risks damage of tooth buds in patients with deciduous dentition.

In treating maxillary hypoplasia the surgeon would reposition the maxillae anteriorly
and rigidly fix the segments with plates and screws according to the preoperative plan.
Treating vertical maxillary access will require maxillary bone to be removed and the
segments repositioned superiorly.

Facial Fractures
Facial fractures are most frequently caused by motor vehicle accidents and physical
assaults. Although the specifics of facial fracture treatment have evolved since the
advent of craniofacial techniques in the 1980s, the principles remain the same. The
patient with facial fracture is often a multiple trauma patient and requires thorough
evaluation. Although the facial fracture is rarely a surgical emergency, other
associated injuries frequently require emergency care. For instance, the patient with a
gunshot wound to the angle of the mandible is first and foremost a patient with a
penetrating neck wound, and the patient with a depressed supraorbital fracture is first
and foremost a patient with closed head trauma.

Physical Examination
Examination for facial trauma must be systematic and complete (Fig. 43- 39).
Proceeding from superior to inferior, the forehead and supraorbital ridge is palpated
for any fracture. The orbital rims are also evaluated for any stepoff or irregularity. The
ophthalmologic examination must include pupillary responses, extraocular muscle
function, and visual acuity. Any enophthalmos, inferior displacement of the globe, or
limitation in extraocular muscle function is a sign of orbital fracture. Any patient with
signs of direct injury to the ocular globe or an orbital fracture should have a formal
ophthalmologic examination. The nose is examined for any gross deformity, the
septum is examined for hematoma, and patency of the airway is ascertained. The
zygomatic arches are palpated for fractures. Depressed fractures of the zygomatic arch
can impinge on the temporalis muscle. It is important to note whether there is pain
associated with movement of the mandible or any limitation in mandibular excursion.
Fractures of the maxilla frequently run through the infraorbital foramen, and these
patients frequently have paresthesia of the upper lip and teeth. Midface stability is
assessed by grasping the upper incisors and alveolar ridge with one hand and
palpating the nasofrontal junction and anterior maxilla with the other. An attempt is
then made to gently rock the alveolar ridge anteriorly and posteriorly. Occlusion is
noted and the patient is asked if his teeth “fit together” as usual. The mandible is
palpated for any tenderness or fracture.

Radiologic Examination
The radiologic examination is guided by the history and physical examination (Table
43-1). Most patients will need clear views of the cervical spine, including odontoid,
posteroanterior, and lateral to include the first thoracic vertebrae. The standard facial
bone series includes posteroanterior, lateral, and Waters views. Standard views of the
mandible include oblique, lateral, and Towne views. A Panorex radiograph will
provide an image of the entire mandible, including the temporomandibular joints.
This film is necessary in most cases of suspected mandible fracture. Submental vertex
films free the zygomatic arches of other bony silhouettes and are useful in diagnosing
zygomatic arch fractures (Fig. 43-40).

Computed tomography is the mainstay in diagnosing and planning treatment for
orbital fractures. Standard axial slices should be reformatted to provide coronal views
of the orbit. These coronal images are extremely helpful in diagnosing orbital floor
fractures.

Treatment
Mandibular Fractures
Specific mandibular fractures are treated according to the characteristics of the
fracture and its anatomic location. The goal in treating any mandibular fracture is
restoration of function occlusion with firm healing at the fracture site. Any open
mandible fracture requires operative irrigation, debridement, and intravenous
antibiotics.

A number of techniques may be employed in the management of mandibular
fractures. Intermaxillary fixation is the ligation of the maxilla to the mandible with the
teeth in occlusion, serving to immobilize the mandible. This may be accomplished by
ligating metal arch bars to the upper and lower dental arch and then fixing these bars
to each other by means of heavy elastics or wire. Alternatively, when the teeth are in
occlusion, mandibular and maxillary teeth may be directly wired together.
Intermaxillary fixation requires a patent nasal airway and must be used with caution
in alcoholics and other patients prone to loss of consciousness or vomiting. Use of
intermaxillary fixation is contraindicated in patients with a seizure disorder. Open
reduction and internal fixation has become the treatment of choice for most unstable
fractures of the mandible. Most fractures can be exposed intraorally through a buccal
sulcus incision and rigidly fixed with plates and screws. This precludes the need for
intermaxillary fixation and allows the patient to resume oral intake on the first
postoperative day. It also reduces the possibility of limited mandibular excursion
secondary to prolonged intermaxillary fixation. External fixation devices are
employed only rarely, for large bony defects and recurrent infections.

Mandibular fractures may be classified as favorable or unfavorable, according to the
manner in which the muscles of mastication serve to distract the fracture. Fractures of
the body of the mandible that course obliquely and anteriorly when followed from
interior to superior are termed unfavorable. In these fractures the masseter muscle, by
pulling on the posterior segment, will displace the fracture (Fig. 43-41). Fractures of
the body that course posteriorly in the inferior to superior direction are termed
favorable. In these fractures the masseter muscle, by pulling superiorly on the
posterior segment, serves to appose the mandibular segments.

Fractures of the rami and mandibular condyles are frequently not greatly displaced by
the muscles of mastication. These may be treated with intermaxillary fixation or a soft
diet alone if not widely displaced and occlusion is adequate. Widely displaced
fractures of the condyle may require open reduction and internal fixation. Fractures of
the coronoid process usually do not interfere with occlusion unless the fracture
fragments interfere with mandibular excursion. Coronoid process fractures usually
may be treated with a soft diet. Fractures of the angle and body of the mandible are
subjected to significant stress and motion by the muscles of mastication. These
fractures usually require open reduction and internal fixation. Minimally displaced
fractures may be treated by internal maxillary fixation. Nondisplaced fractures can be
treated with a soft diet alone in selected patients. Fractures of the symphysis and
parasymphyseal area also are usually displaced by the muscles of mastication and
normally require open reduction and internal fixation. Fractures of the alveolar
process may be seen alone or in combination with other fractures of the mandible.
These are usually treated by ligating the teeth of the fractured segment to adjacent
stable teeth by the application of arch bars.

Nasal Fractures
A nasal fracture is usually diagnosed on the basis of gross deformity and nasal airway
obstruction. In patients with craniofacial trauma any deformity should be noted and
the nasal airway should be examined with a speculum for patency and the presence of
a septal hematoma. Septal hematomas require prompt incision, drainage, and nasal
packing to prevent subsequent infection and septal perforation. With early treatment
nasal fractures usually can be reduced with closed techniques under local or general
anesthesia. Late treatment of nasal fractures usually requires osteotomies to mobilize
and adequately reposition the nasal bones.
More severe nasal fractures often occur when the nasofrontal area strikes the steering
wheel during a motor vehicle accident. These fractures involve not only the nasal
bones but also the nasofrontal junction, the ethmoid sinuses bilaterally, and the medial
orbits. These fractures are also known as nasoorbital-ethmoid fractures. Typically the
patient with a nasoorbital- ethmoid fracture has a depressed and deformed nasal
contour, and telecanthus, an increased distance between the medial canthi. The medial
canthus inserts into the frontal process of the maxilla and the lacrimal bone in the
medial orbit. In a nasoorbital-ethmoid fracture these bones are comminuted and
displaced laterally, increasing the distance between the medial canthi (Fig. 43-42).
Nasoorbital-ethmoid fractures are best treated by extensive exposure through a
bicoronal incision. The multiple small fracture fragments are accurately reduced and
wired or plated in place. If the medial canthi remain attached to a large fracture
fragment, accurate reduction and rigid fixation of this fragment will reposition the
medial canthi. A transnasal wire placed posterior and superior to the native insertion
of the medial canthus can also be used to reduce the traumatic telecanthus. This wire
is placed as a loop through each medial canthus and then tightened, repositioning the
canthi in a more favorable and medial position.

Zygoma Fractures
Fractures of the zygoma commonly occur as isolated fractures of the zygomatic arch
or as zygomaticomaxillary complex fractures (Fig. 43-43). Fractures of the zygomatic
arch, when depressed, may impinge on the temporalis muscle, causing pain with
mandibular excursion. The depression in the lateral face may also be a significant
distortion in appearance. Noncomminuted zygomatic arch fractures sometimes may
be elevated by sliding an instrument beneath the arch via an incision in the temporal
scalp. Comminuted zygomatic arch fractures usually require plating via a bicoronal
incision. Zygomaticomaxillary complex fractures result in a depressed malar
eminence and infraorbital rim. The fracture lines are typically along the zygomatic
frontal suture, zygomatic arch, and infraorbital rim and floor of the orbit, through the
infraorbital foramen (Fig. 43-44). These patients typically present with an inferiorly
and laterally displaced eye, enophthalmos, and paresthesia of the infraorbital nerve.
Malocclusion also can result if the fracture extends along the anterior wall of the
maxilla into the dental arch. These fractures require open reduction and internal
fixation of the fracture fragments and, if any significant defect exists, reconstruction
of the orbital floor.

Orbital Floor Fractures
Orbital floor fractures may occur as a result of a direct blow to the eye. An increase in
the infraorbital pressure can result in herniation of intraorbital contents through a
fracture in the orbital floor (Fig. 43-45). These “blowout” fractures may involve
entrapment of intraorbital fat and occasionally extraocular muscles within the orbital
floor defect. These patients typically present with enophthalmos, opacification of the
maxillary sinus on radiography, and diplopia, particularly on upward gaze. The orbital
floor defect, in effect, increases the orbital volume, allowing the eye to settle
posteriorly and inferiorly, resulting in enophthalmos. Diplopia and limitation of
upward gaze is the result of entrapment of orbital fat or extraocular muscles within the
orbital floor defect. Trauma to the extraocular muscles and resultant edema also can
cause diplopia.
The indications for operation on orbital floor fractures have always been
controversial. Enophthalmos of 2 mm or more is generally recognized as an indication
for operation. It is important to remember, however, that edema after trauma can mask
significant enophthalmos. Patients with a normally positioned globe in the immediate
posttrauma period may become significantly enophthalmic several weeks later as
edema and inflammation subside. We attempt to individualize the decision to operate
based on enophthalmos after fully discussing the risks and benefits with each patient.
Central to this discussion is the principle that minor degrees of enophthalmos after
trauma that are easily correctable can evolve to significant enophthalmos that is
difficult to correct once bone and soft tissues are well healed. Entrapment and
limitation of extraocular muscles is also a general indication for operation. In some of
these patients the limitation of gaze will resolve spontaneously, but as a general rule a
floor defect large enough to limit ocular movement will also eventually leave the
patient enophthalmic.

Exploration of the orbital floor is performed through an eyelid incision or a
transconjunctival incision in the subperiosteal plane. The limits of the floor defect are
defined and all periorbita herniated through the fracture are reduced. Most
craniofacial surgeons favor repair of floor defects with onlay split calvarial bone
grafts. Available data suggest that for moderate and small defects of the orbital floor
alloplastic materials also may be safely used. Orbital floor implants are available
composed of titanium, hydroxyapatite, silicone, Teflon, and other materials. Any
patient with an orbital floor fracture should have a forced duction test performed pre-
and postoperatively. Tetracaine is instilled locally to anesthetize the conjunctiva, and
then the conjunctiva and insertion of the inferior rectus muscle are grasped with a
fine-toothed forceps. Attempting to rotate the globe superiorly will reveal any
limitation caused by entrapment. The forced duction test is mandatory as a means of
evaluating reduction of entrapped periorbita.

Maxillary Fractures
Maxillary fractures may be classified according to the LeFort classification system
(Fig. 43-46). LeFort recorded the pattern of fracture in fresh cadaver skulls subjected
to blunt trauma. He noted several characteristic patterns of maxillary fracture. The
LeFort I fracture extends from the piriform aperture laterally to the pterygomaxillary
fissure. This fracture separates the lower maxilla, hard palate, and maxillary teeth
from the remainder of the skull. The LeFort II fracture extends from the
pterygomaxillary fissure superiorly across the anterior maxilla to the nasofrontal
junction through the inferior orbital rim. This fracture separates the lower maxilla and
nose from the craniofacial skeleton. The craniofacial disjunction or LeFort III fracture
separates the entire midface from the cranium by fracturing through the
pterygomaxillary fissure and zygomatic frontal sutures, along the floor of the orbit,
and through the nasofrontal junction. LeFort fractures are normally treated by placing
the patient in intermaxillary fixation and then rigidly fixing the fractures with plates
and screws. Typically, 1.5-mm plates are placed on the nasomaxillary and
zygomaxillary buttresses in LeFort I fractures. Additional fixation is provided at the
nasofrontal junction and zygomatic arches in LeFort III fractures. The intermaxillary
fixation may then be released once rigid fixation is established.

Ear Reconstruction
Microtia refers to a congenitally absent or small ear. This condition is often seen with
other abnormalities of the first and second branchial arches, including micrognathia,
hemifacial microsomia, and lateral facial clefts. The development of middle ear
structures in a microtic ear is variable. Hearing is normally decreased in an affected
ear. For this reason otitis media in the contralateral ear must be treated aggressively to
preserve hearing. Reconstruction of a microtic ear normally begins at age five or six,
before the child enters school (Fig. 43-47). The reconstruction is staged beginning
with the insertion of a cartilaginous framework sculpted from costochondral cartilage.
This stage requires meticulous technique to create a natural- looking ear framework
and to avoid hematoma or infection. Subsequent stages include rotation of the native
ear lobule and elevation of the ear from the mastoid fascia. A final stage often
includes excavation of the concha and reconstruction of the tragus using a composite
skin/cartilage graft from the contralateral ear.

Prominent ears are a congenital abnormality, resulting from some combination of an
excessively large concha and a poorly developed antihelical fold. These ears tend to
project excessively from the lateral skull. Otoplasty for prominent ears is undertaken
to recreate an antihelical fold and decrease ear prominence. The Stenstrom technique
takes advantage of the natural tendency of cartilage to bend away from any disruption
of the perichondrium. When the perichondrium is scored anteriorly along the natural
course of the antihelical fold, the ear cartilage will tend to bend posteriorly in this
area, recreating the antihelical fold. The Mustarde technique involves placing sutures
along the posterior auricular cartilage to recreate the antihelical fold. This cartilage is
then fully mobilized and tubed to recreate the antihelical fold. Skin is also sometimes
removed from the posterior surface of the ear, and the ear also may be sutured to the
mastoid fascia (Fig. 43-48).

Nasal Reconstruction
Nasal defects commonly occur with the excision of squamous and basal cell
carcinomas of the nose (Fig. 43-49). Depending on the location and size of these
defects, they may be handled by skin grafting or local flaps. Defects of the alar rim
may be reconstructed with a composite graft of cartilage and skin from the ear. Total
nasal reconstruction remains one of the greatest challenges in plastic surgery. This
requires a stable bony framework, often in the form of an iliac bone graft secured to
the nasofrontal junction. The lining of the nasal airway may be provided by local flaps
in the region of the nasolabial fold or by skin grafts. The nasal contour may be
restored with a midline forehead flap, scalp flap, or free-tissue transfer.

Lip Reconstruction
Most defects of the lip encountered by the reconstructive surgeon may be closed
primarily. Defects of up to one-third of the lower lip and one-fourth of the upper lip
can usually be closed directly without the need for more complex reconstructive
techniques. When closing lip defects that cross the vermilion-cutaneous border, it is
imperative to align perfectly the vermilion and white roll edge of the vermilion. Any
notching of the vermilion tends to catch the eye of an observer and is usually
cosmetically unacceptable. A number of local flaps are available for reconstructing
larger defects. The Abbe flap, or cross-lip flap, is an extremely useful technique to
transfer full-thickness lip (Figs. 43-50 and 43-51).

Eyelid Reconstruction
Full-thickness defects of 25 percent of the upper and lower eyelid often may be closed
primarily. When closing lid margins the tarsal plate should be approximated with fine
absorbable suture and the gray line of the lid margin accurately approximated. In any
laceration medial to the punctum of the lacrimal apparatus a lacrimal injury must be
ruled out. Larger defects of the upper lid can be closed by advancing adjacent and
lateral eyelid and temporal skin. Lower eyelid skin also can be advanced or rotated
into an upper eyelid defect. At a second operation the flap is completely divided from
the lower lid to complete the reconstruction. Large defects of the lower lid also may
be closed by advancing lateral eyelid and cheek skin. Conjunctival lining can be
provided by a free mucosal graft taken from the nasal septum with or without
cartilage.

Eyebrow lacerations usually can be closed primarily with precise realignment of hair
follicles (Fig. 43-52). Complete reconstruction of an eyebrow is usually done with
thin strips of free scalp grafts or a thin island flap based on the temporal artery (Figs.
43-53 and 43-54).

Eyelid Ptosis
Elevation of the upper eyelid is achieved through contraction of the levator palpebrae
superioris muscle and Müller's muscle. The levator muscle is innervated by the
oculomotor nerve (IIId cranial nerve) and Müller's muscle receives sympathetic
innervation. If either of these muscles functions poorly or not at all, the upper eyelid
will fail to elevate adequately, which is known as ptosis. Ptosis may be congenital or
acquired. Congenital ptosis is usually idiopathic. Acquired ptosis may be a result of
dysfunction of the oculomotor nerve or the sympathetic chain. Horner's syndrome
includes upper eyelid ptosis, miosis, and decreased sweating on the affected side of
the face. Horner's syndrome is seen with disruption of the sympathetic tract and may
be a presenting sign of malignancy. Myasthenia gravis can present as eyelid ptosis.
Most cases of acquired ptosis are the result of trauma. In these cases disruption or
stretching of the levator aponeurosis is usually seen.

Treatment of eyelid ptosis is generally determined by the degree of levator function.
Levator function is assessed by immobilizing the frontalis muscle with gentle pressure
above the eyebrows. Upper lid excursion is then measured as the patient's gaze moves
from inferior to superior. Levator function is classified as excellent (12 to 15 mm),
good (8 to 12 mm), fair (5 to 7 mm), poor (less than 4 mm). Most cases of congenital
ptosis have poor levator function, whereas cases of acquired ptosis generally have fair
to good excursion of the upper lid. Minimal ptosis with good levator function can be
treated with transconjunctival excision of part of the tarsal plate and Müller's muscle.
This is known as the Fasanella-Servat procedure. More significant ptosis with fair to
good levator function is usually treated by resection of the levator muscle through an
upper eyelid incision. The shortened levator muscle is then approximated to the tarsal
plate. Resection or plication of the levator muscle is usually accomplished through an
upper eyelid skin incision. In cases of severe congenital ptosis with absent levator
function, suspension of the upper eyelid to the frontalis muscle usually is required.
Fascia lata or alloplastic material may be used for suspension of the lid.

Skull and Scalp Reconstruction
Partial defects of the scalp and calvaria are usually the result of trauma or surgical
defects after tumor excision. Acute coverage of small or moderate- sized scalp defects
can be accomplished with scalp flaps. Orticochea has described raising the entire
scalp as three or four flaps that are then transposed into the defect. By scoring the
galea aponeurotica on the undersurface of each flap, increased length can be gained.
Large defects can also be closed with split-thickness skin grafts. Split-thickness skin
grafts placed on the calvaria provide unstable coverage in the long term, however, and
are prone to breakdown. Acute coverage of large, full- thickness defects involving
both scalp and calvaria may require free-tissue transfer. The calvaria may be
reconstructed with split calvarial or rib grafts that are in turn covered by a free flap.
The omentum and latissimus dorsi or serratus anterior muscle are frequent choices for
free flaps in reconstruction of the scalp and calvaria. These flaps are thin and broad
and easily support a skin graft.

Tissue expansion is a useful technique for reconstructing partial defects of the scalp.
By effectively increasing the amount of hair-bearing scalp, areas of burn alopecia or
prior skin grafts placed on the scalp may be excised and closed with adjacent hair-
bearing scalp.

Total scalp avulsion is usually the result of hair becoming entangled in machinery.
Because the galea is a strong layer that resists separation, scalp avulsions frequently
separate between the galea and the periosteum. The avulsed segment usually includes
the eyebrow and upper ear. This devastating injury should be treated by microvascular
replantation whenever possible. As the scalp is relatively resistant to hypoxia, long
delays in treatment do not preclude replantation. Contraindications to scalp
replantation include an unstable patient or severe damage to the avulsed scalp.

Facial Reanimation
The facial nerve is both a motor and a sensory nerve. The sensory component of the
nerve includes both an afferent division, which is responsible for taste from the
anterior two-thirds of the tongue via the chorda tympani nerve, and an efferent
division with secretory fibers to the lacrimal gland and, also via the chorda tympani,
to the sublingual and submandibular glands. The motor component innervates the
muscles of facial expression and the stapedius muscle in the middle ear. Facial nerve
paralysis is seen in a wide variety of disease stages. Congenital facial nerve paralysis
is seen in Möbius' syndrome. Bell's palsy is thought to be the result of swelling within
the bony canal. It is frequently idiopathic and occurs most commonly in young adults.
Penetrating trauma can lacerate the nerve at any point after it exits from the
stylomastoid foramen (Fig. 43-55). Facial nerve paralysis can also be seen with
fractures of the temporal bone.

A lacerated facial nerve should be explored and repaired as soon as possible. Using
microsurgical techniques, the nerve ends are directly coapted whenever possible.
Nerve grafts are used for segmental nerve loss when direct repair is not possible.
Facial nerve resection as part of a cancer operation also should be reconstructed with
nerve grafts. Planned postoperative radiation therapy does not contraindicate nerve
grafting. Fractures of the temporal bone usually do not disrupt the facial nerve. When
the facial nerve is affected by temporal bone fractures, partial facial nerve paralysis or
late appearance of the facial nerve paralysis indicates that the nerve has not been
completely disrupted. Nonoperative management should be pursued in these cases.
With immediate and complete facial paralysis after a temporal bone fracture,
decompression of the facial nerve within the bony canal should be undertaken.
Paralysis of the facial musculature results in functional problems that include
incompetence of the oral and ocular sphincter mechanisms (Fig. 43- 56). Paralysis of
the orbicularis oculi muscle results in an inability to close the eyelid. This may lead to
exposure keratitis. Paralysis of the orbicularis oris muscle can result in oral
incompetence and abnormal speech. Facial symmetry and facial expression are also
profoundly affected by facial paralysis. When the distal facial nerve–muscle unit is
thought to be intact, nerve grafts from the contralateral intact facial nerve or from a
partial transection of the ipsilateral hypoglossal nerve may be used to reanimate the
affected side of the face (Fig. 43-57). These techniques must be employed within 2
years of the time of injury, as motor endplates degenerate in the absence neural
stimulation. Static techniques have long been used to suspend the paralyzed face (Fig.
43-58). These techniques typically involve slings of fascia lata to the eyelids and
mouth. More dynamic techniques include transfer of part of the temporalis or
masseter musculature to the oral commissure and eyelid. As these muscles are
innervated by the Vth cranial nerve, considerable practice is required by the patient to
produce a coordinated smile (Fig. 43-59).

Microneurovascular muscle transfers have yielded some of the most promising results
in facial reanimation surgery. With these techniques a cross-facial nerve graft is
performed and the advancing Tinel's sign followed. Approximately 1 year later a free
vascularized muscle flap is performed and its motor nerve anastomosed to the cross-
facial nerve graft. The gracilis muscle is the most common donor muscle. The
pectoralis minor and latissimus dorsi muscles have also been used. Typically the
gracilis muscle would be sutured to the oral commissure and the body of the zygoma
in an effort to produce a more normal smile (Fig. 43-60). The advantages of this
technique are that facial movement is controlled by the contralateral facial nerve and
that new vascularized muscle with well- preserved motor endplates is brought to the
face. The main disadvantages of the technique are that two long operations are
required, donor site scars results, and at least 2 years are usually required before facial
movement returns.

Reconstruction After Tumor Extirpation
Surgical extirpation of head and neck tumors can create large complex defects that are
potentially very disfiguring. Reconstruction of these defects requires not only
restoration of form but also attention to the functions of speech, oral competence, and
alimentation. Through the 1970s large head and neck defects were of necessity
reconstructed by regional transposition flaps. The most common and reliable local
flaps available to the head and neck included the deltopectoral flap and the pectoralis,
latissimus, and trapezius myocutaneous flaps. The advent of microsurgical techniques
has revolutionized head and neck reconstruction. Free flaps can provide thin, pliable
oral lining, bone, and skin without bulky pedicles or disfiguring donor sites. For this
reason free-tissue transfer has become the first choice in reconstruction of most
complex head and neck defects.

Intraoral defects require reconstruction with thin, pliable tissue. For small defects
split-thickness skin grafting is sometimes adequate. Care must be taken that, with
secondary contraction of the skin graft, tongue mobility is maintained. Flaps of tongue
tissue occasionally may be employed, but they too may adversely affect tongue
mobility and limit speech or swallowing. Large defects of oral lining are usually
reconstructed by free-tissue transfer. The free radial forearm flap based on the radial
artery provides a flap with relatively thin skin and subcutaneous tissue and a long
pedicle. Other available free flaps include scapular and parascapular flaps, based on
cutaneous branches of the circumflex scapular artery, and the groin flap, based on the
superficial circumflex iliac artery. Salvage techniques after free-flap failure or for
patients thought not to be candidates for free-tissue transfer include deltopectoral and
pectoralis major flaps.

Resection of more advanced oral cancers or primary tumors of bone may include
defects of the mandible or maxilla. Small defects sometimes may be reconstructed
with some combination of a soft-tissue flap and nonvascularized bone graft.
Nonvascularized bone grafts do poorly in radiated beds and also poorly tolerate
subsequent radiation therapy. When radiation therapy is part of the clinical picture, or
for very large defects, free vascularized bone flaps are the procedure of choice. Donor
sites include the fibula, based on the peroneal vessels, the lateral border of the
scapula, based on circumflex scapular vessels, and the iliac crest, based on the deep
circumflex iliac vessels. These free bone flaps may also be taken with an associated
skin island to provide tissue for reconstruction of skin or mucosal defects.

The cervical esophagus must often be resected as part of the treatment for a stage T3
or T4 carcinoma of the hypopharynx and larynx. Tubed myocutaneous flaps have
been used to reconstruct the cervical esophagus, but they are bulky and prone to
fistula formation. The stomach can also be delivered into the neck and an
esophagogastrostomy performed for reconstruction of cervical esophageal defects. A
segment of jejunum transferred as a free vascularized flap, however, is our preferred
method. This flap is reliable in a radiated wound and also tolerates radiation therapy.
It is performed in a single stage and allows early resumption of oral feeding (Fig. 43-
61).

Hemangiomas and Vascular Malformations
Hemangiomas are common pediatric tumors that enlarge by cellular proliferation.
Historically, hemangiomas have been given a number of names based on their clinical
appearance. Capillary hemangiomas and strawberry hemangiomas have a similar
biology. Cavernous hemangiomas occur deeper in subcutaneous tissue or muscle and
hence appear darker or blue from the skin surface. Hemangiomas usually present
within the first month of life and typically undergo a period of proliferation lasting 6
to 18 months. The lesion then begins to involute and this process may continue for
several years. The majority of hemangiomas require no treatment. Even large lesions
of the face frequently resolve with minimal or no cosmetic sequelae. Treatment is
indicated for lesions that obstruct the visual axis, airway, or bilateral external auditory
canals. Less commonly hemangiomas may be associated with hemorrhage or platelet
consumption (Kasabach- Merritt syndrome), which requires treatment. Treatment
modalities include systemic or intralesional steroids. Recent reports have also
indicated that interferon-alpha may be effective in rapidly expanding hemangiomas.
Invasive treatment generally entails surgical excision for small tumors in areas where
a surgical scar does not pose a cosmetic problem.

Vascular malformations are abnormal vascular structures formed during
embryogenesis. These lesions are not neoplastic and do not exhibit the rapid cellular
proliferation of hemangiomas. Vascular malformations may be predominantly
capillary, venous, or lymphatic in composition. Frequently some combination of these
components is present. Vascular malformations also may be present as abnormal
connections between arteries and veins, known as arteriovenous malformations. These
may be high-flow lesions that demonstrate bruits or thrills. Arteriovenous
malformations can obstruct cervical viscera or massively bleed on dental
manipulation if they arise in the head and the neck. Treatment is by intraarterial
embolization under radiographic control followed by surgical removal when possible.
These lesions can be extensive, and morbidity and mortality can be correspondingly
high.

Intradermal capillary malformations are also known as port-wine stains. These present
at birth and do not undergo resolution with time. Port-wine stains frequently present
in the skin area innervated by the trigeminal nerve. Small lesions may be directly
excised. Larger intradermal lesions usually benefit from treatment with laser.

Lymphatic malformations often present with some component of venous
malformation. Lymphatic malformations most commonly occur in the neck and upper
chest. Cystic hygroma is a form of lymphatic malformation commonly found in the
neck, with large cystic cavities and abnormal venous connections. Treatment of
lymphatic malformations is usually by direct surgical excision. Indications for
treatment include recurrent infection and airway obstruction. Because these lesions
frequently extensively invest vital structures of the neck, it is frequently possible only
to debulk the lesion at the time of operation. Involution of cystic hygroma has been
observed in some centers.

BREAST
Postmastectomy Breast Reconstruction
Breast cancer is a major public health concern in the United States. Currently most
patients with breast cancer are treated by local excision of the cancer followed by
radiation or mastectomy and axillary dissection. Even women who have undergone
breast-conserving procedures frequently must make a decision about breast
reconstruction.

The ideal candidate for breast reconstruction is a woman with a full understanding of
the surgical procedures, possible complications, and realistic goals of breast
reconstruction. Patients with a favorable prognosis are also usually good candidates
for breast reconstruction, although an unfavorable prognosis does not necessarily rule
out reconstruction. Possible benefits of breast reconstruction include an improved
body image, preservation of feminine identity, elimination of external prostheses, and
lessened psychological impact of mastectomy. Available data suggest that breast
reconstruction does not delay detection of breast cancer recurrence.

Breast reconstruction often may be performed at the time of the mastectomy.
Immediate reconstruction allows the patient to recover from anesthesia with a breast
mound in place. Studies suggest that patients who have undergone immediate
reconstruction experience less psychological disturbance. Immediate reconstruction
requires that the patient undergo a longer initial period of anesthesia. Complications
of the mastectomy or reconstruction could also conceivably delay subsequent
chemotherapy or radiation therapy. For this reason many reconstructive surgeons
prefer to offer immediate reconstruction to patients in whom the likelihood of
advanced disease is small. For patients who choose delayed breast reconstruction, the
reconstructive procedure usually is performed after chemotherapy or radiation therapy
is complete. Advanced age and disease states are not absolute contraindications to
reconstruction.

Breast reconstruction techniques may involve autologous or alloplastic materials.
Alloplastic materials generally involve some combination of tissue expander and
permanent breast prosthesis. Typically a patient choosing reconstruction with an
expander/implant would have a tissue expander placed via the original mastectomy
incision. Tissue expanders are generally placed in the submuscular position after
raising the pectoralis major muscle, the serratus anterior muscle, and the anterior
rectus sheath as a unit. Expansion is then carried out postoperatively, allowing for
slight overexpansion relative to the desired final breast size. The tissue expander is
exchanged for a permanent breast prosthesis during a second surgical procedure. In
some patients there is adequate skin after a mastectomy for insertion of an implant
large enough to match the contralateral breast without the use of a tissue expander,
but this obtains only rarely.

Patients with significant deficiencies in skin and subcutaneous tissue may need to
have a latissimus dorsi myocutaneous flap transposed into the surgical defect. The
expander/prosthesis may then be positioned beneath the latissimus dorsi flap (Fig. 43-
62). Complications following breast reconstruction with a tissue expander or implant
include hematoma, infection, exposure of the implant, and capsular contraction.
Contraction of the fibrous capsule that forms around a breast implant can cause
significant deformity or pain. The true incidence of capsular contraction is unknown
but probably ranges from 5 to 20 percent. Capsular contraction may be seen less
frequently with textured implants.

Breast reconstruction with autologous tissue offers the patient a warm, natural-feeling
breast without the use of alloplastic materials. The abdomen is an excellent source of
autologous tissue for breast reconstruction. The entire lower abdominal ellipse of skin
and subcutaneous tissue may be lifted as a myocutaneous flap based on perforators
from the rectus abdominis muscles. These muscles receive most of their blood supply
from the superior epigastric vessels, and care must be taken to preserve these vessels
as the rectus abdominis muscle is dissected to the costal margin. The transverse rectus
abdominis musculocutaneous (TRAM) flap is then passed under the skin of the upper
abdomen and set into the surgical defect. The flap is shaped to match the contralateral
breast. Because of the abundant tissue supplied to the TRAM flap a prosthesis is
rarely necessary to complete the reconstruction (Fig. 43-63).

In experienced hands, the TRAM flap is extremely reliable and has a low overall
complication rate. The incidence of partial flap loss and ventral hernia has been low.
The TRAM flap also may be transferred as a free flap pedicled on the inferior
epigastric vessels. These are typically anastomosed in the axilla to the thoracodorsal
or axillary vessels. The free TRAM flap has the theoretical advantages of improved
vascularity of the flap and less disturbance of abdominal wall integrity with a harvest
of only a small block of rectus abdominis muscle. The inferior gluteal
musculocutaneous unit is less commonly used as a donor site for free-flap breast
reconstruction. The inferior gluteal donor site is acceptable but generally provides less
tissue and is a more difficult dissection than the TRAM flap.
Nipple reconstruction is usually delayed for at least 6 weeks after breast
reconstruction. The nipple itself may be reconstructed using local dermal flaps or
grafted tissue from the contralateral nipple. The areola may be reconstructed with a
combination of full-thickness skin grafts and tattooing.

Prophylactic mastectomy is considered for some patients with a high risk of breast
cancer or extreme mastodynia. When a subcutaneous mastectomy is offered to these
patients it must be well understood by both surgeon and patient that a small amount of
breast tissue remains. The remaining breast tissue is usually in the region of the nipple
areola. Immediate reconstruction after subcutaneous mastectomy can be carried out
with breast implants. Because of the paucity of soft tissue between the skin surface
and the breast implant, these reconstructions are frequently unsatisfactory. These
patients frequently complain of a cold, unnatural-feeling breast and capsular
contracture. In these instances, a latissimus dorsi flap may be transposed to
supplement the reconstruction.

Gynecomastia
Gynecomastia is enlargement of the male breast secondary to an increase in ductal
tissue. This is seen in a number of disease states, including testicular tumors and liver
disease, and is a side effect of use of certain drugs, notably cimetidine and cannabis.
Gynecomastia is normally observed in many adolescent males. If the gynecomastia is
judged to be severe and interferes with psychosocial development, the excess breast
tissue is usually carried out through a periareolar incision. Suction-assisted lipectomy
is also helpful in treating mild cases.

Breast Reduction
Macromastia refers to an abnormal enlargement of the breast. This may be due to
genetic factors, hormonal imbalances, or obesity. Complications of macromastia
include back pain, brassiere strap furrowing, skin irritation in the inframammary
folds, and breast pain, particularly in the rapidly enlarging breast.

Treatment of macromastia involves a physician-directed weight-loss program for
obese patients. Reduction mammoplasty may be offered to the patient with
macromastia after a thorough discussion of the risks and benefits of surgery. Most
reduction techniques involve long scars that can be difficult to conceal completely.
Lactation and nipple sensibility can be affected by the procedure. Other complications
include hematoma, fat necrosis, nipple necrosis, and hypertrophic scar formation.
There are a wide number of reduction techniques employed by reconstructive
surgeons to reduce the size of the breast and reposition the nipple-areola complex.
The nipple and areola are carried on a dermal pedicle that may be based superiorly,
inferiorly, or medially (Fig. 43-64). The central pedicle technique maintains the nipple
areola complex at the apex of the breast mound (Fig. 43-65). Breast tissue is excised
with relatively more removed from the inferior and lateral poles of the breast. Excess
breast skin is also excised and skin redraped around the new breast mound and nipple-
areola complex (Fig. 43-66). The blood supply to the breast is from branches of the
internal mammary arteries, intercostal perforators, lateral thoracic artery, and
branches of the thoracoacromial trunk. Any technique of breast reduction selected
must preserve the blood supply to the breast parenchyma and nipple. The central
breast pedicle has the theoretical advantage of preserving all these arterial
contributions.

The patient with extremely large breasts will necessarily have a long pedicle from the
chest wall to the nipple-areola complex. This makes the blood supply to the nipple
more tenuous and thus carries a higher risk of nipple necrosis. In these patients it is
safest to move the nipple as a free nipple graft.

Breast Augmentation
Hypomastia refers to an abnormally small breast. This may be the result of genetic
influences. Hypomastia is also seen in Poland's syndrome, along with the absence of
the pectoralis major muscle. Breast augmentation can do much to enhance self-image
in women with hypomastia. Most techniques of breast augmentation involve placing a
prosthesis in a subglandular or submuscular position. Breast prostheses are saline-
filled silicone shells or silicone shells filled with a combination of saline and silicone
gel (Fig. 43- 67). A breast implant may be inserted via an axillary, periareolar, or
inframammary incision. Capsular contraction is the most frequent complication of
breast augmentation and may be reduced when the implant is placed in a submuscular
position deep to the pectoralis major muscle, or with textured implants. Rare
complications of breast augmentation include hematoma and infection.

Implants filled with silicone gel are no longer available for augmentation procedures.
These implants were the subject of much controversy in the early 1990s, prompting
the Food and Drug Administration to remove them from the market. Concerns
included migration of the silicone material and possible secondary connective tissue
diseases. A number of large retrospective studies have failed to show an increased
incidence of connective tissue disease in women who had undergone breast
augmentation compared to the general population. Currently silicone gel implants are
available for postmastectomy reconstruction only and within the confines of a
research protocol. Only saline-filled silicone shells are available for breast
augmentation.

Mastopexy
Breast ptosis refers to a sagging breast in which the nipple has descended below the
inframammary fold. This condition is due to a relative excess of breast skin compared
to breast parenchyma. Breast ptosis is usually the result of some combination of
weight loss, aging, and postpartum atrophy. Mastopexy techniques are similar to
breast reduction techniques in that the nipple is repositioned superiorly and excess
breast skin excised. Breast parenchyma is preserved and repositioned.

TRUNK
Chest Wall Defects
Defects of the chest wall have the potential to expose vital organs and compromise
respiration. These defects may be seen after tumor extirpation or trauma, or as a result
of radiation necrosis. A number of local flaps are available to close chest-wall defects.
The pectoralis major muscle may be mobilized to cover defects of the anterior chest
wall and sternum. The latissimus dorsi muscle, because of its length and wide arch of
rotation, is available to cover most defects of the back and anterolateral chest wall.
The rectus abdominis muscle is frequently transposed into sternal defects. Because of
its large surface area the greater omentum is available to resurface large areas of the
anterior and lateral chest wall. This flap is particularly useful with extensive radiation
injury.

Full-thickness defects of the chest wall may be reconstructed as a single stage with rib
grafts or prosthetic materials used for skeletal reconstruction. Alloplastic materials
used for skeletal reconstruction of the chest wall include Prolene mesh, Marlex Mesh
Gore-Tex, and methyl methacrylate. Prosthetic materials, however, should not be used
in radiated wounds.

Sternal Wounds
The infected sternal wound poses a particular challenge in chest-wall reconstruction.
The overall infection rate after median sternotomy for coronary artery bypass
procedures is generally reported to be less than 2 percent. Given the large number of
these procedures performed annually, however, a significant number of infected
sternal wounds require treatment. Historically, the infected sternal wound was treated
by debridement and open packing. This yielded mortality rates as high as 50 to 70
percent and long hospitalizations. In the late 1960s and 1970s debridement and
reclosure of the sternum over closed irrigation systems reduced the mortality rate of
sternal wound infections to 20 percent. Jurkiewicz and associates reported in 1980
their experience with the treatment of infected median sternotomy wounds by
debridement and closure with muscle flaps, usually in a single stage (Fig. 43-68). This
technique has reduced mortality to less than 5 percent and decreased the length of
hospitalization significantly. Muscle flaps available for closure of sternal wounds
include the pectoralis major and the rectus abdominis muscles, and occasionally the
latissimus dorsi muscles. The omentum also has been effectively used in the treatment
of infected sternal wounds but requires a laparotomy.

Use of the internal mammary artery as a conduit for coronary artery bypass influences
the treatment of sternal wound infections. Blood supply to the ipsilateral pectoralis
and rectus muscles are affected by internal mammary artery harvest. In these
instances, most surgeons select a muscle flap contralateral to the internal mammary
artery graft. More aggressive sternal debridement is usually required in these cases as
the ipsilateral sternum is significantly devascularized by internal mammary artery
harvest.

Back
Reconstruction of the back is typified by meningomyelocele closure. This variant of
spina bifida requires early closure to prevent infection and preserve remaining neural
function. These defects are usually closed with some combination of gluteus and
latissimus dorsi myocutaneous flap advancement. The latissimus dorsi muscle may be
transferred on its thoracodorsal pedicle or reversed and transposed into the defect
based on paraspinal perforators. Tissue-expansion techniques have been useful in this
disorder when time is not of the essence.

Pressure Sores
Unrelieved pressure over bony prominences results in tissue necrosis if the sustained
pressure exceeds the arterial capillary pressure of 32 mmHg. These so-called pressure
sores frequently follow spinal cord injuries. They also occur in patients subjected to
prolonged anesthesia. Decubitus ulcers refer to pressure sores that develop when the
patient is recumbent for long periods. These wounds typically occur at the sacrum, the
back of the head, and the greater trochanters. Pressure sores that occur over the ischial
tuberosities in a sitting patient therefore are not decubitus ulcers. A typical pressure
sore involves a cavernous wound overlying a larger area of subcutaneous fat or
muscle necrosis. When chronic, these wounds form large bursas lined with
granulation tissue.

Small superficial sores may be treated with local care and avoidance of pressure.
More extensive sores usually require flap coverage. Flap selection is individualized to
the location of the event of recurrence. Sacral sores may be closed with a transverse
back flap or gluteus myocutaneous units. Wounds over the ischial tuberosities are
often closed with a gluteus myocutaneous flap, posterior thigh flap, or biceps femoris
musculocutaneous flap (Fig. 43-69). The tensor fascia lata musculocutaneous flap is
often the first choice for closure of greater trochanteric wounds. After flap closure of
pressure sores patients are normally kept in air-fluidized or low-air-loss beds for 3
weeks. Mobilization is then begun and the wound carefully observed for any signs of
breakdown. Positive nitrogen balance established preoperatively must be maintained
in the postoperative period. Behavior patterns must be changed to avoid recurrence.
Despite these efforts recurrence rate is high, and recurrence in the young patient with
traumatic paraplegia is the rule rather than the exception.

Abdominal Wall
Flaps available for anterior abdominal wall reconstruction are limited. Superiorly or
inferiorly based rectus abdominis muscle flaps can reach most of the anterior
abdomen, but these muscles are frequently involved in the abdominal wall defect. The
tensor fascia lata and rectus femoris muscle flaps may be rotated into the defects of
the lower anterior abdomen. Particularly useful for closing wounds of the irradiated
perineum are the gracilis muscle and portions of gluteus muscle, usually with
overlying skin as musculocutaneous unit.

LOWER EXTREMITY
Difficult wounds of the lower extremity are usually seen in the setting of other disease
states, including venous or arterial insufficiency and diabetes. Patients with significant
soft tissue defects over the tibia frequently require flap closure. These include patients
with type III and IV open tibial fractures. Local gastrocnemius and soleus muscle
flaps are preferred for proximal wounds when possible. Wounds of the distal one-
third of the leg with exposed bone usually require free-tissue transfer. Posttraumatic
chronic osteomyelitis of the tibia also usually requires debridement and muscle flap
coverage. Cure rates higher than 90 percent are routinely reported for this difficult
problem when muscle flaps are employed. Large defects of the tibia are frequently
treated with free vascularized bone flaps. Segmental defects larger than 6 cm may be
reconstructed by microsurgical transfer of fibula or iliac crest grafts. This technique
typically yields success rates in the range of 80 to 90 percent.

Stasis Ulcers
Patients with venous stasis ulcers should be evaluated for treatment of their venous
insufficiency. This may include ligation of incompetent perforators or venous bypass.
The majority of patients are treated with compressive garments. Venous stasis ulcers
that do not close with conservative care are usually excised and skin grafted. Local
flaps are reserved for the most severe stasis ulcers. Free-tissue transfer has not been
effective in the treatment of venous stasis ulcers.
Diabetic Ulcers
Recent advances have been made in the care of diabetic foot ulcers and limb salvage.
A certain degree of fatalism has always existed concerning the care of diabetic foot
ulcers, rooted in the misconception of “small-vessel disease.” Historically, diabetic
patients have been thought to develop occlusive disease at the level of the arteriole.
The concept of small-vessel disease stems from postmortem studies demonstrating
proliferative changes and hyaline deposition in vessels of diabetic patients. More
recent prospective studies have failed to confirm these findings.

A large number of fasciocutaneous flaps have been described in the foot for closure of
diabetic wounds. A number of small series have also reported success with free-tissue
transfer for closure of large diabetic foot ulcers. The success of any reconstructive
effort in the diabetic foot depends on a thorough vascular evaluation and bypass of
flow-limiting lesions. Foot reconstruction may be performed at the time of
revascularization. Free flaps have been performed at the time of distal
revascularization, and theoretically they may improve patency of distal bypass grafts
by providing additional outflow for the graft.

Lymphedema
Lymphedema, the abnormal collection of lymph in the interstitial space, is classified
as primary when it occurs independently of other disease processes or surgery.
Primary lymphedema is termed lymphedema congenitum when it is present at birth,
lymphedema praecox when it occurs before the age of 35 years, and lymphedema
tardum when it presents after the age of 35 years. Secondary lymphedema refers to
lymphatic obstruction or ablation usually from malignancies, surgery, infection, or
radiation.

Treatment of lymphedema is usually nonsurgical. The patient must be instructed to
avoid even minor trauma to the extremity and to wear only well-fitting clothing and
shoes. Elevation, when possible, and individually fitted compressive garments are the
mainstay of treatment. In severe cases, surgical options are limited. Procedures
involving skin flaps and skin grafts have been used since the early part of this century.
Kondoleon in 1912 described the excision of deep muscle fascia beneath large skin
flaps to facilitate lymphatic drainage directly into muscle tissue. This was largely
unsuccessful and was modified by Sistrunk in 1918 to include staged subcutaneous
excisions of edematous tissue beneath large skin flaps. Charles in 1912 described
excision of skin and subcutaneous tissue with immediate regrafting of fascia and
muscle of the limb with split- or full- thickness grafts. Full-thickness grafts generally
provide a better result than split-thickness grafts, which tend toward unstable
coverage, excessive scarring, and hyperkeratotic changes. The Charles technique, in
the main, has been abandoned.

A number of procedures have been proposed to bypass or reconstruct the lymphatic
system. These include dermal flaps buried in muscle, flaps of omentum placed
subcutaneously in the lymphedematous extremity, demucosalized segments of ileum
placed over lymph node basins, and microsurgical lymphaticovenous anastomoses.
Clinical data and experience remain inadequate to demonstrate efficacy in these
techniques. None of these procedures has gained widespread acceptance to date.
Staged excision of the subcutaneous tissue and excess skin followed by rigorous
adherence to use of pressure garments provide the best palliation.

AESTHETIC SURGERY
Facial Aging
Increased laxity of skin and subcutaneous tissues of the face is a normal part of aging.
This typically presents as “bags” in the lower eyelids, the appearance of jowls along
the jaw line, a deepened nasolabial fold, and excess skin and wrinkling in the face and
neck. These changes can be treated effectively by surgical techniques to improve the
appearance of the face.

The facelift, or rhytidectomy, is designed to excise excess skin and reposition the
sagging soft tissue of the face (Fig. 43-70). The procedure may be performed under
general or local anesthesia. The face and neck are infiltrated with 0.25% lidocaine
with 1:400,000 epinephrine. The standard incision extends from a point in the
temporal scalp approximately 6 cm superior to the root of the helix along the anterior
margin of the ear around the lobe and along the posterior sulcus of the ear,
terminating in hair-bearing scalp. In this manner all but a very fine scar anterior to the
ear is hidden by hair-bearing scalp. The skin of the face and neck is then dissected
from underlying muscles of facial expression.

A thin facial layer known as the superficial muscular aponeurotic system (SMAS)
extends over the facial musculature and is contiguous with the platysma inferiorly and
the frontalis muscle and temporal fascia superiorly. The SMAS may be dissected with
the skin flap or as a separate layer and tightened by excising redundant SMAS or by
plicating it to itself. Tightening the SMAS theoretically gives a more effective lift and
longer-lasting results. Additional techniques include dissection in a deeper plane just
superficial to the branches of the facial nerve as they exit the parotid gland, or in a
subperiosteal plane. After excess SMAS and skin have been excised, the SMAS is
sutured to fascia anterior to the ear and over the mastoid process. The skin is then
closed. Drains may or may not be used. Ancillary techniques often used with the
facelift procedure include suction-assisted lipectomy of the face, direct submental
lipectomy through an incision beneath the chin, and tightening the platysma by
suturing it laterally or in the midline should there by any diastasis.

Care must be taken to preserve vascularity to the skin flaps. Delayed wound healing
may be seen in the posterior auricular incision, especially in patients who smoke.
Hematomas sometimes occur and may range from small collections that resolve
spontaneously to large hematomas requiring surgical drainage. The overall rate of
significant hematoma formation is approximately 4 percent. Facial nerve injury is
rare, occurring in less than 1 percent of patients.

As in other surgical specialties, minimally invasive surgery is becoming a standard
part of the plastic surgeon's repertoire. Most of the commonly used endoscopic plastic
surgery procedures are in the realm of cosmetic surgery. The endoscopic brow lift is
one of the most common such procedures. Where previously a coronal incision was
used to access the brow musculature and excise lax scalp, now three endoscopic ports
are made in the scalp in the temporal and frontal regions (Fig. 43-71). Through these
ports the brow musculature can be altered, usually by resection of the corrugator and
procerus muscles in the nasofrontal region.
Long-term results in endoscopic aesthetic surgery remain controversial. Difficulty in
standardizing pre- and postoperative results contributes to the difficulty. Despite this,
patient preference for the limited incision of endoscopic approaches makes the
endoscopic brow lift a mainstay of aesthetic surgery.

The fine wrinkles seen in the perioral region are generally not improved by
rhytidectomy. These wrinkles may be addressed, however, by dermabrasion or
chemical peel. Dermabrasion is a technique employing a rotating abrasive cylinder on
a hand-held power tool. With this instrument skin surface irregularities such as
shallow acne scars and fine wrinkles are removed. Dermabraded skin heals as a
superficial partial-thickness burn. The wound is cared for in an open manner with
antibiotic ointment. Pigmentation changes can occur, and it is important to avoid
sunlight for several months after the procedure to diminish this risk. Phenol and
trichloracetic acid have been used to induce a superficial chemical burn to the face.
This technique, known as a chemical face peel, has also been used to treat fine
wrinkles around the mouth and eyes. When performed by experienced practitioners,
the complication rates in chemical face peels are very low. Hypertrophic scarring has
been reported. Pigmentation changes are the most common complication.

Similarly, the CO2 laser also may resurface the face by removing a portion of the
epidermis and superficial dermis. Some surgeons feel that this is a more precise
technique than dermabrasion or chemical peel.

Eyelid
Facial aging can result in laxity in the soft tissues of the eyelid. The patient may
complain of “bags” under the eyes and with excessive upper eyelid skin may actually
have the visual field reduced on superior gaze. These changes are the result of
excessive eyelid skin, redundant festoons of orbicularis oculi muscle, and prominence
of intraorbital fat. The technique of blepharoplasty attempts to restore the eyelids to a
more youthful appearance. This technique involves some combination of skin
removal and fat excision. Incisions for lower eyelid blepharoplasty may be
transconjunctival if no skin excision is planned, or in a subciliary position,
immediately below the lower eyelid lashes. The incision for an upper eyelid
blepharoplasty is typically in the supratarsal skin fold. The overall complication rate
of blepharoplasty is low. Excessive lower lid skin excision in the lower lid may result
in ectropion, especially in the elderly patient with poor lower-lid tone. Excessive fat
excision results in a sunken or hollow look to the eyes. Blindness, however rare, has
been reported in the literature from retrobulbar hemorrhage.

Nasal Deformity
Rhinoplasty is undertaken to alter the form of the nose or the function of the nasal
airway. Patient complaints frequently include a dorsal nasal hump, broad nasal tip,
asymmetry of the tip or dorsum, and nasal airway obstruction. Rhinoplasty may be
performed under general or local anesthesia with open or closed technique. An open
rhinoplasty involves an incision in the skin at the base of the columella that is then
carried inside the nose along the alar rim. Through this incision the skin of the
columella and nasal tip is dissected away from the alar cartilages. The surgeon then
may reduce or modify alar and tip cartilage under direct vision. Changes in the bony
pyramid of the nose are made by using a small osteotome to rasp the dorsum (to
reduce any nasal hump) and the infracture of the nasal bones arising from the maxillae
(to narrow the nose). The closed technique employs incisions inside the nose near or
within the alar cartilages. The surgeon then modifies the nasal cartilages or bony
pyramid of the nose as desired (Fig. 43-72). Because the closed technique does not
allow these changes to be made under direct vision (Fig. 43-73), many surgeons
prefer the open technique for difficult problems of the nasal tip. If nasal airway
obstruction is present, the surgeon may elect to resect or modify the nasal septum at
the time of rhinoplasty. Excision of hypertrophic inferior turbinates may also improve
the nasal airway.

Abdomen, Thighs, and Buttocks
Pregnancy, weight loss, and aging can result in redundancy of abdominal skin.
Abdominoplasty involves direct excision of a lower abdominal ellipse of skin to
remove excesses of abdominal skin and fat (Fig. 43-74). The umbilicus is repositioned
in the superior skin flap as it is advanced over the lower abdomen. If a diastasis recti
or ventral hernia is present it may be repaired at the same time. This technique
typically leaves an acceptable scar at the level of the pubis that may be concealed
under clothing and swimwear.

The most common aesthetic complaint in the region of the abdomen, buttocks, and
thighs is localized fat refractory to exercise and diet. For males this fat is typically
found in the lower abdomen; females frequently complain of “saddlebags” of the
lateral hips and thighs. Suction-assisted lipectomy has proved very helpful for these
problems. Direct excision of the redundant skin of the buttocks and thighs is generally
reserved for the patient who has undergone massive weight loss, as may be seen after
gastric bypass for morbid obesity.


(Bibliography omitted in Palm version)

Back to Contents
CHAPTER 44 - Minimally Invasive Surgery
 John G. Hunter

Minimally invasive surgery describes an area of surgery that crosses all traditional
disciplines, from ophthalmology to podiatric surgery. It is not a discipline unto itself
but more a philosophy of surgery, a way of thinking. Minimally invasive surgery is to
perform major operations through small incisions, often using miniaturized high-tech
imaging systems, to minimize the trauma of surgical exposure. Some believe that
minimal access surgery more accurately describes the small incisions generally
necessary to gain access to surgical sites in high-tech surgery, but John Wickham's
term minimally invasive surgery (MIS) is widely used because it describes the
paradox of postmodern high-tech surgery, small holes, big operations—the
“minimalness” of the access and the invasiveness of the procedures, captured in three
words.

HISTORICAL BACKGROUND
While the term minimally invasive surgery is relatively recent, the history of its
component parts is nearly a hundred years old. The newest and most popular variety
of minimally invasive surgery, laparoscopy, is in fact the oldest. Primitive
laparoscopy, placing a cystoscope within an inflated abdomen, was first performed by
Kelling in 1901. Illumination of the abdomen required hot elements at the tip of the
scope and was dangerous. In the late 1950s Hopkins described the rod lens, a method
of transmitting light through a solid quartz rod with no heat and little light loss.
Around the same time, thin quartz fibers were discovered to be capable of trapping
light internally and conducting it around corners, opening the field of fiber optics and
allowing the rapid development of flexible endoscopes. In the 1970s the application
of flexible endoscopy grew faster than that of rigid endoscopy except in a few fields
such as gynecology and orthopaedics. By the mid-1970s rigid and flexible endoscopes
made a rapid transition from diagnostic instruments to therapeutic instruments. The
explosion of video surgery in the past 10 years was a result of the development of
compact high-resolution charge- couple devices, which could be mounted on the
internal end of flexible endoscopes or to the external end of a Hopkins telescope.
Coupled with bright light sources, fiberoptic cables, and high-resolution video
monitors, the video endoscope has changed our understanding of surgical anatomy
and changed the shape of surgical practice.

While optical imaging produced the majority of minimally invasive surgical
procedures, other (traditionally radiologic) imaging technologies allowed the
development of innovative procedures in the 1970s. Fluoroscopic imaging allowed
the adoption of percutaneous vascular procedures, the most revolutionary of which
was balloon angioplasty. Balloon-based procedures spread into all fields of medicine,
assisting in a minimally invasive manner to open up clogged cylinders. Stents were
then developed that were used in many disciplines to keep the newly ballooned
segment open. The culmination of fluoroscopic balloon and stent proficiency is
exemplified by the transvenous intrahepatic portosystemic shunt (TIPS) (Fig. 44-1).

Minimally invasive surgical procedures using ultrasound imaging have been limited
to fairly crude exercises such as fragmenting kidney stones and freezing liver tumors
because of the relatively low resolution of ultrasound devices. Newer, high-resolution
ultrasound methods with high-frequency crystals may act as a guide while performing
minimally invasive resections of individual layers of the intestinal wall.

Axial imaging, such as computed tomography (CT), has allowed the development of
an area of minimally invasive surgery that is not often recognized because it requires
only a CT scanner and a long needle. CT- guided drainage of abdominal fluid
collections and percutaneous biopsy of abnormal tissues are minimally invasive
means of performing procedures that previously required a celiotomy.

The most powerful noninvasive method of imaging that will allow the development of
the least invasive—and potentially noninvasive—surgery is magnetic resonance
imaging (MRI). MRI is an extremely valuable diagnostic tool, but it is only slowly
coming to be of therapeutic value. One obstacle to the use of MRI for minimally
invasive surgery is that image production and refreshment of the image as a procedure
progresses are slow. Another is that all instrumentation must be nonmetallic when
working with the powerful magnets of an MRI scanner. Moreover, MRI magnets are
bulky and limit the surgeon's access to the patient. “Open magnets” have been
developed that allow the surgeon to stand between two large MRI coils, obtaining
access to the portion of the patient being scanned. The advantage of MRI, in addition
to the superb images produced, is that there is no radiation exposure to patient or
surgeon. Some neurosurgeons are accumulating experience using MRI to perform
frameless stereotactic surgery.

PHYSIOLOGY
With the least invasive of the minimally invasive surgical procedures no significant
physiologic alterations occur. Many minimally invasive procedures require no
sedation or minimal sedation, and there are few alterations to the cardiovascular,
endocrinologic, or immunologic systems. The least invasive of such procedures
include stereotactic biopsy of breast lesions and flexible gastrointestinal endoscopy.
Minimally invasive procedures that require general anesthesia have a greater
physiologic impact because of the anesthetic agent, the incision (even if small), and
the induced pneumoperitoneum.

Laparoscopy
The unique feature of endoscopic surgery in the peritoneal cavity is the need to lift the
abdominal wall from the abdominal organs. Two methods have been devised for
achieving this. The first, used by most surgeons, is the induction of a
pneumoperitoneum. Throughout the early twentieth century intraperitoneal
visualization was achieved by inflating the abdominal cavity with air, using a
sphygmomanometer bulb. The problem with using air insufflation is that nitrogen is
poorly soluble in blood and is slowly absorbed across the peritoneal surfaces. Air
pneumoperitoneum was believed to be more painful than nitrous oxide
pneumoperitoneum. Subsequently, carbon dioxide and nitrous oxide were used for
inflating the abdomen. N2O had the advantage of being physiologically inert and
rapidly absorbed. It also provided better analgesia for laparoscopy performed under
local anesthesia when compared with CO2 or air. The disadvantage of N2O when
compared to CO2 was that it did not suppress combustion. CO2suppresses
combustion and is rapidly absorbed and therefore is the preferred gas for laparoscopy
(Fig. 44-2).

The physiologic effects of CO2 pneumoperitoneum can be divided into two areas: (1)
gas-specific effects and (2) pressure-specific effects. CO2 is rapidly absorbed across
the peritoneal membrane into the circulation. In the circulation, CO2 creates a
respiratory acidosis by the generation of carbonic acid. Body buffers, the largest
reserve of which lies in bone, absorb CO2 (up to 120 L) and minimize the
development of hypercarbia or respiratory acidosis during brief endoscopic
procedures. Once the body buffers are saturated, respiratory acidosis develops rapidly,
and the respiratory system assumes the burden of keeping up with the absorption of
CO2 and its release from these buffers.

In patients with normal respiratory function this is not difficult; the anesthesiologist
increases the ventilatory rate or vital capacity on the ventilator. If the respiratory rate
required exceeds 20 breaths per minute there may be less efficient gas exchange and
increasing hypercarbia. Conversely, if vital capacity is increased substantially there is
a greater opportunity for barotrauma and greater respiratory-motion-induced
disruption of the upper abdominal operative field. In some situations, it is advisable to
evacuate the pneumoperitoneum or reduce the intraabdominal pressure to allow time
for the anesthesiologist to adjust for hypercarbia. While mild respiratory acidosis
probably is an insignificant problem, more severe respiratory acidosis leading to
cardiac arrhythmias has been reported. Hypercarbia also causes tachycardia and
increased systemic vascular resistance, which elevates blood pressure and increases
myocardial oxygen demand.

The pressure effects of the pneumoperitoneum on cardiovascular physiology also
have been studied. In the hypovolemic individual, excessive pressure on the inferior
vena cava and a reverse Trendelenburg position with loss of lower-extremity muscle
tone may cause decreased venous return and cardiac output. This is not seen in the
normovolemic patient. The most common arrhythmia created by laparoscopy is
bradycardia. A rapid stretch of the peritoneal membrane often causes a vagovagal
response with bradycardia and, occasionally, hypotension. The appropriate
management of this event is desufflation of the abdomen, administration of vagolytic
agents (e.g., atropine), and adequate volume replacement.

With the increased intraabdominal pressure compressing the inferior vena cava, there
is diminished venous return from the lower extremities. This has been well
documented in the patient placed in the reverse Trendelenburg position for upper
abdominal operations. Venous engorgement and decreased venous return promote
venous thrombosis. Many series of advanced laparoscopic procedures in which deep
venous thrombosis (DVT) prophylaxis was not used demonstrate the occurrence of
pulmonary embolus. This usually is an avoidable complication with the use of
sequential compression stockings, subcutaneous heparin, or low- molecular-weight
heparin. In short-duration laparoscopic procedures, such as appendectomy, hernia
repair, or cholecystectomy, the risk of DVT may not be sufficient to warrant extensive
DVT prophylaxis.

The increased pressure of the pneumoperitoneum is transmitted directly across the
paralyzed diaphragm to the thoracic cavity, creating increased central venous pressure
and increased filling pressures of the right and left sides of the heart. If the
intraabdominal pressures are kept under 20 mmHg, the cardiac output usually is well
maintained. The direct effect of the pneumoperitoneum on increasing intrathoracic
pressure increases peak inspiratory pressure, pressure across the chest wall, and also
the likelihood of barotrauma. Despite these concerns, disruption of blebs and
consequent pneumothoraces are rare after uncomplicated laparoscopic surgery.

Increased intraabdominal pressure decreases renal blood flow, glomerular filtration
rate, and urine output. These effects may be mediated by direct pressure on the kidney
and the renal vein. The secondary effect of decreased renal blood flow is to increase
plasma renin release, thereby increasing sodium retention. Increased circulating
antidiuretic hormone (ADH) levels also are found during the pneumoperitoneum,
increasing free water reabsorption in the distal tubules. Although the effects of the
pneumoperitoneum on renal blood flow are immediately reversible, the hormonally
mediated changes, such as elevated ADH levels, decrease urine output for up to 1 h
after the procedure has ended. Intraoperative oliguria is common during laparoscopy,
but the urine output is not a reflection of intravascular volume status; intravenous
fluid administration during an uncomplicated laparoscopic procedure should not be
linked to urine output. Because fluid losses through the open abdomen are eliminated
with laparoscopy, the need for supplemental fluid during a laparoscopic surgical
procedure is rare.
The hemodynamic and metabolic consequences of pneumoperitoneum are well
tolerated by healthy individuals for a prolonged period and by most individuals for at
least a short period. Difficulties can occur when a patient with compromised
cardiovascular function is subjected to a long laparoscopic procedure. It is during
these procedures that alternative approaches should be considered or insufflation
pressure reduced. Alternative gases that have been suggested for laparoscopy include
the inert gases—helium, neon, and argon. These gases are appealing because they
cause no metabolic effects, but they are poorly soluble in blood (unlike CO2 and
N2O) and are prone to create gas emboli if the gas has direct access to the venous
system. Gas emboli are rare but serious complications of laparoscopic surgery. They
should be suspected if hypotension develops during insufflation. Diagnosis may be
made by listening (with an esophageal stethoscope) for the characteristic “mill wheel”
murmur. The treatment of gas embolism is to place the patient in a left lateral
decubitus position with the head down to trap the gas in the apex of the right
ventricle. A rapidly placed central venous catheter then can be used to aspirate the gas
out of the right ventricle.

In some situations minimally invasive abdominal surgery should be performed
without insufflation. This has led to the development of an abdominal lift device that
can be placed through a 10- to 12-mm trocar at the umbilicus. These devices have the
advantage of creating little physiologic derangement, but they are bulky and intrusive.
The exposure and working room offered by lift devices also are inferior to those
accomplished by pneumoperitoneum. Lifting the anterior abdominal wall causes a
“pinching in” of the lateral flank walls, displacing the bowel medially and anteriorly
into the operative field. A pneumoperitoneum, by its well- distributed intraabdominal
pressure, provides better exposure. Abdominal lift devices also cause more
postoperative pain, but they do allow the performance of minimally invasive surgery
with standard (nonlaparoscopic) surgical instruments.

Early it was predicted that the surgical stress response would be significantly lessened
with laparoscopic surgery, but this is not always the case. Serum cortisol levels after
laparoscopic operations are often higher than after the equivalent operation performed
in through an open incision. In terms of endocrine balance, the greatest difference
between open and laparoscopic surgery is the more rapid equilibration of most stress-
mediated hormone levels after laparoscopic surgery. Immune suppression also is less
after laparoscopy than after open surgery. There is a trend toward more rapid
normalization of cytokine levels after a laparoscopic procedure than after the
equivalent procedure performed by celiotomy.

Thoracoscopy
The physiology of thoracic minimally invasive surgery (thoracoscopy) is different
from that of laparoscopy. Because of the bony confines of the thorax it is unnecessary
to use positive pressure when working in the thorax. The disadvantages of positive
pressure in the chest include decreased venous return, mediastinal shift, and the need
to keep a firm seal at all trocar sites. Without positive pressure, it is necessary to place
a double-lumen endotracheal tube so that the ipsilateral lung can be deflated when the
operation starts. By collapsing the ipsilateral lung, working space within the thorax is
obtained.

Extracavitary Minimally Invasive Surgery
Many new minimally invasive surgical procedures are creating working spaces in
extrathoracic and extraperitoneal locations. Laparoscopic inguinal hernia repair
usually is performed in the anterior extraperitoneal Retzius space. Laparoscopic
nephrectomy often is performed with retroperitoneal laparoscopy. Lower extremity
vascular procedures and plastic surgical endoscopic procedures require the
development of working space in unconventional planes, often at the level of the
fascia, sometimes below the fascia, and occasionally in nonanatomic regions. Some of
these techniques use insufflation of gas, but many use balloon inflation to develop the
space followed by low-pressure gas insufflation or lift devices to maintain the space
(Fig. 44-3). These techniques produce fewer and less severe adverse physiologic
consequences than does the pneumoperitoneum, but the insufflation of gas into
extraperitoneal locations can spread widely, causing subcutaneous emphysema and
metabolic acidosis.

Anesthesia
The most important factors in appropriate anesthesia management are related to CO2
pneumoperitoneum. The laparoscopic surgeon can influence cardiovascular
performance by releasing intraabdominal retraction and dropping the
pneumoperitoneum. Insensible fluid losses are negligible, and therefore intravenous
fluid administration should not exceed a maintenance rate. Minimally invasive
surgical procedures usually are outpatient procedures, and short-acting anesthetic
agents are preferable. Because the factors that require hospitalization after
laparoscopic procedures include the management of nausea, pain, and urinary
retention, the anesthesiologist should minimize the use of agents that provoke these
conditions and maximize the use of medications that prevent such problems. Critical
to the anesthesia management of these patients is the use of nonnarcotic analgesics
(e.g., ketorolac) and the liberal use of antiemetic agents.

GENERAL PRINCIPLES OF ACCESS
The most natural ports of access for minimally invasive surgery are the anatomic
portals of entry and exit. The nares, mouth, urethra, and anus are used to access the
respiratory, gastrointestinal, and urinary systems. The advantage of using these points
of access is that no incision is required. The disadvantages lie in the long distances
between the orifice and the region of interest.

Access to the vascular system may be accomplished under local anesthesia by
“cutting down” and exposing the desired vessel, usually in the groin. Increasingly,
vascular access is obtained with percutaneous techniques using a small incision, a
needle, and a guide wire, over which are passed a variety of different-sized access
devices. This approach, known as the Seldinger technique, is most frequently used by
general surgeons for placement of Hickman catheters but also is used to gain access to
the arterial and venous system for performance of minimally invasive procedures.
Guide-wire-assisted, Seldinger-type techniques also are helpful for gaining access to
the gut for procedures such as percutaneous endoscopic gastrostomy, for gaining
access to the biliary system through the liver, and for gaining access to the upper
urinary tract.

In thoracoscopic surgery, the access technique is similar to that used for placement of
a chest tube. In these procedures general anesthesia and split-lung ventilation are
essential. A small incision is made over the top of a rib and, under direct vision,
carried down through the pleura. The lung is collapsed, and a plastic trocar is inserted
across the chest wall to allow access with a telescope. Once the lung is completely
collapsed, subsequent access may be performed with direct puncture, viewing all
entry sites through the videoendoscope. Because insufflation of the chest is
unnecessary, simple plastic sheaths that keep the small incisions open are all that is
required to allow repeated access to the thorax.

The requirements for laparoscopy are more involved, because the creation of a
pneumoperitoneum requires that instruments of access (trocars) contain a valve to
maintain abdominal inflation. Two methods are used for establishing abdominal
access during laparoscopic procedures. The first, direct puncture laparoscopy, begins
with the elevation of the relaxed abdominal wall with two towel clips or a well-placed
hand. A small incision is made in the umbilicus, and a specialized spring-loaded
(Veress) needle is placed in the abdominal cavity (Fig. 44-4). With the Veress needle,
two distinct pops are felt as the surgeon passes the needle through the abdominal wall
fascia and the peritoneum. The umbilicus usually is selected as the preferred point of
access because in this location the abdominal wall is quite thin, even in obese patients.
The abdomen is inflated with a pressure-limited insufflator. CO2 gas usually is used
with maximal pressures in the range of 14 to 15 mmHg. Laparoscopic surgery can be
performed under local anesthesia, but general anesthesia is preferable. Under local
anesthesia, N2O is used as the insufflating agent and insufflation is stopped after 2 L
of gas is insufflated or when a pressure of 10 mmHg is reached.

After peritoneal insufflation, direct access to the abdomen is obtained with a 5- or 10-
mm trocar. The critical issues for safe direct-puncture laparoscopy include the use of a
vented stylet for the trocar or a trocar with a safety shield. The trocar must be pointed
away from the sacral promontory and the great vessels. For performance of
laparoscopic cholecystectomy, the trocar is angled toward the right upper quadrant.

Occasionally the direct peritoneal access (Hasson) technique is advisable. With this
technique, the surgeon makes a small incision just below the umbilicus and under
direct vision locates the abdominal fascia. Two Kocher clamps are placed on the
fascia, and with a curved Mayo scissors a small incision is made through the fascia
and underlying peritoneum. A finger is placed into the abdomen to make sure that
there is no adherent bowel. A sturdy suture is placed on each side of the fascia and
secured to the wings of a specialized trocar, which is then passed directly into the
abdominal cavity (Fig. 44-5). Rapid insufflation can make up for some of the time lost
with the initial dissection. This technique is preferable for the abdomen of patients
who have undergone previous operations, in which small bowel may be adherent to
the undersurface of the abdominal wound. The close adherence of bowel to the
peritoneum in the previously operated abdomen does not eliminate the possibility of
intestinal injury but should make great vessel injury extremely unlikely. Because of
the difficulties in visualizing the abdominal region immediately adjacent to the
primary trocar, it is recommended that the telescope be passed through a secondary
trocar in order to inspect the site of initial abdominal access. This examination usually
is performed at the end of the operative procedure.

Secondary punctures are made with 5- and 10-mm trocars. For safe access to the
abdominal cavity, it is critical to visualize all sites of trocar entry. At the completion
of the operation, all trocars are removed under direct vision and the insertion sites are
inspected for bleeding. If bleeding occurs, direct pressure with an instrument from
another trocar site or balloon tamponade with a Foley catheter placed through the
trocar site generally stops the bleeding within 3 to 5 min. When this is not successful,
a full-thickness abdominal wall suture has been used successfully to tamponade trocar
site bleeding.

It is generally agreed that 5-mm trocars need no site suturing. Ten- millimeter trocars
placed off the midline and above the transverse mesocolon do not require repair.
Conversely, if the fascia has been dilated to allow the passage of the gallbladder, all
midline 10-mm trocar sites should be repaired at the fascial level with interrupted
sutures. Specialized suture delivery systems similar to crochet needles have been
developed for mass closure of the abdominal wall in obese patients, in whom it is
difficult through a small skin incision to visualize the fascia. Failure to close lower
abdominal trocar sites that are 10 mm in diameter or larger can lead an incarcerated
hernia.

Access for Subcutaneous and Extraperitoneal Surgery
There are two methods for gaining access to nonanatomic spaces. For retroperitoneal
locations, balloon dissection is effective. This access technique is appropriate for the
extraperitoneal repair of inguinal hernias and for retroperitoneal surgery for
adrenalectomy, nephrectomy, lumbar discectomy, or para-aortic lymph node
dissection. The initial access to the extraperitoneal space is performed in a way
similar to direct puncture laparoscopy except that the last layer (the peritoneum) is not
traversed. Once the transversalis fascia has been punctured, a specialized trocar with a
balloon on the end is introduced. The balloon is inflated in the extraperitoneal space
to create a working chamber. The balloon then is deflated, and a Hasson trocar is
placed. An insufflation pressure of 10 mmHg usually is adequate to keep the
extraperitoneal space open for dissection. Higher gas pressures force CO2 into the
soft tissues and may contribute to hypercarbia. Extraperitoneal endosurgery provides
less working space than laparoscopy but eliminates the possibility of intestinal injury,
intestinal adhesion, herniation at the trocar sites, and ileus. These issues are important
for laparoscopic hernia repair because extraperitoneal approaches protect the small
bowel from sticking to the prosthetic mesh.

Subcutaneous surgery, the newest method of access in minimally invasive surgery,
uses the creation of working room in nonanatomic spaces. This technique has been
most widely used in cardiac, vascular, and plastic surgery. In cardiac surgery,
subcutaneous access has been used for saphenous vein harvesting, and in vascular
surgery for ligation of subfascial perforating veins (Linton procedure). With
minimally invasive techniques the entire saphenous vein above the knee may be
harvested through a single incision (Fig. 44-6). Once the saphenous vein is located, a
long retractor that holds a 5-mm laparoscope allows the coaxial dissection of the vein
and coagulation or clipping of each side branch. A small incision above the knee also
can be used to ligate perforating veins in the lower leg.

Subcutaneous access also is used for plastic surgical procedures. Minimally invasive
approaches are especially well suited to cosmetic surgery, in which attempts are made
to hide the incision. It is easier to hide several 5-mm incisions than one long incision.
The technique of blunt dissection along fascial planes combined with lighted
retractors and endoscope holding retractors is most successful for extensive
subcutaneous surgery. Some prefer gas insufflation of these soft tissue planes. The
primary disadvantage of soft tissue insufflation is that subcutaneous emphysema can
be created.

Imaging Systems
Two methods of video imaging are widely used. The first of these is flexible video
endoscopy. With flexible video endoscopy, a charge-couple device (CCD) is placed
on the internal end of a long flexible endoscope. In the second method, thin quartz
fibers are packed together in a bundle, and the CCD camera is mounted on the
external end of the endoscope. Most standard gastrointestinal endoscopes have the
CCD chip at the distal end, but small, delicate choledochoscopes and nephroscopes
are equipped with fiberoptic bundles. Distally mounted CCD chips were developed
for laparoscopy but are unpopular.

Imaging for laparoscopy, thoracoscopy, and subcutaneous surgery uses a rigid metal
telescope, usually 30 cm in length. This telescope contains a series of quartz optical
rods with differing optical characteristics that provide a specific “character” to each
telescope (Fig. 44-7). These metal telescopes vary in size from 2 to 10 mm in
diameter. Since light transmission is dependent on the cross-sectional area of the
quartz rod, when the diameter of a rod/lens system is doubled, the illumination is
quadrupled. Little illumination is needed in highly reflective small spaces such as the
knee, and a very small telescope will suffice. When working in the abdominal cavity,
especially if blood is present, the full illumination of a 10-mm telescope usually is
necessary.

Rigid telescopes may have a flat or angled end. The flat end provides a straight view
(0 degrees), and the angled end provides an oblique view (30 or 45 degrees). Angled
scopes allow greater flexibility in viewing a wider operative field through a single
trocar site; rotating an angled telescope changes the field of view. The use of an
angled telescope has distinct advantages for most videoendoscopic procedures,
particularly in visualizing the common bile duct during laparoscopic cholecystectomy
or visualizing the posterior esophagus or the tip of the spleen during laparoscopic
fundoplication.

Light is delivered to the endoscope through a fiberoptic light cable. These light cables
are highly inefficient, losing more than 90 percent of the light delivered from the light
source. Extremely bright light sources (300 watts) are necessary to provide adequate
illumination for video endosurgery.

Video cameras come in two basic designs. The one-chip camera has a black-and-
white video chip that has an internal processor capable of converting gray scales to
approximate colors. Perfect color representation is not possible with a one-chip
camera, but perfect color representation is rarely necessary for endosurgery. The most
accurate color representation is obtained using a three-chip video camera. A three-
chip camera has red, green, and blue (RGB) input and is identical to the color cameras
used for television production. RGB imaging provides the highest fidelity but is
probably not necessary for everyday use. An additional feature of new video cameras
is digital enhancement. Digital enhancement detects edges, areas where there are
drastic color or light changes between two adjacent pixels. By enhancing this
difference, the image appears sharper and surgical resolution is improved. Digital
enhancement is available on one- and three-chip cameras. Priorities in a video system
for minimally invasive surgery are illumination first, resolution second, and color
third. Without the first two attributes, video surgery is unsafe.

There has been a recent interest in three-dimensional endoscopy. Three- dimensional
laparoscopy provides the additional depth of field that is lost with 2-D endosurgery
and allows greater facility for novice laparoscopists performing complex tasks of
dexterity, including suturing and knot tying. The advantages of 3-D systems are less
obvious to experienced laparoscopists. Additionally, because 3-D systems require the
flickering of two similar images, which are resolved with special glasses, the image
edges become fuzzy and resolution is lost. The optical accommodation necessary to
rectify these slightly differing images negates any advantage offered by the additional
depth of field.

Energy Sources for Endoscopic Surgery
Minimally invasive surgery uses conventional energy sources, but the requirement of
bloodless surgery to maintain optimal visualization has spawned new ways of
applying energy. The most common energy source is radio frequency (RF)
electrosurgery using an alternating current with a frequency of 500,000 cycles/s (Hz).
Tissue heating progresses through the well-known phases of coagulation (60°C),
vaporization and desiccation (100°C), and carbonization (>200°C).

The two most common methods of delivering RF electrosurgery are with monopolar
and bipolar electrodes. With monopolar electrosurgery a remote ground plate on the
patient's leg or back receives the flow of electrons that originate at a point source, the
surgical electrode. A fine-tipped electrode causes a high current density at the site of
application and rapid tissue heating. Monopolar electrosurgery is inexpensive and
easy to modulate to achieve different tissue effects. A short-duration, high-voltage
discharge of current (coagulation current) provides extremely rapid tissue heating.
Lower-voltage, higher-wattage current (cutting current) is better for tissue desiccation
and vaporization. When the surgeon desires tissue division with the least amount of
thermal injury and least coagulation necrosis, a cutting current is used.

With bipolar electrosurgery, the electrons flow between two adjacent electrodes. The
tissue between the two electrodes is heated and desiccated. There is little opportunity
for tissue cutting when bipolar current is used, but the ability to coapt the electrodes
across a vessel provides the best method of small-vessel coagulation without thermal
injury to adjacent tissues.

Another method of delivering radio frequency electrosurgery is argon beam
coagulation. This is a type of monopolar electrosurgery in which a uniform field of
electrons is distributed across a tissue surface by the use of a jet of argon gas. The
argon gas jet distributes electrons more evenly across the surface than does spray
electrofulguration. This technology has its greatest application for coagulation of
diffusely bleeding surfaces, such as the cut edge of liver or spleen. It is of less use in
laparoscopic procedures because the increased intraabdominal pressures created by
the argon gas jet can increase the chances of a gas embolus.

Gas, liquid, and solid-state lasers have been available for medical application since
the mid-1960s. The CO2laser (wavelength 10.6 mm) is most appropriately used for
cutting and superficial ablation of tissues. It is most helpful in locations unreachable
with a scalpel, such as excision of vocal cord granulomas. The CO2 laser beam must
be delivered with a series of mirrors and is therefore somewhat cumbersome to use.
The next most popular laser is the neodymium:yttrium-aluminum-garnet (Nd:YAG)
laser. Nd:YAG laser light is 1.064 mm (1064 nm) in wavelength. It is in the near-
infrared portion of the spectrum and, like the CO2laser, is invisible to the naked eye.
A unique feature of the Nd:YAG laser is that 1064-nm light is poorly absorbed by
most tissue pigments and therefore travels deep into tissue. Deep tissue penetration
provides deep tissue heating (Fig. 44-8). For this reason the Nd:YAG laser is capable
of the greatest amount of tissue destruction with a single application. Such capabilities
make it the ideal laser for destruction of large fungating tumors of the rectosigmoid or
tracheobronchial tree. A disadvantage is that the deep tissue heating may cause
perforation of a hollow viscus.

When it is desirable to coagulate flat lesions in the cecum, a different laser should be
chosen. The frequency-doubled Nd:YAG laser, also known as the KTP laser
(potassium thionyl phosphate crystal is used to double the Nd:YAG frequency),
provides 532-nm light. This is in the green portion of the spectrum; at this
wavelength, selective absorption by red pigments in tissue (such as hemangiomas and
arteriovenous malformations) is optimal. The depth of tissue heating is intermediate
between those of the CO2 and the Nd:YAG lasers. Coagulation (without vaporization)
of superficial vascular lesions can be obtained without intestinal perforation.

In flexible gastrointestinal endoscopy, the CO2 and Nd:YAG lasers have largely been
replaced by heater probes and endoluminal stents. The heater probe is a metal ball that
is heated to a temperature (60 to 100°C) that allows coagulation of bleeding lesions
without perforation.

A unique application of laser technology provides extremely rapid discharge (<10- 6
seconds) of large amounts of energy (>103volts). These high- energy lasers, of which
the pulsed dye laser has seen the most clinical use, allow the conversion of light
energy to mechanical disruptive energy in the form of a shock wave. Such energy can
be delivered through a quartz fiber and, with rapid repetitive discharges, can provide
sufficient shock-wave energy to fragment kidney stones and gallstones. Shock waves
also may be created with miniature electric spark-plug discharge systems, known as
electrohydraulic lithotriptors. These devices also are inserted through thin probes for
endoscopic application. Lasers have the advantage of pigment selectivity, but
electrohydraulic lithotriptors are more popular because they are substantially less
expensive and are more compact.

Methods of producing shock waves or heat with ultrasonic energy also is of interest.
Extracorporeal shockwave lithotripsy creates focused shock waves that intensify as
the focal point of the discharge is approached. When the focal point is within the
body, large amounts of energy are capable of fragmenting stones. Slightly different
configurations of this energy can be used to provide focused internal heating of
tissues. Potential applications of this technology include the ability noninvasively to
produce sufficient internal heating to destroy tissue without an incision.

A third means of using ultrasonic energy is to create rapidly oscillating instruments
that are capable of heating tissue with friction; this technology represents a major step
forward in energy technology. An example of its application is the laparoscopic
coagulation shears (LCS) device (Harmonic Scalpel), which is capable of coagulating
and dividing blood vessels by first occluding them and then providing sufficient heat
to weld the blood vessel walls together and to divide the vessel. This nonelectric
method of coagulating and dividing tissue with a minimal amount of collateral
damage has facilitated the performance of numerous endosurgical procedures. It is
especially useful in the control of bleeding from medium-sized vessels that are too big
to manage with monopolar electrocautery and require bipolar desiccation followed by
cutting.

Balloons and Stents
All minimally invasive procedures, from coronary angioplasty to palliation of
pancreatic malignancy, invoke the use of endoluminal balloon dilators and prostheses.
Endoluminal balloon dilators may be inserted through an endoscope, or they may be
fluoroscopically guided. Balloon dilators all have low compliance—that is, the
balloons do not stretch as the pressure within the balloon is increased. The high
pressures achievable in the balloon create radial expansion of the narrowed vessel or
orifice, usually disrupting the atherosclerotic plaque, the fibrotic stricture, or the
muscular band (e.g., esophageal achalasia).

Once the dilation has been attained, it is frequently beneficial to hold the lumen open
with a stent. Stenting is particularly valuable in treating malignant lesions and
endovascular procedures (Fig. 44-9). Stenting usually is not applicable for the long-
term management of benign gastrointestinal strictures, except in patients with limited
life expectancy.

A variety of stents are available, but they may be divided into two basic categories,
plastic stents and expandable metal stents. Plastic stents came first and are used
widely as endoprostheses for temporary bypass of obstructions in the biliary or
urinary systems. Metal stents generally are delivered over a balloon and expanded
with the balloon to the desired size. These metal stents usually are made of titanium or
nitinol. Although great progress has been made with expandable metal stents, two
problems remain. The first is the propensity for tissue ingrowth through the interstices
of the stent. Ingrowth may be an advantage in preventing stent migration, but such
tissue ingrowth may occlude the lumen and cause obstruction anew. This is a
particular problem when stents are used for palliation of gastrointestinal malignant
growth and may be a problem for the long-term use of stents in vascular disease.
Filling the interstices with silastic or other materials may prevent tumor ingrowth but
also makes stent migration more likely. Stent designs have incorporated hooks and
barbs in an attempt to minimize migration, addressing the second problem.

Hand Instruments
Hand instruments for minimally invasive surgery usually are duplications of
conventional surgical instruments made longer, thinner, and smaller at the tip. Certain
conventional instruments such as scissors are easy to reproduce with a diameter of 3
to 5 mm and a length of 20 to 45 cm, but other instruments, such as forceps and
clamps, cannot provide remote access. Different configurations of graspers were
developed to replace the various configurations of surgical forceps and surgical
clamps. Standard hand instruments are 5 mm in diameter and 30 cm long, but smaller
and shorter hand instruments are now available for pediatric surgery, for
microlaparoscopic surgery, and for arthroscopic procedures. A unique laparoscopic
hand instrument is the monopolar electrical hook. This device usually is configured
with a suction and irrigation apparatus to eliminate smoke and blood from the
operative field. The monopolar hook allows tenting of tissue over a bare metal wire
with subsequent coagulation and division of the tissue.

Room Setup
Nearly all minimally invasive surgery, whether using fluoroscopic, ultrasound, or
optical imaging, incorporates a video monitor as a guide. Occasionally two images are
necessary to adequately guide the operation, as in such procedures as endoscopic
retrograde cholangiopancreatography (ERCP), laparoscopic common bile duct
exploration, and laparoscopic ultrasonography. When two images are necessary, the
images should be mounted on two adjacent video monitors or projected on a single
screen with a “picture in picture” effect. The video monitor(s) should be set across the
operating table from the surgeon. The patient should be interposed between the
surgeon and the video monitor; ideally, the operative field also lies between the
surgeon and the monitor. In pelviscopic surgery it is best to place the video monitor at
the patient's feet, and in laparoscopic cholecystectomy, the monitor is placed at the 10
o'clock position (relative to the patient) while the surgeon stands on the patient's left
at the 4 o'clock position. The insufflating and patient monitoring equipment also is
ideally placed across the table from the surgeon, so that the insufflating pressure and
the patient's vital signs and end tidal CO2 tension can be monitored.

Trocars for the surgeon's left and right hand should be placed at least 10 cm apart. For
most operations it is possible to orient the telescope between these two trocars and
slightly retracted from them. The ideal trocar orientation creates an equilateral triangle
between the surgeon's right hand, left hand, and the telescope with 10 to 15 cm on
each leg. If one imagines the target of the operation (e.g., the gallbladder or
gastroesophageal junction) oriented at the apex of a second equilateral triangle built
on the first, these four points of reference create a diamond (Fig. 44-10). The surgeon
stands behind the telescope, which provides optimal ergonomic orientation but
frequently requires that a camera operator (or robotic arm) reach between the
surgeon's hands to guide the telescope.

The position of the operating table should permit the surgeon to work with both
elbows in at the sides, with arms bent 90 degrees at the elbow. It usually is necessary
to alter the operating table position with left or right tilt with the patient in the
Trendelenburg or reverse Trendelenburg position, depending on the operative field.

Patient Positioning
Patients usually are placed in the supine position for laparoscopic surgery. When the
operative field is the gastroesophageal junction or the left lobe of the liver, it is easiest
to operate from between the legs. The legs may be elevated in Allen stirrups or
abducted on leg boards to achieve this position. When pelvic procedures are
performed, it usually is necessary to place the legs in Allen stirrups to gain access to
the perineum. A lateral decubitus position with the table flexed provides the best
access to the retroperitoneum when performing nephrectomy or adrenalectomy. For
laparoscopic splenectomy, a 45-degree tilt of the patient provides excellent access to
the lesser sac and the lateral peritoneal attachments to the spleen. For thoracoscopic
surgery, the patient is placed in the lateral position.
When the patient's knees are to be bent for extended periods or the patient is going to
be placed in a reverse Trendelenburg position for more than a few minutes, deep
venous thrombosis prophylaxis should be used. Sequential compression of the lower
extremities during prolonged (more than 90 min) laparoscopic procedures increases
venous return and provides inhibition of thromboplastin activator inhibitor.

MINIMALLY INVASIVE GENERAL SURGICAL PROCEDURES (Table 44-1)
Cholecystectomy
Although flexible endoscopy introduced many general surgeons to video- assisted
procedures (e.g., percutaneous endoscopic gastrostomy), it was laparoscopic
cholecystectomy that provided the cornerstone around which minimally invasive
surgery units were built.

The benefits of laparoscopic cholecystectomy are that it causes little pain and minimal
scarring, requires only a short rehabilitation period, and usually can be performed as
an outpatient procedure. Common bile duct injury occurs more frequently with
laparoscopic cholecystectomy because it frequently is mistaken for the cystic duct.
Five steps that help minimize the risk of bile duct injury are: (1) use of an angled (30-
degree) scope, (2) maximal cephalic retraction of the gallbladder fundus, (3) lateral
retraction of the infundibulum, (4) complete dissection of the gallbladder at its
junction
with the cystic duct, and (5) liberal use of fluoroscopic cholangiography (Fig. 44-11).

Appendectomy
The indications for laparoscopic appendectomy depend on the surgeon's confidence in
the diagnosis, the age, sex, and weight of the patient, and the stage of appendicitis.
Most agree that patients who have right iliac fossa tenderness of uncertain origin
might benefit from diagnostic laparoscopy. If uncomplicated appendicitis is found, the
appendix should be removed. If the appendix is normal and no other pathology is
detected, the appendix should be removed. If a condition is detected that is likely to
cause recurrent pain (e.g., terminal ileitis), the appendix should be removed. The
appendix is left only if another surgical problem (e.g., acute cholecystitis) is detected.
When unsuspected advanced inflammatory conditions of the appendix (gangrene,
phlegmon, abscess) are discovered, conversion to a celiotomy, or rarely antibiotic
therapy and interval appendectomy, is indicated. The perforated appendix can be
treated laparoscopically if the inflammatory reaction is minimal and the base of the
appendix is normal.

Additional indications for a selective approach to laparoscopic appendectomy include
obese patients and active patients for whom rapid rehabilitation is paramount. The
advantages of a nonselective approach to laparoscopic appendectomy were
demonstrated in several prospective, randomized trials. In most of these trials,
laparoscopic appendectomy resulted in less pain, a more rapid recovery, and an earlier
hospital discharge. A meta-analysis of all prospective randomized trials confirmed
these findings.

Laparoscopic appendectomy generally requires three ports, at least one of which is 10
mm in diameter. The surgeon needs an assistant to guide the video endoscope.
Trocars are placed in the umbilicus (10 to 12 mm) in the suprapubic position (5 mm),
and halfway between the umbilicus and the pubis (5 or 10 mm) for the telescope (Fig.
44-12 A). Working through the umbilical and suprapubic trocars, the appendix is
mobilized and the mesoappendix divided with clips, bipolar electrosurgery, or staples.
When the mesoappendix is involved with the inflammatory process, it is impossible to
mobilize the appendix; it often is best to make a window next to the base of the
appendix, divide the appendix with a stapler, then divide the mesoappendix
immediately adjacent to the appendix with clips, stapler, or bipolar coagulation. The
appendix is removed through a 10-mm trocar if it is small, or in a specimen bag if it is
enlarged.

Inguinal Hernia Repair
Laparoscopic inguinal hernia repair is the most controversial of the minimally
invasive procedures, for several reasons: it does not shorten hospitalization; the long-
term efficacy of the procedures will take 20 years to evaluate; the technique is
different from standard hernia repairs; and the hospital costs are higher than those of
open hernia repair.

The early laparoscopic hernia repairs (plication of the internal ring, plug of the hernia
sac, and prosthetic “onlay” over the hernia defect) have been abandoned. The two
repairs performed today are the transabdominal preperitoneal (TAPP) repair and the
totally extraperitoneal (TEP) repair. Although the TEP repair is slightly more
difficult, many experienced laparoscopic surgeons prefer it for all but incarcerated
hernias and for patients who have had previous lower abdominal operations.

The leading indication for the TEP repair is recurrent hernia. Anterior repair of
recurrent hernias is associated with a 20 percent recurrence rate, division of the
ilioinguinal nerve, and the possibility of testicular damage. These are the patients for
whom the preperitoneal repairs were developed. The TEP repair nearly reproduces
these repairs without the need for the large counterincision to place the mesh into the
preperitoneal plane. It appears that the TEP repair will be able to achieve a recurrence
rate similar to those of the open procedures, which is less than 5 percent.

Bilateral hernias are a second indication for TEP. The bilateral groin dissection and
repair uses the same number and size of incisions as a unilateral repair. The “tension-
free” nature of the repair eliminates concerns about a higher recurrence rate associated
with simultaneous repair of bilateral hernias. The majority of the expense of
laparoscopic herniorrhaphy is related to equipment charges and the time required to
establish access. Repair of a contralateral side adds little time or equipment cost.
Because of the ease associated with dissection and repair of the contralateral groin
after one side has been repaired, a number of surgeons advocate routine dissection of
the contralateral groin with simultaneous repair of asymptomatic hernias that are
detected.

The preferred TEP approach requires three trocars placed in the lower midline (see
Fig. 44-12 B). A small infraumbilical incision is opened down to the space between
either rectus muscle and the posterior rectus sheath. A large balloon dissector is
passed immediately to the pubic symphysis and inflated at this level. The balloon does
90 percent of the dissection of Hesselbach's triangle posteriorly. The balloon is
removed and a Hasson cannula and 45-degree telescope are replaced. The only
remaining dissection separates the spermatic cord from an indirect hernia sac. Small
hernia sacs may be reduced entirely and left behind the mesh in the preperitoneal
space. Rather than trying to reduce a large sac from the inguinal canal, sufficient sac
is mobilized to ensure that no intraperitoneal structures remain within (sliding hernia).
A 30-inch nonabsorbable suture is looped around the sac and tied extracorporeally.
Extracorporeal knotting should be performed by sliding square knots down with a
“knot pusher.” Most jamming knots (e.g., Roeder's knot) slip before breaking and
have been abandoned. The sac is opened widely distal to the knot and left in the
inguinal canal. A large piece of mesh, 10 × 15 cm at a minimum, is placed to cover
Hesselbach's triangle, the internal inguinal ring, and the femoral canal. The mesh is
fixed to Cooper's ligament, the pubic tubercle, the posterior rectus muscle, and the
transversalis fascia lateral to the epigastric vessels. The fixation device should be
palpable through the abdominal wall before any tacks are placed. This technique
eliminates the possibility of entrapping the genitofemoral or lateral femoral cutaneous
nerve within a staple.

Fundoplication
In the landmark study from the Veterans Administration Cooperative Study group it
was proved that antireflux surgery better eliminated gastroesophageal reflux (GER)
than did medical therapy in patients with severe reflux. These data arrived at the time
that laparoscopic fundoplication was in its infancy. The results achieved with
laparoscopic antireflux surgery in the 5 years since its inception have been virtually
identical to the results of open fundoplication.

The indications for operation is gastroesophageal reflux that requires daily proton-
pump inhibitors, symptomatic reflux associated with the complications of stricture, or
Barrett's esophagus. Respiratory symptoms (e.g., asthma, cough, hoarseness)
associated with well-documented gastroesophageal reflux constitute another
indication. Evaluation of patients should be thorough and generally should include
esophagogastroduodenoscopy (EGD), barium swallow, 24-h ambulatory pH, and
esophageal motility study (EMS). A gastric emptying study is performed when gastric
abnormalities are suspected (e.g., diabetes, vomiting, peptic ulcer disease).
Abnormalities in gastric emptying may be addressed with prokinetic agents or
concomitant pyloroplasty at the time of laparoscopic fundoplication.

In laparoscopic fundoplication the approach to the field of dissection involves the
placement of the primary trocars in a diamond configuration (see Fig. 44-12 C). The
surgeon stands at the base of the diamond. The table height is adjusted so that the
surgeon's elbows are kept close to the sides. Intracorporeal knot tying reduces tissue
trauma and is preferable to extracorporeal tying.

With laparoscopic fundoplication, it is most important to understand which cases are
likely to present difficulty. This group includes patients with previous
subdiaphragmatic surgery, obese patients, those with large diaphragmatic hernias (>5
cm), and those with significant esophageal shortening.

Assisted Colectomy
Laparoscopic removal of the colon is an area of rapid growth, but its application in
patients with colon cancer has engendered heated debate. Metastatic tumor
implantation at the site of the laparoscopic trocars occurs about twice as frequently
after laparoscopic colectomy as implantation at the site of incision after open
colectomy. Current indications for laparoscopy- assisted colectomy are benign or
premalignant disease, colostomy creation, and rectopexy for pelvic floor dysfunction.
A creative use of laparoscopy is the mobilization of the splenic and hepatic flexures in
procedures being performed primarily in the pelvis. After laparoscopic mobilization
of the flexures, almost any operation—e.g., total abdominal colectomy, low anterior
resection, or ileoanal pull-through—may be performed through a Pfannenstiel's
incision.

The field of dissection usually traverses several quadrants of the abdomen. As the
colon is progressively mobilized, it is frequently necessary to change the telescope to
other trocar sites, and it may be necessary to add additional trocars. With increasing
experience, trocar placement based on triangulation has simplified the approach (see
Fig. 44-12 D, E). Additionally, it is necessary to make a counterincision to remove the
colon specimen or to create a stoma. The duration of ileus is less than after
conventional colectomy.

Splenectomy
The most common indication for laparoscopic splenectomy is immunologic disease
(particularly idiopathic thrombocytopenic purpura) in patients with a normal or
slightly enlarged spleen. Because of difficulties in getting the spleen into a collection
bag, it is wise to restrict laparoscopic splenectomy to spleens that weigh less than 500
g.

The techniques for laparoscopic splenectomy include the supine technique, the left
lateral decubitus (“hanging spleen”) technique, and the “leaning spleen” position,
which is a compromise between the other two. The patient is positioned on the table at
a 45-degree tilt, using a bean bag. Four trocars are placed while the table is rolled so
that the patient is nearly supine (see Fig. 44-12 F). It may be necessary to take down
the splenic flexure of the colon before placing the last trocar. The splenic artery is
identified in the lesser sac by dividing short gastric vessels and rolling the gastric
fundus to the right. The splenic artery is ligated (Fig. 44-13). At this point the table is
tilted so that the patient moves into the right lateral decubitus position and the spleen
allowed to fall anteriorly. The splenophrenic attachments (peritoneal reflection) are
divided to allow access to the splenic hilum. In the hilum the splenic vessels are
controlled with a linear cutting stapler, or they are individually ligated. Smaller
vessels are clipped. The most difficult part of this operation may lie in manipulating
the spleen into the retrieval bag. This step is made easier if the bag is opened in the
left upper quadrant with the open mouth facing the laparoscope. A strong nylon bag is
recommended for retrieving the spleen, as weaker bags may rupture. The neck of the
bag is pulled out of a trocar site, and the spleen is morcellated and removed with ring
forceps or with mechanized morcellation devices.

Adrenalectomy
Hyperfunctioning adenomas (including pheochromocytoma) are effectively dealt with
laparoscopically. When adrenal carcinoma is suspected or the mass is greater than 5
cm, a laparoscopic approach is less appropriate. Similarly, when a search for
paragangliomas is indicated or when it is necessary to perform simultaneous bilateral
adrenalectomy, a transabdominal or posterior extraperitoneal approach might be
warranted. The “no-touch” technique afforded by laparoscopic surgery is ideal for
addressing a unilateral pheochromocytoma.
The preferred technique for laparoscopic adrenalectomy is to place the patient in the
lateral decubitus position. Four trocars are placed beneath the costal margin, in the
epigastrium, the midclavicular line, the anterior axillary line, and the posterior axillary
line (see Fig. 44-12 G, H). On the left side, the surgeon begins the dissection by
rolling the spleen anteriorly by dividing the splenophrenic ligament. Occasionally this
is all that is needed to find the adrenal gland. In an obese patient endoscopic
ultrasonography may be helpful in locating the adrenal gland. Sticking close to the
adrenal gland but being careful not to grasp the gland, the surgeon teases away the
retroperitoneal fat with a monopolar electrocautery hook, blunt dissection, and clips.
The adrenal vein is located (inferomedially), and two clips are placed on the renal
vein side of the adrenal vein. The adrenal vein is placed immediately into a bag and
extracted through one of the trocar sites. The dissection on the right side is nearly
identical to that on the left side except that a liver retractor is necessary to hold the
right lobe of the liver anteriorly. Dissection of the gland away from the inferior vena
cava starts inferiorly, allowing identification of the short right adrenal vein, which is
divided between clips.

Common Bile Duct Exploration (CBDE)
Data from several centers have demonstrated that laparoscopic cholecystectomy with
laparoscopic retrieval of bile duct stones is substantially more cost-effective than
laparoscopic cholecystectomy followed by endoscopic sphincterotomy and stone
retrieval.


Laparoscopic bile duct exploration starts with fluoroscopic cholangiography. A
cholangiogram should be performed with a ureteral catheter or a modified ERCP
catheter that allows the passage of a guide wire. If stones are detected, a hydrophilic
guide wire is passed through the cystic duct into the duodenum. If the common bile
duct is small, and the stones are small (<3mm), the cholangiogram catheter can easily
be advanced over the guide wire to a position just above the stones. Intravenous
glucagon is given, and a rapid infusion of saline will push small stones into the
duodenum. When stones larger than 3 mm are detected or the common bile duct is
dilated, it is best to remove the stones through the cystic duct. A helical stone basket
frequently is all that is needed to remove small stones (5 mm or less). Larger common
bile duct stones usually require an endoscopic approach. The cystic duct is dilated
with an 8-mm balloon that has been passed over a guide wire. The balloon is left in
place for 5 min while the choledochoscope is set up and an extra 5-mm trocar is
placed (see Fig. 44-12 I). A thin choledochoscope (8 to 10 French) is passed with a
rubber shod grasper over the guide wire and into the distal common bile duct. A 2- to
2.5-mm flat wire basket is passed through the operating channel of the
choledochoscope and the stone is entrapped. Stones larger than 8 mm in diameter are
best dealt with by performing a choledochotomy, stone extraction, and placement of a
T tube (choledocholithotomy) (Fig. 44-14). Some use choledocholithotomy as their
primary laparoscopic approach to stones of the common bile duct. Most bile duct
stones (80 to 90 percent) can be dealt with using these techniques. Laparoscopic
CBDE is as effective as endoscopic sphincterotomy and may reduce the risk of
postoperative pancreatitis and the long-term and largely unknown sequelae of
sphincter destruction.
SPECIAL CONSIDERATIONS
Pediatric Considerations
The advantages of minimally invasive surgery in children may be more significant
than in the adult population. Minimally invasive surgery in the adolescent is little
different from that in the adult, and standard instrumentation and trocar positions
usually can be used. Laparoscopy in the infant and young child requires specialized
instrumentation. The instruments are shorter (15 to 20 cm), and many are 3 mm in
diameter rather than 5 mm. Because the abdomen of the child is much smaller than
that of the adult, a 5-mm telescope provides sufficient illumination for most
operations. The development of 5-mm clippers and bipolar devices has obviated the
need for 10-mm trocars in pediatric laparoscopy. Because the abdominal wall is much
thinner in infants, a pneumoperitoneum pressure of 8 mmHg can provide adequate
exposure. Deep venous thrombosis is rare in children, and prophylaxis against
thrombosis is probably unnecessary.

Pregnancy
Concerns about the safety of laparoscopic cholecystectomy or appendectomy in the
pregnant patient have been eliminated. The pH of the fetus follows the pH of the
mother linearly, and therefore fetal acidosis may be prevented by avoiding a
respiratory acidosis in the mother. A second concern was that of increased
intraabdominal pressure, but it has been proved that midpregnancy uterine
contractions provide a much greater pressure in utero than a pneumoperitoneum.
Experiences of well over 100 cases of laparoscopic cholecystectomy in pregnancy
have been reported with uniformly good results. Operation should be performed
during the second trimester if possible. Protection of the fetus against intraoperative
x-rays is imperative. Some believe it advisable to track fetal pulse rate with a
transvaginal ultrasound probe. Access to the abdomen in the pregnant patient should
take into consideration the height of the uterine fundus, which reaches the umbilicus
at 20 weeks. In order not to damage the uterus or its blood supply, most surgeons feel
that the open (Hasson) approach should be used in favor of direct puncture
laparoscopy.

Cancer
Minimally invasive techniques have been used for many decades to provide palliation
for the patient with an obstruction cancer. Laser treatment, intracavitary radiation,
stenting, and dilation are outpatient techniques that can be used to reestablish the
continuity of an obstructed esophagus, bile duct, ureter, or airway. Minimally invasive
techniques also have been used in the staging of cancer. Mediastinoscopy is still used
occasionally before thoracotomy to assess the status of the mediastinal lymph nodes.
Laparoscopy also is used to assess the liver in patients being evaluated for pancreatic,
gastric, or hepatic resection. New technology and greater surgical skills allow
accurate minimally invasive staging of cancer. Occasionally it is appropriate to
perform palliative measures (e.g., laparoscopic gastrojejunostomy to bypass a
pancreatic cancer) at the time of diagnostic laparoscopy if diagnostic findings
preclude attempts at curative resection.

The most controversial role of minimally invasive techniques is that of providing
potentially curative surgery to the patient with cancer. It is possible to perform
laparoscopy-assisted colectomy, gastrectomy, pancreatectomy, and hepatectomy in
patients with intraabdominal malignant disease, as well as thoracoscopic
esophagectomy and pneumonectomy in patients with intrathoracic malignant disease.
There are not yet enough data to indicate whether minimally invasive techniques
provide survival rates or disease-free intervals comparable to those of conventional
techniques. It has been proved that in laparoscopy-assisted colectomy and
gastrectomy equivalent numbers of lymph nodes to the open procedure can be
removed without any compromise of resection margins. A second concern centers
around excessive tumor manipulation and the possibility that cancer cells would be
shed during the dissection. Alarming reports of trocar site implantation with viable
cancer have appeared in the literature.

Considerations in the Elderly and Infirm
Laparoscopic cholecystectomy has made possible the removal of a symptomatic
gallbladder in many patients previously thought to be too elderly or too ill to undergo
a laparotomy. Operations on these patients require closely monitored anesthesia. The
intraoperative management of these patients may be more difficult with laparoscopic
access than with open access. The advantage of minimally invasive surgery lies in
what happens after the operation. Much of the morbidity of surgery in the elderly is a
result of impaired mobilization. In addition, pulmonary complications, urinary tract
sepsis, deep venous thrombosis, pulmonary embolism, congestive heart failure, and
myocardial infarction often are the result of improper fluid management and
decreased mobility. By allowing rapid and early mobilization, laparoscopic surgery
has made possible the safe performance of procedures in the elderly and infirm.

Economics of Minimally Invasive Surgery
Minimally invasive surgical procedures reduce the costs of surgery most when length
of hospital stay can be shortened. Shorter hospital stays can be demonstrated in
laparoscopic cholecystectomy, fundoplication, splenectomy, and adrenalectomy, for
example. Procedures such as inguinal herniorrhaphy that are already performed as
outpatient procedures are less likely to provide cost advantage. Procedures that still
require a 4- to 7-day hospitalization, such as laparoscopy-assisted colectomy, are even
less likely to deliver a lower bottom line than their open-surgery counterparts.
Nonetheless, with responsible use of disposable instrumentation and a commitment to
the most effective use of the inpatient setting, most laparoscopic procedures can be
made less expensive than their conventional equivalents.


(Bibliography omitted in Palm version)

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