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                            PLASTIC SURGERY
                        EDUCATIONAL FOUNDATION

                       plastic surgery
The American Society of Plastic Surgeons® (ASPS®) is the
largest organization of board-certified plastic surgeons
in the world. With over 6,000 members, the society is
recognized as a leading authority and information
source on cosmetic and reconstructive plastic surgery.
ASPS comprises 94 percent of all board-certified plastic                 for students
surgeons in the United States. Founded in 1931, the
society represents physicians certified by The American
Board of Plastic Surgery, Inc.® or The Royal College of
Physicians and Surgeons of Canada.
ASPS is recognized as the voice of plastic surgery by the
public, organized medicine, industry, and government
and works to position its members for success in a
highly competitive environment through educational
forums and the development of guidelines and products
to enhance the profession.

                                                              plastic surgery
                                                       This book has been written primarily for medical students, with
                    Adam Lowenstein, Chair             constant attention to the thought, “Is this something a student
                  David H. Song, MD, Vice Chair        should know when he or she finishes medical school?” It is not
                                                       designed to be a comprehensive text, but rather an outline that can
    Seventh Edition 2007                               be read in the limited time available in a burgeoning curriculum. It is
                                                       designed to be read from beginning to end.
                Essentials for Students Workgroup
                        David H. Song, MD              Plastic surgery had its beginning thousands of years ago, when
                        Ginard Henry, MD               clever surgeons in India reconstructed the nose by transferring a
                     Russell R. Reid, MD, PhD          flap of cheek and then forehead skin. It is a modern field, stimulated
                          Liza C. Wu, MD               by the challenging reconstructive problems of the unfortunate
                        Garrett Wirth, MD              victims of the World Wars. The advent of the operating microscope
                    Amir H. Dorafshar, MBChB           has thrust the plastic surgeon of today into the forefront of advances
                                                       in small vessel and nerve repair, culminating in the successful
UNDERGRADUATE EDUCAT ION COMMITTEE OF THE              replantation of amputated parts as small as distal fingers. Further,
PLASTIC SURGERY EDUCAT IONAL FOUNDATION                these techniques have been utilized to perform the first composite
                                                       tissue transplantations of both hands and partial faces. The field is
                                                       broad and varied and this book covers the many areas of
    First Edition 1979                                 involvement and training of today’s plastic surgeons.
                 Ruedi P. Gingrass, MD, Chairman       The American Society of Plastic Surgeons is proud to provide
                     Martin C. Robson, MD              complimentary copies of the Plastic Surgery Essentials for Students
                    Lewis W. Thompson, MD              handbook to all third year medical students in the United States and
                       John E. Woods, MD               Canada.
                        Elvin G. Zook, MD

                                                          Continually updated information about various
                                                          procedures in plastic surgery and other medical
                                                          information of use to medical students and other
                                                          physicians can be found at the ASPS/PSEF website at
                    Copyright © 2007 by the
             Plastic Surgery Educational Foundation
                     444 East Algonquin Road
                   Arlington Heights, IL 60005
                         14th Printing 2007
                         All rights reserved.
             Printed in the United States of America
TABLE OF CONTENTS                                                                   PREFACE
                                                                                    A CAREER IN PLASTIC SURGERY
    Preface:                                                                        Originally derived from the Greek “plastikos” meaning to mold and
    A Career in Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . i   reshape, plastic surgery is a specialty which adapts surgical
                                                                                    principles and thought processes to the unique needs of each
                                                                                    individual patient by remolding, reshaping and manipulating bone,
    Chapter 1: Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1   cartilage and all soft tissues. Not concerned with a given organ
                                                                                    system, region of the body, or age group, it is best described as a
                                                                                    specialty devoted to the solution of difficult wound healing and
    Chapter 2: Grafts and Flaps . . . . . . . . . . . . . . . . . . . . . . 10      surgical problems, having as its ultimate goal the restoration or
                                                                                    creation of the best function, form and structure of the body with a
                                                                                    superior aesthetic appearance ultimately enhancing a patients
    Chapter 3: Skin and Subcutaneous Lesions. . . . . . . . . . 18                  quality of life.
                                                                                    Plastic surgeons emphasize the importance of treating the patient as
                                                                                    a whole. Whether reconstructing patients with injuries,
    Chapter 4: Head and Neck . . . . . . . . . . . . . . . . . . . . . . 32         disfigurements or scarring, or performing cosmetic procedures to
                                                                                    recontour facial and body features not pleasing to the patient, plastic
                                                                                    surgeons are concerned with the effect of the outcome on the
    Chapter 5: Breast, Trunk and External Genitalia . . . . . . 53                  entire patient. Not necessarily concerned with a set and limited
                                                                                    repertoire of surgical procedures, plastic surgery is more a point of
                                                                                    view with the ultimate goal of solving problems and thus, exposure
    Chapter 6: Upper Extremity . . . . . . . . . . . . . . . . . . . . . 68         to a wide variety of surgical problems and disciplines enhance the
                                                                                    ability of the plastic surgeon to care for all patients.
                                                                                     The challenge of plastic surgery then is the wedding of the
    Chapter 7: Lower Extremity . . . . . . . . . . . . . . . . . . . . . 81         surgeon’s judgment and problem solving abilities to surgical
                                                                                    technique at any given moment. Because of this approach, the
                                                                                    plastic surgeon often acts as a “last resort” surgical consultant to
    Chapter 8: Thermal Injuries. . . . . . . . . . . . . . . . . . . . . . 89       surgeons and physicians in the treatment of many wound problems
                                                                                    and is often called “the surgeon’s surgeon.”

    Chapter 9: Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . 107        Plastic surgery not only restores body function, but helps to renew
                                                                                    or improve a patient’s body image and sense of self-esteem. Along
                                                                                    with psychiatrists, plastic surgeons are especially equipped to
                                                                                    handle the patient’s problem of body image and to help the patient
    Chapter 10: Body Contouring . . . . . . . . . . . . . . . . . . . 113
                                                                                    deal with either real or perceived problems.
                                                                                    Consistent with these far reaching goals, the scope of the operations
                                                                                    performed by plastic surgeons is extremely broad. As outlined by
                                                                                    The American Board of Plastic Surgery, “the specialty of plastic
                                                                                    surgery deals with the repair, replacement, and reconstruction of

     physical defects of form or function involving the skin,                   The results of the plastic surgeon’s expertise and ability are highly
     musculoskeletal system, craniomaxillofacial structures, hand,              visible, leading to a high degree of professional and personal
     extremities, breast and trunk, and external genitalia. It uses aesthetic   satisfaction. The discipline requires meticulous attention to detail,
     surgical principles not only to improve undesirable qualities of           sound judgment and technical expertise in performing the intricate
     normal structures, but in all reconstructive procedures as well.”          and complex procedures associated with plastic surgery. In addition,
     Among the problems managed by plastic surgeons are congenital              plastic surgeons must possess a flexible approach that will enable
     anomalies of the head and neck. Clefts of the lip and palate are the       them to work on a daily basis with a tremendous variety of surgical
     most common, but many other head and neck congenital                       problems. Most importantly, the plastic surgeon must have creativity,
     deformities exist. In addition, the plastic surgeon treats injuries to     curiosity, insight, and an understanding of human psychology.
     the face, including fractures of the bone of the jaw and face.
                                                                                Because of the breadth of the specialty and its ever changing
     Craniofacial surgery is a discipline developed to reposition and           content, opportunities for individuals with varied backgrounds is
     reshape the bones of the face and skull through inconspicuous              particularly important. Individuals with undergraduate majors
     incisions. Severe deformities of the cranium and face, which               ranging from art to engineering find their skills useful in various
     previously were uncorrectable or corrected with great difficulty, can      areas of plastic surgery. This need for a broad education continues
     now be better reconstructed employing these new techniques. Such           into medical school.
     deformities may result from a tumor resection, congenital defect,
                                                                                Students should use elective time to acquire the broadest base of
     previous surgery, or previous injury. Treatment of tumors of the head
                                                                                medical knowledge. Experience in surgery and psychiatry are of
     and neck and reconstruction of these regions after the removal of
                                                                                particular value. Clinical rotations in surgical specialties, such as
     these tumors is also within the scope of plastic surgery.
                                                                                neurosurgery, orthopaedics, otolaryngology, pediatric surgery,
     Another area of expertise for the plastic surgeon is hand surgery,         transplantation, or urology may prove more valuable than general
     including the management of acute hand injuries, the correction of         surgery since most of the early residency experience will be in
     hand deformities and reconstruction of the hand. Microvascular             general surgery.
     surgery, a technique that allows the surgeon to connect blood
                                                                                While there are several approved types of prerequisite surgical
     vessels of one millimeter or less in diameter, is a necessary skill in
                                                                                education, most candidates for the traditional plastic surgery
     hand surgery for re-implanting amputated parts or in moving large
                                                                                residency programs have had from three to five years of training in
     pieces of tissue from one part of the body to another.
                                                                                general surgery after graduating from medical school. Applicants may
     Defects of the body surface resulting from burns or from injuries,         also apply for a plastic surgery residency after completing a
     previous surgical treatment, or congenital deformities may also be         residency in otolaryngology, orthopaedics, neurosurgery, or urology
     treated by the plastic surgeon. One of the most common of such             or oral and maxillofacial surgery (the latter requiring two years of
     procedures is reconstruction of the breast following mastectomy.           general surgery training in addition to an MD/DDS). Plastic surgery
     Breasts may also be reduced in size, increased in size, or changed in      residency in the traditional format is generally for two or three
     shape to improve the final aesthetic appearance. Operations of this        years. Another residency model in plastic surgery is the Integrated
     type are sometimes cosmetic in purpose, but in cases where the             Residency. Applicants apply to start immediately following
     patient has a significant asymmetry or surgical defect, the procedure      graduation from medical school and will have either five or six years
     serves important therapeutic purposes.                                     of training under the leadership of the program director of plastic
                                                                                surgery. Following residency training, many physicians spend an
     The most highly visible area of plastic surgery is aesthetic or
                                                                                additional six to twelve months of fellowship training in a particular
     cosmetic surgery. Cosmetic surgery includes facelifts, breast
                                                                                area of plastic surgery such as craniofacial surgery, aesthetic surgery,
     enlargements, nasal surgery, body sculpturing, and other similar
                                                                                hand surgery, or microsurgery.
     operations to enhance one’s appearance.

ii                                                                                                                                                         iii
     The American Board of Plastic Surgery (ABPS) issues a Booklet of          ADDITIONAL RESOURCES ON THE SPECIALTY OF
     Information each year which outlines the training and requirements        PLASTIC SURGERY
     for eligibility to take the examinations offered by the board. You may
     request information from ABPS at:                                         I.    American Society of Plastic Surgeons
                                                                                     444 East Algonquin Road
              The American Board of Plastic Surgery, Inc.                            Arlington Heights, IL 60005-4664
              Seven Penn Center, Suite 400                                           Phone: 847-228-9900
              1635 Market Street                                                     Fax:    847-228-9131
              Philadelphia, PA 19103-2204                                  
              Phone: 215-587-9322
                                                                               II.   Residency Review Committee for Plastic Surgery
              Fax:    215-587-9622
                                                                                     515 North State Street, Suite 2000
                                                                                     Chicago, IL 60610
                                                                                     Phone: 312-755-5000
     Traditionally, plastic surgeons have established their practices in             Fax:   312-464-4098
     large urban settings. However, there is an increasing need for more
     plastic surgeons in the smaller communities and rural areas of this
     country — many metropolitan areas with populations of 65,000 to
     268,000 have no plastic surgeons, leaving a large number of areas
     needing plastic surgery expertise. There are approximately 6,000
     board certified plastic surgeons in the United States; many of those
     currently certified by The American Board of Plastic Surgery
     received certification in the past ten years. Despite this recent rapid
     growth, there are opportunities for plastic surgeons in community
     and academic practice.
     Plastic surgery is an old specialty with references that date back
     thousands of years. It has survived and flourished because it is a
     changing specialty built by imaginative, creative and innovative
     surgeons with a broad background and education.
     The limit of the specialty is bound only by the imagination and
     expertise of those in its practice. The opportunities for the future
     are open to those who wish to be challenged.

iv                                                                                                                                    v
A wound can be defined as a disruption of the normal anatomical
relationships of tissues as a result of injury. The injury may be
intentional such as a surgical incision or accidental following
trauma. Immediately following wounding, the healing process
     Regardless of type of wound healing, stages or phases are the
     same except that the time required for each stage depends on
     the type of healing.
     A. Substrate phase (inflammatory, lag or exudative stage or
          phase — days 1-4)
          1. Symptoms and signs of inflammation
              a. Redness (rubor), heat (calor), swelling (tumor),
                   pain (tumor), and loss of function
          2. Physiology of inflammation
              a. Leukocyte margination, sticking, emigration
                   through vessel walls
              b. Venule dilation and lymphatic blockade
              c. Neutrophil chemotaxis and phagocytosis
          3. Removal of clot, debris, bacteria, and other
              impediments of wound healing
          4. Lasts finite length of time (approximately four days)
              in primary intention healing
          5. Continues until wound is closed (unspecified time) in
              secondary and tertiary intention healing
     B. Proliferative phase (collagen and fibroblastic stage or
          phase — approximately days 4-42)
          1. Synthesis of collagen tissue from fibroblasts
          2. Increased rate of collagen synthesis for 42-60 days
          3. Rapid gain of tensile strength in the wound (Fig. 1-1)
     C. Remodeling phase (maturation stage or phase — from
          approximately three weeks onward)
          1. Maturation by intermolecular cross-linking of collagen
              leads to flattening of scar
          2. Requires approximately 9 months in an adult —
              longer in children
          3. Dynamic, ongoing

                                                                                          4.   Although contraction (the process of contracting) is
                                                                                               normal in wound healing, one must beware of
                                                                                               contracture (an end result — may be caused by
                                                                                               contraction of scar and is a pathological deformity)
                                                                                          5. Secondary healing beneficial in some wounds,
                                                                                               e.g. perineum, heavily contaminated wounds, scalp
                                                                                     C.   Tertiary healing (by tertiary intention) — delayed wound
                                                                                          closure after several days
                                                                                          1. Distinguishing feature of this type of healing is the
                                                                                               intentional interruption of healing begun as
                                                                                               secondary intention
                                                                                          2. Can occur any time after granulation tissue has
                                                                                               formed in wound
                                                                                          3. Delayed closure should be performed when wound is
                                                                                               not infected (usually 105 or fewer bacteria/gram of
                                   Fig. 1-1                                                    tissue on quantitative culture except with beta-

    II.   WOUND CLOSURE                                                        III. FACTORS INFLUENCING WOUND HEALING
          A. Primary healing (by primary intention) — wound closure                 A. Local factors most important because we can control
             by direct approximation, pedicle flap or skin graft                       them
             1. Debridement and irrigation minimize inflammation                       1. Tissue trauma — must be kept at a minimum
             2. Dermis should be accurately approximated with                          2. Hematoma — associated with higher infection rate
                   sutures (see chart at end of chapter) or skin glue (i.e.,           3. Blood supply
                   Dermabond)                                                          4. Temperature
             3. Scar red, raised, pruritic, and angry-looking at peak of               5. Infection
                   collagen synthesis                                                  6. Technique and suture materials — only important
             4. Thinning, flattening and blanching of scar occurs                           when factors 1-5 have been controlled
                   over approximately 9 months in adults, as collagen               B. General factors — cannot be readily controlled by
                   maturation occurs (may take longer in children)                     surgeon; systemic effects of steroids, nutrition,
             5. Final result of scar depends largely on how the                        chemotherapy, chronic illness, etc., contribute to wound
                   dermis was approximated                                             healing
          B. Spontaneous healing (by secondary intention) — wound
             left open to heal spontaneously — maintained in
                                                                               IV.   MANAGEMENT OF THE CLEAN WOUND
             inflammatory phase until wound closed
                                                                                     A. Goal — obtain a closed wound as soon as possible to
             1. Spontaneous wound closure depends on contraction
                                                                                        prevent infection, fibrosis and secondary deformity
                   and epithelialization
                                                                                     B. General principles
             2. Contraction results from centripetal force in wound
                                                                                        1. Immunization — use American College of Surgeons
                   margin probably provided by myofibroblasts
                                                                                            Committee on Trauma recommendation for tetanus
             3. Epithelialization proceeds from wound margins
                   towards center at 1 mm/day
                                                                                        2. If necessary, use pre-anesthetic medication to reduce
2                                                                                                                                                     3
         3.  Local anesthesia — use Lidocaine with epinephrine      D.   Wounds of face
             unless contraindicated, e.g. tip of penis                   1. Important to use careful technique
         4. Tourniquet to provide bloodless field in extremities             a. Urgency should not override judgement
         5. Cleansing of surrounding skin — do NOT use strong                b. There is a longer “period of grace” during which
             antiseptic in the wound itself                                       the wound may be closed since blood supply to
         6. Debridement                                                           face is excellent
             a. Remove clot and debris, necrotic tissue                      c. Do not forget about other possible injuries
             b. Copious irrigation good adjunct to sharp                          (chest, abdomen, extremities). Very rare for
                  debridement                                                     patient to die from facial lacerations alone
         7. Closure — use atraumatic technique to approximate            2. Facial lacerations of secondary importance to airway
             dermis. Consider undermining of wound edges to                  problems, hemorrhage or intracranial injury
             relieve tension                                             3. Beware of overaggressive debridement of
         8. Dressing — must provide absorption, protection,                  questionably viable tissue
             immobilization, even compression, and be                    4. Isolate cavities from each other by suturing linings,
             aesthetically acceptable                                        such as oral and nasal mucosa
    C.   Types of wounds and their treatment                             5. Use anatomic landmarks to advantage, e.g. alignment
         1. Abrasion — cleanse to remove foreign material                    of vermilion border, nostril sill, eyebrow, helical rim
             a. Consider scrub brush or dermabrasion to             E.   Wounds of the upper extremity (See Chapter 6)
                  remove dirt buried in dermis to prevent           F.   Special Wounds
                  traumatic tattoos (permanent discoloration due         1. Amputation of parts
                  to buried dirt beneath new skin surface) —                 a. Attempt replacement if within six hours of
                  needs to be accomplished within 24 hours of                     injury
                  injury                                                     b. Place amputated part in saline soaked gauze in a
         2. Contusion — consider need to evacuate hematoma if                     plastic bag and the bag in ice
             collection is present                                       2. Cheek injury — examine for parotid duct and/or
             a. Early — minimize by cooling with ice (24-48                  facial nerve injury
                  hours)                                                 3. Intraoral injuries — tongue, cheek, palate, and lip
             b. Later — warmth to speed absorption of blood                  wounds require suturing
         3. Laceration — trim wound edges if necessary (ragged,          4. Eyelids — align grey line and close in layers —
             contused) and suture                                            consider temporary tarrsoraphy
         4. Avulsion                                                     5. Ear injuries
             a. Partial (creates a flap) — revise and suture if              a. Hematoma — incision and drainage of
                  viable                                                          hematoma and well-molded dressing to prevent
             b. Total — do not replace totally avulsed tissue                     cauliflower ear deformity
                  except as a skin graft after fat is removed                b. Through-and-through laceration requires 3 layer
         5. Puncture wound — evaluate underlying damage,                          closure including cartilage
             possibly explore wound for foreign body, etc. Animal        6. Animal bites — debridement, irrigation, antibiotics,
             bites — debride and close primarily or leave open,              and possible wound closure. Be particularly careful
             depending upon anatomic location, time since bite,              of cat bites which can infect with a very small
             etc. Use antibiotics                                            puncture wound

4                                                                                                                                      5
    V.   MANAGEMENT OF THE “CONTAMINATED” WOUND                                    3.   Systemic antibiotics of little use
         A. Guidelines for management of contaminated acute                        4.   Topical antibacterial creams — silver sulfadiazine
            wounds                                                                      (Silvadene®) and mafenide acetate (Sulfamylon®)
            1. Majority of civilian traumatic wounds can be closed                      a. Continual surface contact
                primarily after adequate debridement                                    b. Good penetrating ability
                a. Adequate debridement                                                 c. Decrease bacterial counts of wounds
                     i. Mechanical/sharp or chemical/enzymatic                     5.   Biological dressings (allograft, xenograft, some
                          (eg. Collagenase, Panafil®)                                   synthetic dressings) debride wound, decrease pain.
                     ii. Irrigation — copious pulsatile lavage                     6.   Final closure
                b. Exceptions (may opt to leave wound open)                             a. With a delayed flap, skin graft or flap
                     i. Heavy bacterial inoculum (human bites)                          b. Convert the chronic contaminated wound
                     ii. Long time lapse since wounding (relative)                           bacteriologically to an acute clean wound by
                     iii. Crushed or ischemic tissue — severe                                decreasing the bacterial count (debridement)
                          contused avulsion injury
                     iv. Sustained high-level steroid ingestion          VI.   WOUND DRESSINGS
            2. Antibiotics — Systemic antibiotics are only of use if a         A. Protect the wound from trauma
                therapeutic tissue level can be reached within four            B. Provide environment for healing
                hours of wounding or debridement                               C. Antibacterial medications
            3. Wound closure                                                      1. Bacitracin® and Neosporin®
                a. Buried sutures should be used to keep wound                         a. Provide moist environment conducive to
                     edge tension to a minimum; however, each                               epithelialization
                     suture is a foreign body which increases the                 2. Silver sulfadiazine (Silvadene®) and mafenide acetate
                     chance of infection (use least number of sutures                  (Sulfamylon®)
                     possible to bring wound together without                          a. Useful for burns or other wounds with an eschar
                     tension)                                                          b. Antibacterial activity penetrates eschar
                b. Skin sutures of monofilament material are less              D. Splinting and casting
                     apt to become infected                                       1. For immobilization to promote healing
                c. Porous tape closure may be used for some                       2. Do not splint too long — may promote joint stiffness
                     wounds                                                    E. Pressure Dressings
            4. Follow up — contaminated traumatic wounds should                   1. May be useful to prevent “dead space” (potential
                be checked for infection within 48 hours after                         space in wound) or to prevent seroma/hematoma
                closure                                                           2. Do not compress flaps tightly
            5. If doubt exists, it is always safer to delay closure            F. Do not leave dressing on too long (<48 hours) before
                (revision can be done later)                                      changing
         B. Guidelines for management of contaminated chronic
            1. Examples — wounds greater than 24 hours old
                a. Common ingredient — granulation tissue
            2. Debridement as important as in an acute wound
                a. Excision (scalpel, scissors)
                b. Frequent dressing changes
                c. Enzymatic — seldom indicated
6                                                                                                                                            7
                                                                                                                                                                                    ETHICON* Synthetic Absorbable Sutures
        SUTURE &          COLOR &                                                                                                                                        BSR                                                                      ABSORPTION                                                                                                                                                                     FREQUENT USES                                                                                                                                                                                                                   MAIN BENEFIT
     COMPOSITION            TYPE                                                                                                                                                                                                                      RATE
      Coated VICRYL        Undyed                                                                                                            50% at 5 days                                                                                          Essentially                                                                                                  Skin              and Mucosa:                                                                                                                                                                                                                                             Patient comfort
         RAPIDE*                                                                                                                                                                                                                                  complete by 42                                                                                                  -                Episotomy repair
     (polyglactin 910)     Braided                                                                                           0% at 10 to 14 days                                                                                                       days                                                                                                       -                Lacerations under casts                                                                                                                                                                                                                                 No suture removal
          suture                                                                                                                                                                                                                                                                                                                                                  -                Mucosa in oral cavity
                                                                                                                                                                                                                                                                                                                                                                  -                Skin repairs where rapid absorption
                                                                                                                                                                                                                                                                                                                                                                                   may be beneficial, excluding joints and
                                                                                                                                                                                                                                                                                                                                                                                   high stress areas
       MONOCRYL*         Undyed/Dyed                                                                                            Dyed:                                                                                                               Essentially                                                                                                  Soft           Tissue Approximation:                                                                                                                                                                                                                                      Unprecedented
      (poliglecaprone      (violet)                                                                                      60 to 70% at 7 days                                                                                                        complete                                                                                                      -              Ligation                                                                                                                                                                                                                                                  monofilament pliability
        25) suture                                                                                                       30 to 40% at 14 days                                                                                                    between 91 and                                                                                                   -              Skin Repairs
                         Monofilament                                                                                                                                                                                                                119 days                                                                                                     -              Bowel                                                                                                                                                                                                                                                     Smooth tissue passage
                                                                                                                               Undyed:                                                                                                                                                                                                                            -              Peritoneum
                                                                                                                         50 to 60% at 7 days                                                                                                                                                                                                                      -              Uterus
                                                                                                                         20 to 30% at 14 days                                                                                                                                                                                                                     -              Vaginal Cuff
      Coated VICRYL      Undyed/Dyed                                                                                                     75% at 14 days                                                                                             Essentially                                                                                                  Soft           Tissue Approximation:                                                                                                                                                                                                                                      Strength, preferred
     (polyglactin 910)     (violet)                                                                                                                                                                                                                 complete                                                                                                      -              Ligation                                                                                                                                                                                                                                                  performance and
          suture                                                                                                                      50% at 21 days†                                                                                            between 56 and                                                                                                   -              General Closure                                                                                                                                                                                                                                           handling
                           Braided                                                                                                                                                                                                                   70 days                                                                                                      -              Ophthalmic Surgery
                                                                                                                                      40% at 21 days‡                                                                                                                                                                                                             -              Orthopaedic Surgery                                                                                                                                                                                                                                       Knot security
                                                                                                                                                                                                                                                                                                                                                                  -              Bowel
         PDS* II         Undyed/Dyed                                                                                                     70% at 14 days                                                                                           Essentially                                                                                                    Soft           Tissue Approximation:                                                                                                                                                                                                                                      Longest lasting
     (polydioxanone)       (violet)                                                                                                                                                                                                             complete within                                                                                                   -              Fascia Closure                                                                                                                                                                                                                                            absorbable
          suture                                                                                                                         50% at 28 days                                                                                            6 months                                                                                                       -              Orthopaedic Surgery                                                                                                                                                                                                                                       monofilament wound
                         Monofilament                                                                                                                                                                                                                                                                                                                             -              Blood Vessel Anatomoses                                                                                                                                                                                                                                   support
                                                                                                                                         25% at 42 days                                                                                                                                                                                                           -              Pediatric Cardiovascular and
                                                                                                                                                                                                                                                                                                                                                                                 Ophthalmic procedures                                                                                                                                                                                                                                     Outstanding pliability
                                                                                                                                                                                                                                                                                                                                                                           -     Patients with compromised wound
                                                                                                                                                                                                                                                                                                                                                                                 healing conditions
    * Trademark                                          † Sizes 6/0 and larger                                                                                                                                                                                         ‡ Sizes 7/0 and larger



                                                                                                                                                                           1998; 176:26S-38S.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             1999; 104:1761-83.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Surg. 2001; 28:53-62.

                                                                                                                                                                                                                                                                                                                                                                               Obstet. 1992; 174:441.
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                                                                                                                                                                                                                                                                                                              wound. Clin Plast Surg. 1998; 25:3.

                                  Surg Clin North Am. 1997; 77:509-28.
                                                                                                         aesthetic soft tissue augmentation. Clin Plast Surg. 2001;
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Eppley, B.L. Alloplastic Implantation. Plast Reconstr Surg.

                                                                                                                                                                                                                                                                                                                                                                                                                                               Lawrence, W.T. Physiology of the acute wound. Clin Plast

                                                                                                                                                                                                                                            Saltz, R. and Zamora, S. Tissue adhesives and applications in
                                                                                                                                                                                                                                                                                                                                                                               Mast, B.A., Dieselmann, R.F., Krummel, T.M., and Cohen, I.K.

                                                                                                                                                                           healing dynamics if chronic cutaneous wounds. Am J Surg.

                                                                                                     10. Terino, E.O. Alloderm acellular dermal graft: applications in
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Alster, T.S., and West, T.B. Treatment of scars: a review. Ann

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Klein, A.W. Collagen substitutes: bovine collagen. Clin Plast

                                                                                                                                                                                                                                            plastic and reconstructive surgery. Aesthetic Plast Surg. 1998;

                                                                                                                                                                           Stadleman, W.K., Digenis, A.G., and Tobin, G.R. Physiology and
                                                                                                                                                                                                                                                                                                              Nwomeh, B.C., Yager, D.R., Cohen, K. Physiology of the chronic

                              11. Witte, M.B., and Barbul, A. General principles of wound healing.
                                                                                                                                                                                                                                                                                                                                                                               Scarless wound healing in the mammalian fetus. Surg. Gynecol.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Hunt, T.K., et al. Physiology of wound healing. Adv Skin Wound

     CHAPTER 2                                                                         consistency, texture, and undergoes less secondary
     GRAFTS AND FLAPS                                                              2. Split thickness — Split thickness grafts are usually
     When a deformity needs to be reconstructed, either grafts or flaps                used to resurface larger defects. Depending on how
     can be employed to restore normal function and/or anatomy. For                    much of the dermis is included, STSGs undergo
     instance, when wounds cannot be closed primarily or allowed to                    secondary contraction as they heal
     heal by secondary intention, either grafts or flaps can be used to       D.   Survival
     close an open wound.                                                          1. Full thickness and split thickness skin grafts survive
                                                                                       by the same mechanisms
     Grafts — Grafts are harvested from a donor site and transferred to                a. Plasmatic imbibition — Initially, the skin grafts
     the recipient site without carrying its own blood supply. It relies on                  passively absorbs the nutrients in the wound bed
     new blood vessels from the recipient site bed to be generated                           by diffusion
     (angiogenesis).                                                                   b. Inosculation — By day 3, the cut ends of the
     I.   SKIN GRAFTS                                                                        vessels on the underside of the dermis begin to
          A. Thickness (Figure 2-1)                                                          form connections with those of the wound bed
              1. Full thickness — Full thickness skin grafts (FTSGs)                   c. Angiogenesis — By day 5, new blood vessels
                  consist of the entire epidermis and dermis                                 grow into the graft and the graft becomes
              2. Split thickness — Split thickness skin grafts (STSGs)                       vascularized
                  consist of the epidermis and varying degrees of                  2. Skin grafts fail by four main mechanisms
                  dermis. They can be described as thin, intermediate,                 a. Poor wound bed — Because skin grafts rely on
                  or thick                                                                   the underlying vascularity of the bed, wounds
              3. Harvested using a dermatome or freehand (Fig. 2-2)                          that are poorly vascularized with bare tendons or
          B. Donor site                                                                      bone, or because of radiation, will not support a
              1. Full thickness — The full thickness skin graft leaves                       skin graft
                  behind no epidermal elements in the donor site from                  b. Sheer — Sheer forces separate the graft from the
                  which resurfacing can take place. Thus, the donor site                     bed and prevent the contact necessary for
                  of a FTSG must be closed. It must be taken from an                         revascularization and subsequent “take”
                  area that has skin redundancy. It is usually harvested               c. Hematoma/seroma — Hematomas and seromas
                  with a knife between the dermis and the                                    prevent contact of the graft to the bed and
                  subcutaneous fat                                                           inhibit revascularization. They must be drained
              2. Split thickness — The split thickness skin graft leaves                     by day 3 to ensure “take”
                  behind adnexal remnants such as hair follicles and                   d. Infection — Bacteria have proteolytic enzymes
                  sweat glands, foci from which epidermal cells can                          that lyse the protein bonds needed for
                  repopulate and resurface the donor site. It is usually                     revascularization. Bacterial levels greater than 105
                  harvested with either a special blade or dermatome                         are clinically significant
                  that can be set to a desired thickness                      E.   Substitutes
          C. Recipient site                                                        1. Allograft/Alloderm — Cadaveric skin or dermis
              1. Full thickness — Full thickness skin grafts are usually           2. Xenograft — Skin from a different species, ie pig skin
                  used to resurface smaller defects because they are               3. Synthetic — Biobrane, Integra
                  limited in size. It is commonly used to resurface
                  defects of the face. It provides a better color

10                                                                                                                                                  11
     II.   OTHER GRAFTS                                                            2.  Regional — Regional flaps are raised from tissue in
           A. Nerve                                                                    the vicinity but not directly adjacent to the primary
           B. Fat                                                                      defect. The movement is described as transposition or
           C. Tendon                                                                   interpolation
           D. Cartilage                                                            3. Distant — Distant flaps are raised from tissue at a
           E. Bone                                                                     distance from the primary defect. This usually
           F. Muscle                                                                   requires re-anastamosis of the blood vessels to
           G. Composite-A graft that has more than one component, i.e.                 recipient blood vessels in the primary defect. These
              cartilage and skin graft, dermal-fat graft                               are called free flaps
                                                                              C.   By vascular pattern
     Flaps — Flaps are elevated from a donor site and transferred to the           1. Random vs. Axial (Figure 2-3)
     recipient site with an intact vascular supply. It survives by carrying            a. Random pattern flaps do not have a specific or
     its own blood supply until new blood vessels from the recipient site                   named blood vessel incorporated in the base of
     are generated in which the native blood supply (pedicle) can be                        the flap. Because of the random nature of the
     divided. Flaps can be used when the wound bed is unable to                             vascular pattern, it is limited in dimensions,
     support a skin graft or when a more complex reconstruction is                          specifically in the length: breadth ratio
     needed.                                                                           b. Axial pattern flaps (Fig. 2-4) are designed with a
                                                                                            specific named vascular system that enters the
     I.    CLASSIFICATION                                                                   base and runs along its axis. This allows the flap
           A. By composition — Flaps can be classified by the type of                       to be designed as long and as wide as the
              tissue transferred                                                            territory the axial artery supplies
              1. Single component                                                           i. Blood supply by direct artery and
                   a. Skin flap — i.e. Parascapular flap                                         accompanying vein
                   b. Muscle flap — i.e. Rectus muscle flap or                              ii. Greater length possible than with random
                        latissimus dorsi muscle flap                                             flap
                   c. Bone flap — i.e. Fibula flap                                          iii. Can be free flap (see free flap)
                   d. Fascia flap — i.e. Serratus fascia flap                               iv. Peninsular — skin and vessel intact in
              2. Multiple components                                                             pedicle
                   a. Fasciocutaneous — Radial forearm flap or                              v. Island — vessels intact, but no skin over
                        anterolateral thigh flap                                                 pedicle
                   b. Myocutaneous — Transverse rectus abdominis                   2. Pedicled vs. Free
                        myocutaneous flap                                              a. Pedicled flaps remain attached to the body at the
                   c. Osseoseptocutaneous — Fibula with a skin                              harvest site. The pedicle is the base that remains
                        paddle                                                              attached and includes the blood supply. It is
           B. By location — Flaps can be described by the proximity to                      transferred to the defect with its vascular pedicle
              the primary defect that needs to be reconstructed. The                        acting as a leash. Usually via a
              harvest leaves a secondary defect that needs to be closed                     musculocutaneous or fasciocutaneous fashion
              1. Local flaps — Local flaps are raised from the tissue                  b. Free flaps are detached at the vascular pedicle
                   adjacent to the primary defect. Its movement into the                    and transferred from the donor site to the
                   defect can be described as advancement, rotation, or                     recipient site. They require re-anastamosis of the
                   transposition. Specific examples of local skin flaps are                 artery and vein to recipient vessels at the
                   the V-Y, rhomboid, and bilobed flaps                                     recipient site
12                                                                                                                                                13
               3.   Perforator — Perforator flaps are flaps consisting of     B.   The failure of a flap results ultimately from vascular
                    skin and/or subcutaneous fat supplied by vessels that          compromise or the inability to achieve the goals of
                    pass through or in between deep tissues. It is                 reconstruction
                    harvested without the deep tissues in order to                 1. Tension
                    minimize donor site morbidity and to yield only the            2. Kinking
                    necessary amount of skin and/or subcutaneous fat for           3. Compression
                    transfer. It can be transferred either as a pedicled or        4. Vascular thrombosis
                    free flap                                                      5. Infection
                    a. Deep inferior epigastric perforator flap — DIEP
                         flap consists of the skin and fat of the lower
                         abdomen supplied by the deep inferior
                         epigastric artery and vein perforators without
                         the rectus abdominis muscle
                    b. Anterolateral thigh perforator flap — The ALTP
                         consists of the skin and fat of the antero-lateral
                         thigh supplied by the descending branch of the
                         lateral circumflex artery and vein perforators
                         without the vastas lateralis muscle
                    c. Thoracodorsal artery perforator flap — The TAP
                         flap consists of the skin and fat of the lateral
                         back supplied by the thoracodorsal artery and
                         vein perforator without the latissimus dorsi

     II.   CHOOSING THE RIGHT FLAP                                                                      Fig. 2-1
           A. The primary defect — Recipient site considerations
              1. Location and size
              2. Quality and vascularity of surrounding tissues
              3. Presence of exposed structures
              4. Functional and aesthetic considerations
           B. The secondary defect — Donor site considerations
              1. Location
              2. Adhere to the concept of angiosomes, the territory
                  that is supplied by a given vessel
              3. What type of tissues are needed
              4. Functional and aesthetic morbidity

          A. The success of a flap depends not only on its survival but
             also its ability to achieve the goals of reconstruction

                                                                                                        Fig. 2-2
14                                                                                                                                          15
                CHAPTER 2 — BIBLIOGRAPHY
                GRAFTS AND FLAPS
                1.   Mathes, S.J. Reconstructive Surgery: Principles, Anatomy and
                     Techniques. New York, Elsevier Science, 1997.
                2.   McCarthy, J.G. (ed). Plastic Surgery, vol. 1. New York: Elsevier
                     Science, 1990.
                3.   Russell, R.C. and Zamboni, W.A. Manual of Free Flaps New York:
                     Elsevier Science, 2001.
                4.   Serafin, D. Atlas of Microsurgical Composite Tissue
                     Transplantation. New York: Elsevier Science, 1996.

     Fig. 2-3

     Fig. 2-4
16                                                                                      17
     CHAPTER 3                                                                      c.  Keloid scars can develop in areas of tension and
     SKIN AND SUBCUTANEOUS LESIONS                                                  d. A racial predilection exists, as keloid scars
     Lesions can be categorized into benign or malignant types.                         appear more frequently in Asians and African-
                                                                                        Americans compared to Caucasians
     I.   BENIGN                                                                    e. Keloid fibroblasts produce higher levels of
          A. Scars                                                                      collagen, fibronectin, and are hyperresponsive to
             1. Hypertrophic scars. These scars are often                               TGFb1
                  misdiagnosed as keloid scars (see below). One can                 f. Treatment. Keloid scars are difficult to treat, and
                  distinguish between hypertrophic and keloid scars as                  are often refractory to nonsurgical and surgical
                  follows:                                                              therapies. Furthermore, these scars have a high
                  a. Hypertrophic scars are scars confined to the                       recurrence rate in the setting of the various
                       borders of the original incision or traumatic                    modalities of treatment
                       margins                                                          i. Intralesional steroids alone (9-50%
                  b. Hypertrophic scars may regress spontaneously                            recurrence rate)
                       with time                                                        ii. Surgery alone (45-100% recurrence rate)
                  c. Commonly develop in areas of tension                               iii. Surgery and intralesional steroids (50%
                       (upper/lower extremities, back, chest)                                recurrence rate)
                  d. No racial predilection                                             iv. Surgery and radiotherapy (25% recurrence
                  e. Hypertrophic fibroblasts behave as normal                               rate)
                       fibroblasts in terms of collagen and fibronectin    B.   Benign Neoplasms and Hyperplasias.
                       production, as well as in terms of their response        1. Seborrheic Keratosis
                       to transforming growth factor beta type-1                    a. Most common of the benign epithelial tumors
                       (TGFb1)                                                      b. Usually hereditary (questionable autosomal
                  f. Treatment. Scars generally take 18-24 months to                    dominant pattern)
                       mature (reach their final appearance). Therefore             c. Clinically manifest after age 30
                       hypertrophic scars can be modulated with a                   d. More common in male population
                       combination of:                                              e. Progresses from macule (skin-colored or tan
                       i. Constant or intermittent pressure therapy                     lesion in Caucasians), then progresses to plaque
                            (compression garments or massage)                           (“stuck-on” appearance) that is more pigmented
                       ii. Topical silicone sheeting                                    in color. The surface may become “warty” and
                       iii. Intralesional steroid injections (10mg/ml or                horn cysts, resulting from plugged hair follicles,
                            40mg/ml triamcinolone, a.k.a. Kenalog-10 or                 arise. These cysts are pathognomonic for this
                            Kenalog-40)                                                 keratosis.
                       iv. Surgical intervention (scar revision) in                 f. Treatment
                            select cases                                                i. Electrocautery, cryosurgery with liquid
             2. Keloid scars. As opposed to hypertrophic scars,                              nitrogen spray (high recurrence rate)
                  keloid scars have the following characteristics:                      ii. Curettage with cryosurgery (optimal
                  a. Keloid scars are scars that grow beyond the                             modality as this does not destroy
                       borders of the original incision or traumatic                         cytoarchitecture and permits
                       margins                                                               histopathologic analysis)
                  b. Keloid scars do not regress spontaneously with
                       time, and have a high recurrence rate
18                                                                                                                                           19
     2.   Keratoacanthoma                                              c.   Clinically manifest as soft, skin-colored,
          a. Often confused or misdiagnosed with squamous                   pedunculated papilloma or polyp; range in size
               cell carcinoma                                               between 1-10mm. May increase in number and
          b. Clinically manifests in middle years (20-50 years)             size during pregnancy
          c. Male: female ratio 2:1                                    d. DDx: Pedunculated seborrheic keratosis, dermal
          d. Caucasians more likely to be affected; rare in                 or compound nevus, neurofibroma, or
               Asians and African-Americans                                 molluscum contagiosum
          e. Isolated nodule that rapidly grows, achieving a           e. Treatment
               size on average of 2.5cm within weeks. Nodule is             i. Simple excision
               dome-shaped, firm, red-tan in color, and has a               ii. Cryosurgery
               central keratosis that sometimes gives it an       5.   Trichoepithelioma
               umbilicated appearance                                  a. Common during puberty
          f. Anatomical areas of predilection: exposed skin            b. Anatomical sites: face, scalp, neck
          g. DDx: SCC, hypertrophic actinic keratosis, verruca         c. Clinically manifest as small skin-colored or pearl-
               vulgaris                                                     like lesions, that increase in number and size
          h. Lesions often spontaneously regress within 2-12           d. Can be confused with BCC (sclerosing or
               months                                                       morpheaform-type 0.
          i. Treatment                                                 e. Treatment
               i. Single lesion: Surgical excision is often                 i. Surgical excision for concerning lesions
                    recommended (to rule out SCC)                 6.   Syringoma
               ii. Multiple lesions: Retinoids and                     a. Benign adenoma of intraepidermal eccrine ducts
                    methotrexate. If no improvement, must              b. May be familial
                    excise                                             c. Anatomical sites: face (eyelids), axillae, umbilicus,
     3.   Dermatofibroma                                                    upper chest, and vulva
          a. A.k.a. Solitary histiocytoma, sclerosing                  d. Most often multiple, skin-colored or yellow firm
               hemangioma                                                   papules occurring in primarily pubertal women
          b. Females>males                                             e. Treatment
          c. Clinically manifests in adulthood                              i. Electrosurgery.
          d. Button-like dermal nodule, usually develops on       7.   Lipoma
               the extremities, variable in color. Borders ill-        a. Single or multiple benign fatty tumor(s)
               defined. Occasionally tender                            b. Neck and trunk common sites.
          e. Lesions may persist or spontaneously regress              c. Clinically manifest as soft, mobile, almost
          f. Treatment                                                      fluctuant masses that are not adherent to the
               i. Surgical excision rarely indicated                        skin
               ii. Cryosurgery with liquid nitrogen spray              d. Treatment
                    often effective                                         i. Surgical excision (esp. > 5cm)
     4.   Skin Tag (a.k.a. Acrochordon, or cutaneous papilla)     8.   Verruca (wart)
          a. Common; most often present in middle aged or              a. Usual viral etiology (i.e., HPV)
               elderly                                                 b. May disappear spontaneously or respond to
          b. Intertriginous areas (axillae, groin, inframammary             medical treatment
               fold) common sites; also eyelid, neck                   c. Do not excise as recurrence is likely; use cautery
                                                                            or liquid nitrogen
20                                                                                                                                21
          d. Do use pulsed dye laser for recalcitrant warts       C.   Congenital Lesions
     9.   Miscellaneous                                                1. Dermoid Cyst
          a. Pyogenic granuloma                                            a. Congenital lesion usually occurring in lines of
              i. Ulcerating, tumor-like growth of granulation                  embryonic fusion (lateral 1/3 of eyebrow,
                   tissue, the result of chronic infection, may                midline nose, under tongue, under chin)
                   resemble malignant tumor                                c. CT scan of midline dermoid to rule out
              ii. Treat by topical silver nitrate, excision,                   intracranial extension
                   curettage, laser                                    2. Nevi
          b. Xanthoma (xanthelasma)                                        a. Classification
              i. Small deposits of lipid-laden histiocytes,                    i. Intradermal (dermal)
                   most common in eyelids, sometimes                                (a) Most common, usually raised, brown,
                   associated with systemic disorders                                    may have hair
                   (hyperlipidemia, diabetes)                                       (b) Essentially no potential for malignant
              ii. Treat by excision                                                      change to melanoma
          c. Rhinophyma                                                             (c) Treatment: Surgical excision necessary
              i. Severe acne rosacea of the nose, overgrowth                             if concerning changes arise, or if lesion
                   of sebaceous glands causing bulbous nose                              is aesthetically displeasing to patient
              ii. Treat by surgical planing (shaving) with                     ii. Junctional
                   dermabrasion or laser                                            (a) Flat, smooth, hairless, various shades of
          d. Epidermoid (often misnamed sebaceous)                                       brown
              i. Almost always attached to overlying skin,                          (b) Nevus cells most likely at basement
                   frequently acutely inflamed if not excised                            membrane
              ii. Excise with fusiform-shaped island of                             (c) Low malignant potential
                   overlying skin attachment (including                             (d) Treatment: Surgical excision necessary
                   puncture) when not inflamed                                           if concerning changes arise, or if lesion
              iii. Acutely inflamed cyst may require incision                            is aesthetically displeasing to patient
                   and drainage with subsequent excision                       iii. Compound
           e. Hidradenitis suppurativa                                              (a) Often elevated, smooth or finely
              i. A chronic, recurrent inflammatory disease of                            nodular, may have hair
                   hair follicles (folliculitis)                                    (b) Low malignant potential
              ii. Occurs in axilla, groin and perineum and                          (c) Treatment: Surgical excision necessary
                   breast (intertriginous areas)                                         if concerning changes arise, or if lesion
              iii. Treatment                                                             is aesthetically displeasing to patient
                   (a) In early stages, antibiotics (topical                   iv. Large pigmented (bathing trunk nevus)
                        clindamycin or oral minocycline) and                        (a) Congenital lesion commonly occurring
                        local care including incision and                                in dermatome distribution
                        drainage of abcesses                                        (b) Defined as a lesion >20 sq. cm in size
                   (b) Later stages require excision of all                         (c) Potential for malignant transformations
                        involved tissue, and primary closure                             (2-32% lifetime risk reported in
                        (associated with local recurrence) or                            literature)
                        closure by secondary intention                              (d) Treatment: Surgical excision usually
                        (preferred method) or skin grafting                              indicated. Due to large surface area,
22                                                                                                                                   23
                  tissue expanders are required to recruit              ii.   Excision of unsightly or constantly irritated
                  locoregional, unaffected skin via                           nevus (beltline, under bra or beard area)
                  expanded flap transposition.                           iii. Careful follow-up of very large pigmented
                  Alternatives include skin grafting or                       nevus, with excision of any area of change
                  laser resurfacing. It should be noted,                      (nodularity) or staged excision of as much
                  however, with laser treatment only part                     lesion as possible (tissue expanders and
                  of the nevus cells are ablated, which                       primary closure, or skin grafts when
                  leads to destruction of local                               necessary)
                  architecture. This may subvert clinical      3.   Vascular Lesions — Most common benign tumor of
                  monitoring and pathologic analysis of             infancy
                  tissue biopsies                                   a. Hemangioma
          v. Dysplastic nevus                                            i. Hemangioma (a.k.a, strawberry nevi)
              (a) Irregular border                                            (a) Most common benign vascular tumor,
              (b) Variegated in color                                              appearing at or shortly after birth
              (c) Often familial                                              (b) Three clinical phases evident:
              (d) Most likely nevus to become malignant                            proliferative (tumor increases in size for
                  melanoma                                                         up to 6-7 months), involutional (stops
              (e) Treatment: Surgical excision                                     growing, becomes gray/white in areas
          vi. Nevus sebaceous                                                      and then begins to regress over several
              (a) Most often seen on scalp and face                                or more years), and fibrotic.
              (b) 15-20% incidence of basal cell                              (c) Treatment: Need for treatment rare,
                  carcinoma                                                        and depends on anatomical site and
              (c) Yellowish orange, salmon-colored,                                symptoms (see below). Observe
                  greasy elevated plaque                                           frequently at first and reassure parents
              (d) Treatment: Surgical excision. This can                      (d) Indications for treatment: Obstructive
                  either be performed in infancy/early                             symptoms (airway, visual), or bleeding.
                  childhood or adolescence, as the                                 Systemic therapy (corticosteroids,
                  incidence of malignancy rises after                              2mg/kg) is first line option; laser
                  puberty                                                          therapy may be indicated early.
     b.   Summary: Treatment of Congenital Nevi                                    Interferon may be indicated for
          i. Excision and histological examination of all                          uncontrolled lesions. Surgery may
              suspicious pigmented lesions based on:                               eventually be indicated for removal of
              (a) Clinical appearance                                              any disfiguring fibrofatty remnant, or in
              (b) History of recent change in:                                     situations when bleeding is refractory
                  (i) Surface area (enlarging)                                     to conservative measures
                  (ii) Elevation (raised, palpable, nodular,        b. Malformations
                        thickened)                                       i. Capillary malformations (port-wine stain)
                  (iii) Color (especially brown to black)                     (a) Pink-red-purple stain in skin, usually
                  (iv) Surface characteristics (scaly,                             flat, but may be elevated above skin
                        serous discharge, bleeding and                             surface. Does not regress
                        ulceration)                                           (b) Treatment: Laser therapy best
                  (v) Sensation (itching or tingling)                              (flashlamp-pumped, pulsed dye laser,
24                                                                                                                              25
                             585nm); multiple (>3) laser sessions             b.  Frequently associated with chronic arsenic
                             may be necessary; surgical excision not              medication
                             indicated                                         c. May be associated with internal malignancy
                   ii. Arterio-venous malformation                             d. May develop into invasive squamous carcinoma
                        (a) Large blood-filled venous sinuses                  e. Treatment: by excision
                             beneath skin and mucous membranes.           3. Squamous cell carcinoma
                             Low flow. No bruit                                a. Rapidly growing (months) nodular or ulcerated
                        (b) Treatment: Angiography for larger and                 lesion with usually distinct borders
                             progressive lesions. Embolization with            b. Occurs on exposed areas of body and x-
                             (2-3 days prior to) surgery is beneficial.           irradiated areas and in chronic non-healing
                             Excision may be indicated                            wounds (Marjolin’s ulcer). Can metastasize to
                   iii. Arterio-venous                                            regional lymph nodes (10%)
                        (a) Progressive increase in size and extent,           c. Treatment: surgical excision with adequate
                             multiple arteriovenous fistulas, bruit               margins or with histologic frozen section or with
                        (b) A-V shunts or angiography                             Moh’s micrographic surgery followed by
                        (c) Treatment: embolization under                         reconstruction
                             angiographic control by itself or prior      4. Basal cell carcinoma
                             to surgical excision                              a. Most common skin cancer
                   iv. Lymphatic                                               b. Types — all types may show ulceration, with
                        (a) Subcutaneous cystic tumor (cystic                     rolled smooth pearly borders
                             hygroma) of dilated vessels which can                i. Nodular — well-defined “rodent ulcer”
                             be massive and disfiguring                           ii. Superficial
                        (b) May cause respiratory obstruction, may                iii. Pigmented — resembles melanoma
                             become infected                                      iv. Morphea Type — sclerosing — poorly
                        (c) Spontaneous regression can occur, but                      defined borders, high recurrence rates
                             surgical excision is often indicated              c. Usually seen on face or other sun-exposed areas
                        (d) Lymphatic malformation can occur                      of body, caused by UVB ultraviolet radiation
                             with arteriovenous malformation                   d. Slow-growing (years), destroys by local invasion,
                   v. Mixed                                                       particularly hazardous around eyes, ears, nose
     C.   Premalignant and Malignant Lesions of the Skin and                   e. Very rarely metastasizes
          Subcutaneous Tissue                                                  f. Treatment: surgical excision with adequate
          1. Actinic or Senile Keratosis                                          margins or with frozen section or with Mohs
              a. Crusted, inflamed, history of exposed areas of                   micrographic surgical excision followed by
                   face and scalp, chronic sun exposure or history                reconstruction
                   of x-irradiation                                       5. Melanoma
              b. Treatment: premalignant, biopsy of suspicious                 a. Cause of great majority of skin cancer deaths
                   lesions, especially when nodular (excision),                b. Early lymph node and systemic blood-borne
                   liquid nitrogen, topical chemotherapy (5-                      metastases — frequently considered a systemic
                   fluorouracil)                                                  disease
          2. Squamous cell carcinoma in situ (Bowen’s Disease)                 c. Usually appears as black, slightly raised,
              a. Scaly brown, tan or pink patch                                   nonulcerative lesion arising de novo or from a
                                                                                  preexisting nevus
26                                                                                                                                    27
     d.   Early recognition of changes in color, size or                    (a) Less than 0.76 mm — metastases
          consistency of a pigmented nevus is critical                           virtually 0%
          (ABCD’s = asymmetry, irregular borders,                           (b) 1.50-3.99 mm — metastases 50%
          variegated color, diameter > 6mm)                                 (c) Greater than 4 mm — metastases 66%
     e.   Classification                                               ii. Clark’s levels of cutaneous invasion (Fig. 3-1)
          i. Pre-malignant: Lentigo maligna                                 (a) Level I (in situ) above the basement
               (Hutchinson’s freckle)                                            membrane — node metastases
               (a) Flat, varied shades of brown                                  extremely rare
                     pigmentation, larger than most nevi,                   (b) Level II — in the papillary dermis —
                     irregular borders, smooth                                   metastases in 2-5%
               (b) Usually slow-growing, most often on                      (c) Level III — to the junction of papillary
                     face, more frequently in elderly                            and reticular dermis — metastases in
               (c) High incidence of development of                              up to 20%
                     invasive melanoma                                      (d) Level IV — into the reticular dermis —
               (d) Treat by excision, with graft or flap                         metastases in 40%
                     reconstruction if necessary                            (e) Level V — into the subcutaneous tissue
          ii. Invasive                                                           — metastases in 70%
               (a) Lentigo maligna melanoma (10%)                      iii. Staging
                     (i) Develops in a Hutchinson’s                         (a) Stage I: lesions less than 2 mm thick
                           Freckle, usually as a thickened,                      without ulceration
                           elevated nodule                                  (b) Stage II: 1-2 mm thick with ulceration
               (b) Superficial spreading melanoma (70%)                          or greater than 2 mm thick with or
                     (i) Flat to slightly elevated, may have a                   without ulceration
                           great variety of colors                          (c) Stage III: regional node metastasis
                     (ii) Lesion initially spreads horizontally             (d) Stage IV: distant metastasis
               (c) Nodular melanoma (15%)                         g.   Treatment
                     (i) Characteristically blue/black in              i. Most important is the manner in which the
                           color                                            primary lesion is removed
                     (ii) May be unpigmented (amelanotic)              ii. Complete excisional biopsy is necessary to
                     (iii) Grows vertically, often with early               determine level and thickness
                           surface ulceration                          iii. Treated by “wide” excision with primary
               (d) Acral lentiginous melanoma (5%)                          closure, split-thickness skin graft, or flap
                     (i) On mucous membranes, palms,                        closure. Please note that permanent sections
                           soles and subungual                              are often required to determine clear
                     (ii) May be amelanotic in African-                     margins, and that frozen sections may not
                           Americans                                        be reliable for this purpose
     f.   Histologic staging and correlation with                           (a) Thin lesions (less than 1 mm) = 1 cm
          metastases                                                             margin
          i. Breslow’s depth of invasion — more reliable                    (b) Thick lesions (greater than 1 mm) = 2
               indicator of prognosis than Clark’s level                         cm margin
               (Fig. 3-1)

28                                                                                                                           29
                    (c) Note that margin also depends on           CHAPTER 3 — BIBLIOGRAPHY
                         location and may be compromised in
                         critical areas                            SKIN AND SUBCUTANEOUS LESIONS
              iv. Sentinel node biopsy is used to determine        1.   Fitzpatrick T.B., Johnson R.A., Wolff K., Palano M. K., Suurmond
                    regional metastases                                 D. Color Atlas and Synopsis of Clinical Dermatology: Common
              v. Regional node dissection indicated for                 and Serious Diseases. 3rd ed. McGraw-Hill, New York. 1997.
                    positive sentinel nodes
              vi. Node dissection performed for palpable           2.   Niessen F. B., Spauwen P.H.M., Schalkwijk J., Kon M. On the
                    nodes                                               nature of hypertrophic scars and keloids: A review. Plast.
              vii. Extremity perfusion may be helpful for               Reconstr. Surg. 1999; 104: 1435-1458.
                    selected cases                                 3.   Cruse, C.W. and D. Reintgen: Treatment of primary malignant
              viii. Radiotherapy, chemotherapy, and                     melanoma: A Review. Sem Surg Onc., 1993; 9:215-218.
                    immunotherapy have not been proven
                    curative but may have some palliative effect   4.   Eshima, I. Role of plastic surgery in the treatment of malignant
     6.   Dermatofibrosarcoma protuberans (DFSP)                        melanoma. Surg Clin North Amer. 1996; 26:1331-1342.
          a. Rare tumor                                            5.   Goldberg,D.P. Assessment and surgical treatment of basal cell
          b. Frequently occurs in head and neck, and                    skin cancer. Clin Plast Surg. 1997; 24:673-86.
              genitalia (vulvar) regions
          c. Treatment: Chemo — and radioresistant tumor.          6.   Kogan, L. et al. Metastatic spinal basal cell carcinoma: a case
              Requires wide excision to avoid recurrence                report and literature review. Ann Plast Surg. 2000; 44:86-8.
              (3-6cm). High recurrence rate in cases where
                                                                   7.   Morganroth,G.S. and D.J. Leffell “Non-Excisional Treatment of
              wide local excision <3cm
                                                                        Benign and Premalignant Cutaneous Lesions.” Clin Plast Surg.
                                                                        1993; 20:91-104.
                                                                   8.   Thompson, H.G. “Common Benign Pediatric Cutaneous Tumors:
                                                                        Timing and Treatment.” Clin Plast Surg., Jan 1990; 17:49-64.

                         Fig. 3-1
30                                                                                                                                         31
     CHAPTER 4                                                             4.   Occurrence risk in offspring (Table 4-1)
                                                                           5.   Etiology
                                                                                a.  Multifactorial combination of heredity with or
     Problems of the head and neck in the practice of plastic surgery               without environmental factors
     include congenital, traumatic, infectious, neoplastic, and other           b. Teratogenic agents — e.g. pheyntoin, alcohol
     conditions. A working knowledge of embryology and anatomy of the           c. Nutritional factors may contribute — folate
     head and neck is crucial in the diagnosis and surgical treatment of            deficiency
     these diseases. Please refer to references #1 and #2 for a complete   6.   Embryology
     review.                                                                    a. Cleft lip with palate forms at 4-6 weeks due to
                                                                                    lack of mesenchymal penetration (merging) and
          A. Cleft Lip and Cleft Palate                                             fusion
             1. Anatomy (Fig. 4-1)                                              b. Isolated cleft palate forms later, at 7-12 weeks,
                  a. Clefts of the lip occur in the primary palate                  from lack of fusion
                       (anterior to the incisive foramen) and may also     7.   Pathophysiology and Functional Deficits
                       involve the alveolar process                             a. Cleft lip
                  b. Clefts of the palate occur in the secondary                    i. Inability to form fluid and air seal in eating
                       palate, the roof of the mouth posterior to the                    or speech
                       incisive foramen and may involve hard and/or                 ii. Malocclusion as a result of intrinsic
                       soft palate                                                       deformities of alveolar process and teeth
                  c. Submucous cleft (SMCP): occult cleft of the soft               iii. Lack of continuity of skin, muscle and
                       palate encompassing classic clinical triad (bifid                 mucous membrane of lip with associated
                       uvula, notching of the hard palate, zona                          nasal deformity and nasal obstruction
                       pellucida)                                                   iv. Deformity
             2. Classification                                                  b. Cleft palate
                  a. Lip (Fig. 4-2)                                                 i. Inability to separate nasal from oral cavity so
                       i. Unilateral                                                     that air and sound escape through nose in
                            (a) Complete                                                 attempted speech
                            (b) Incomplete                                          ii. Feeding impaired by loss of sucking due to
                       ii. Bilateral                                                     inability to create intra-oral negative
                            (a) Complete                                                 pressure
                            (b) Incomplete                                          iii. Loss of liquids and soft foods through nose
                       iii. Median                                                       due to common nasal-oral chamber
                            (a) Complete                                            iv. Middle ear disease in 100% of patients due
                            (b) Incomplete                                               to Eustachian tube dysfunction, abnormal
                  b. Palate (Fig. 4-3)                                                   mucus
             3. Prevalence                                                          v. May be associated with Pierre-Robin
                  a. Cleft of lip with or without cleft palate (CL±CP)                   sequence (cleft palate, micrognathia,
                       1:750 in Caucasians, less in African-Americans                    glossoptosis). In these cases, airway
                       (0.41 per 1000 live births), greater in Asians                    obstruction and failure to thrive may be
                       (1.41 per 1000 live births)                                       present. These cases may require ICU
                  b. Cleft of palate alone (CP) 1:2500                                   monitoring, prone positioning,
                                                                                         nasopharyngeal airway, tongue-lip adhesion,
32                                                                                                                                       33
                     tracheostomy, and now mandibular                              17-19 years of age, men). With the advent of
                     distraction (moving the base of the tongue                    craniofacial distraction, surgical intervention can
                     forward by mandibular advancement).                           be performed earlier, but both patient and
                     Distraction has been used with some good                      parents must be advised that the growing child
                     effect in severe cases, avoiding                              may “outgrow” the correction, necessitating a
                     tracheostomy                                                  repeat procedure
     8.   Team concept                                                    10. Principles of Primary Repair
          Because of multiple problems with speech, dentition,                a. Cleft lip
          hearing, etc., management of the patient with a cleft                    i. Repair of skin, muscle and mucous
          should be by an interdisciplinary team, preferably in a                       membrane to restore complete continuity of
          cleft palate or craniofacial center. Team members                             lip, symmetrical length and function
          include: plastic surgeon, orthodontist, dentist,                         ii. Simultaneous repair of both sides of a
          geneticist, pediatrician, speech therapist, audiologist,                      bilateral cleft lip
          social worker, and psychologist                                          iii. Preference for primary nasal reconstruction
     9.   Timing of Surgical Intervention                                               at time of lip repair
          a. Cleft lip — most common 10 weeks of age.                              iv. In wide clefts (>10mm), presurgical
               Once followed “rule of 10’s” (10 weeks of age,                           orthodontics (palatal appliance, nasoalveolar
               Hgb 10, 10 lbs.), but now this rule is more                              molding) may be indicated, or a cleft lip
               historical. Range of cleft lip repair varies from                        adhesion (surgery to initially bring lip
               0-3 months of age in full-term, otherwise healthy,                       segments together, followed by definitive
               infant                                                                   repair of lip 3 months later)
          b. Cleft palate — before purposeful sounds made                     b. Cleft palate
               (9 -12 mos), depending upon health of infant,                       i. One stage repair of both hard and soft
               extent of cleft, but certainly before 18 months of                       palate
               age, if possible                                           11. Secondary Repair
          c. Cleft nasal deformity — most centers perform                     a. Cleft lip
               primary correction at the time of lip repair,                       i. Revision of lip repair if needed
               followed by secondary work at preschool age (4-                     ii. Revision of nose as required
               5 years)                                                            iii. Repair of alveolar cleft (if present) with
          d. Alveolar cleft — most centers perform                                      bone graft around 9 years of age (time of
               secondary bone grafting at the stage of mixed                            eruption of canine teeth)
               dentition (9-12 years of age), just before                     b. Cleft palate
               eruption of the permanent canine, which is                          i. Correction of velopharyngeal inadequacy
               often affected by the cleft                                              (nasal escape of sound and air due to
          e. Dentofacial skeletal abnormality — in most cleft                           remaining structural defect of palate): 4-6
               patients, this manifests as maxillary                                    years of age
               retrusion/hypoplasia. In 25% of cleft patients,                     ii. Repair of any palate fistula
               orthognathic surgery (jaw-straightening               B.   Other Congenital Anomalies
               procedure) has to be performed to correct a                1. Craniosynostosis (343 out of 1,000,000 live births).
               malocclusion (abnormal bite). Orthognathic                     a. Definition: Premature fusion of one or more
               surgery can only be performed in skeletally                         cranial vault sutures. Categorized into syndromic
               mature individuals (14-16 years of age, women;                      and nonsyndromic types
34                                                                                                                                       35
     i.    Nonsyndromic:                                                       (Apert, Crouzon---FGFR2, Pfeiffer—
           (a) Order of frequency according to suture                          FGFR1)
               type (ascending to descending):                            (e) Goals of surgery: Release fused cranial
               Sagittal, metopic, coronal, lambdoid,                           sutures, correct profound exorbitism to
               other)                                                          prevent corneal exposure/blindness,
           (b) Characteristic head shape according to                          improve craniofacial dysmorphism,
               suture affected: Sagittal—                                      correct malocclusions
               scaphocephaly (scapho, Gr., meaning                        (f) Surgical interventions:
               boat-shaped); metopic—trigonocephaly                            Anterior/posterior/total vault reshaping
               (trigono, Gr., meaning triangular- or                           (0-1 years), Monobloc (osteotomy and
               keel-shaped forehead); bicoronal –                              advance forehead and face
               brachycephaly (brachy, Gr., meaning                             simultaneously with bone
               short in AP direction)                                          grafts/fixation) vs. Le Fort III
           (c) Ongoing debate as to whether or not                             (osteotomy and advance face) (4-6
               these patients have an increased                                years), with repeating procedures as
               incidence of developmental delay                                necessary. Craniofacial distraction leads
           (d) Treatment: anterior vault reshaping                             to greater advancement, less relapse
               (fronto-orbital advancement/reshaping),                         than conventional procedures
               total vault reshaping, or posterior vault   2.   Facial Dysostoses
               reshaping, depending on location and             a. Treacher-Collins Syndrome (Mandibulofacial
               severity of craniosynostosis. Usually                 Dysostosis)
               performed within first year of life to                i. Rare, autosomal dominant disorder
               take advantage of molding capacity of                 ii. Affected gene on chromosome 5q
               skull                                                 iii. Variable penetrance
     ii.   Syndromic:                                                iv. Clinical manifestations: Lateral orbital wall
           (a) Major associated syndromes include                         deficiency/ midfacial retrusion due to
               Apert (craniosynostosis, exorbitism,                       hypoplasia/aplasia of the zygomatic bone;
               midfacial retrusion with complex                           downward slanting palpebral fissures and
               syndactyly of the 2-4 digits of the                        colobomata; variable external ear
               hands/feet), Crouzon (craniosynostosis,                    malformations with deafness; mandibular
               exorbitism, midfacial retrusion), and                      hypoplasia with microretrognathia;
               Pfeiffer (craniosynostosis, exorbitism,                    underdeveloped lower jaw can lead to
               midfacial retrusion, broad thumbs and                      airway compromise, necessitating
               toes) syndromes                                            distraction or tracheostomy, or both
           (b) Characteristic head shape involves                    v. Treatment: Skeletal and soft tissue
               turribrachycephaly (turri-, Gr., tower)                    augmentation of deficient areas with
           (c) 50% of Apert syndrome patients have                        autogenous bone (calvarium, rib, iliac crest)
               substantial mental delay; Crouzon and                      and autologous fat/tissue transfer,
               Pfeiffer syndrome patients usually                         respectively. Mandibular distraction may be
               develop normally                                           necessary for achieving a stable airway
           (d) Genetic defect identified in fibroblast
               growth factor receptor (FGFR) genes
36                                                                                                                         37
          b. Hemifacial Microsomia                                                        i.   An epithelial-lined tract frequently in the
             i. Third-most common congenital                                                   lateral neck presenting along the anterior
                   malformation (following club foot and cleft                                 border of the sternocleidomastoid muscle.
                   lip and palate)                                                             May present as a cyst or as a sinus
             ii. 1:7000 live births affected                                                   connected with either the skin or
             iii. No genetic defect ascribed; leading theory                                   oropharynx, or as a fistula between both
                   of cause is related to disruption of the                                    skin and oropharynx openings
                   stapedial artery during embryogenesis                                  ii. Treatment — excision
             iv. Part of the oculoauriculovertebral (OAV)                            b.   Thyroglossal duct cyst or sinus
                   spectrum                                                               i. Cyst in the mid-anterior neck over or just
             v. Usually associated with microtia                                               below the hyoid bone, with or without a
             vi. Manifestations include craniofacial or                                        sinus tract to the base of the tongue
                   hemifacial deficiency, both on skeletal and                                 (foramen cecum)
                   soft tissue level; microtia; mandibular                                ii. Treatment — excision
                   hypoplasia; macrostomia; malocclusion from                        c.   Ear deformities
                   an abnormal cant (secondary to reduced                                 i. Types
                   vertical height of the ramus)                                               (a) Complete absence (anotia) — very rare
             vii. Associated with Tessier #7 facial cleft and                                  (b) Vestigial remnants or absence of part of
                   variable facial nerve palsy                                                      ear (microtia)
             viii. Pruzansky classification useful for                                         (c) Absence of part or all of external ear
                   mandibular discrepancy; OMENS                                                    with mandibular deformity (hemifacial
                   classification (orbit, mandible, ear, nerve, soft                                microsomia)
                   tissue) more comprehensive                                                  (d) Abnormalities of position (prominent
             ix. Treatment: Skeletal and soft tissue                                                ears)
                   augmentation of deficient areas with                                   ii. Treatment
                   autogenous bone (calvarium, rib, iliac crest)                               (a) Anotia or microtia-construction from
                   and autologous fat/tissue transfer,                                              autogenous cartilage graft or synthetic
                   respectively. Mandibular distraction may be                                      implant, vascularized fascial flap, skin
                   necessary for achieving correction of                                            graft — usually requires more than one
                   malocclusion, versus conventional                                                operation. (Traumatic loss of part or all
                   orthognathic procedures to correct jaw                                           of ear is treated similarly). Use of a
                   discrepancies in adolescence                                                     prosthetic ear may be indicated in
          c. Goldenhar Syndrome                                                                     some patients
             i. Variant of OAV spectrum                                                        (b) Prominent ears — creation of an
             ii. Manifested by hemifacial microsomia,                                               anthelical fold and/or re-positioning/
                   coloboma and epibulbar dermoids, vertebral                                       reduction of concha
                   spine abnormalities and renal abnormalities
             iii. Treatment as in ii.                                  II.   TRAUMATIC
          d. Nager Syndrome                                                  A. Facial soft tissue injuries
     3.   Embryologic Defects                                                   1. Evaluation of all systems by trauma team (ABCDE,
          a. Branchial cyst, sinus, or fistula                                       primary survey)

38                                                                                                                                              39
          2.   Establishment of airway (may be obstructed by blood           b.  Zygomatic complex (Fig. 4-4)
               clots or damaged parts) by:                                       i. Commonly associated with orbital floor
               a. Finger (jaw thrust, e.g.)                                           fractures; therefore, must check extraocular
               b. Suction                                                             movements and obtain opthalmology
               c. Endotracheal intubation                                             consultation if suspicious of globe injury
               d. Cricothyroidotomy or tracheotomy                               ii. If severe displacement exists, must perform
          3. Control of active bleeding by pressure until control                     ORIF with three-point fixation
               by hemostats and ligatures or cautery in operating            c. Maxillary — Le Fort I, II, III (Fig. 4-5)
               room                                                          d. Naso-orbital-ethmoidal (NOE)
          4. Treatment of shock                                              e. Isolated orbital floor fractures: blowout versus
          5. Very conservative debridement of detached or                        blow-in
               nonviable tissue                                                  i. Check for entrapment (failure to move eye
          6. Careful wound irrigation with physiologic solution                       in all directions)—if present, must
          7. Remove all foreign materials                                             decompress orbit within 48 hours
          8. Palpate or explore all wounds for underlying bone                    ii. Check for enopthalmos (position of globe in
               injury; rule out injury to facial nerve, parotid duct,                 relation to unaffected globe in worm’s eye
               etc.                                                                   view). Must operate for enopthalmos 2mm
          9. Radiologic evaluation                                                    or greater
          10. Repair as soon as patient’s general condition allows           f. Frontal sinus
               with meticulous reapproximation of anatomy                    g. Other isolated fractures — e.g. nasal
               a. Preferably less than 8 hours post-injury                   h. Combination of above (panfacial fracture)
               b. Primary closure may be delayed up to 24 hours              i. Closed or open
                    (dressing should be applied and antibiotics given        j. Pediatric craniofacial fractures: Usually more
                    while waiting)                                               conservative with operative repair in this patient
          11. Tetanus prophylaxis                                                population, due to growing facial skeleton and
          12. Antibiotics if indicated                                           developing dentition
     B.   Facial bone fractures                                         2.   Diagnoses
          1. Classification                                                  a. Consider patient history
               a. Mandible only — often bilateral (ring concept)             b. Physical examination for asymmetry, bone
                    i. Depending on anatomical region                            mobility, diplopia, extraocular muscle
                         (parasymphysis, body, angle, subcondyle)                entrapment, sensory loss, malocclusion, local
                         and overall function (malocclusion), open               pain
                         reduction and internal fixation (ORIF) may          c. Old (pre-injury) photographs often useful to
                         be indicated                                            assess baseline
                    ii. Panorex film and CT scan useful                      d. X-rays
                    iii. Key is displacement of bone segments and                i. Skull (rare) and cervical spine
                         patient’s bite                                          ii. CT scan — axial and coronal — now
                    iv. Approximately 10-13% of fractures in the                      imaging modality of choice
                         mandible coincide with c-spine fracture; so,            iii. Specialized views
                         appropriate workup (x-rays) and c-spine                      (a) Waters view for facial bones (Fig. 4-6);
                         stabilization must be performed prior to                           good for orbital floor, now surpassed by
                         surgery                                                            CT
40                                                                                                                                     41
                             (b) Panorex if mandibular fracture present              E.   Acute Sialadenitis — fever, pain, swelling over the involved
                                  since CT scan does not visualize                        parotid gland. Seen with dehydration, debilitation,
                                  mandible fractures well                                 diabetics, poor oral hygiene. Treat with antibiotics, fluids
              3.   Treatment                                                         F.   Atypical mycobacteria — seen in enlarged lymph nodes;
                   a. Consultant (dentist or ophthalmologist) when                        drainage rarely required. Special cultures may be
                        indicated                                                         necessary
                   b. Re-establishment of normal occlusion is of
                        primary importance                                     IV.   NEOPLASTIC (exclusive of skin — see Chapter 3)
                        i. Use of interdental wiring, plating, or other              A. Salivary gland tumors or disorders
                             devices in patient with teeth                              1. Classification of tumors by location
                        ii. Use of patient’s dentures or fabricated                          a. Parotid — most common (80%),
                             temporary dentures in edentulous patient                             most are benign (80%)
                   c. Reduction and immobilization of other fractures.                       b. Submandibular — 55% incidence of malignancy
                        When dealing with panfacial fracture, handle                         c. Minor salivary glands — least common, with
                        articulating element (mandible). First by                                 highest incidence of malignancy (about 75%)
                        mandibulomaxillary fixation (MMF) followed by                   2. Diagnosis
                        internal fixation of Mandibular fractures. Once                      a. Primarily by physical examination
                        occlusion is aligned, work systematically, either                         i. Any mass in the pre-auricular region or at
                        “outside-in” (Gruss) or “inside-out” (Manson),                                 the angle of the jaw is a parotid tumor until
                        establishing facial height, width, and projection                              proven otherwise
                        by aligning key facial buttresses                                    b. Bimanual palpation — simultaneous intraoral and
                        i. Maintain by plating with or without wiring                             external palpation
                        ii. In orbital floor or wall fractures, reconstitute                 c. X-rays occasionally helpful for diagnosis of stone;
                             floor and walls to prevent enophthalmos.                             sialography (injection of contrast material into
                             Autogenous bone graft or alloplastic                                 duct) is rarely if ever indicated
                             materials (titanium mesh, resorbable mesh,                      d. Signs more commonly seen with malignancy
                             Medpor) are used to re-establish orbital                             i. Fixed or hard mass
                             volume                                                               ii. Pain
                                                                                                  iii. Loss or disturbance of facial nerve function
     III. INFECTIONS                                                                              iv. Cervical lymph node metastases
          A. The head and neck are relatively resistant to infection due                3. Treatment
              to their robust vascularity                                                    a. For stone near duct orifice
          B. Routes of spread                                                                     i. Simple removal
              1. Upper aerodigestive infections may track into the                           b. For benign tumors ( or stones in duct adjacent to
                   mediastinum                                                                    gland)
              2. Scalp and orbital infections may spread intracranially                           i. Surgical removal of gland with sparing of
                   via the dural sinuses and ophthalmic veins                                          adjacent nerves, e.g. facial nerve with
          C. Facial cellulitis — mostly due to staph or strep — may use                                parotid; lingual and hypoglossal nerves with
              a cephalosporin                                                                          submandibular
          D. Oral cavity infections — mostly due to anaerobic strep                          c. For malignant tumors
              and bacteroides. Use extended spectrum penicillin or                                i. Surgical removal of entire gland with
              other anaerobic coverage                                                                 sparing of nerve branches that are clearly
42                                                                                                                                                       43
                        not involved                                             2.   Diagnosis
                        (a) Radiation therapy if tumor not                            a. Examination — including indirect laryngoscopy
                             completely removed                                            and nasopharyneal endoscopy when indicated
                        (b) Cervical lymph node dissection with                       b. Biopsy of any lesion unhealed in 2-4 weeks
                             tumors prone to metastasize to nodes                     c. X-rays and scans as indicated
          4. Pathology                                                                     i. Conventional views, panorex, etc.
             a. Benign                                                                     ii. Tomography
                  i. Pleomorphic adenoma — (benign mixed)                                  iii. Computerized axial tomography
                        high recurrence rate with local excision                           iv. Bone scan
                  ii. Papillary cystadenoma lymphomatosum                                  v. Magnetic resonance imaging
                        (Warthin's tumor) — may be bilateral —                   3.   Treatment
                        (10%) male, age 40-70                                         a. Surgical
             b. Malignant                                                                  i. Benign
                  i. Mucoepidermoid                                                             (a) Simple excision
                  ii. Malignant mixed                                                      ii. Malignant
                  iii. Adenocarcinoma                                                           (a) Wide local excision with tumor-free
     B.   Tumors of oral cavity                                                                     margins
          1. Classification                                                                     (b) Regional lymph node dissection when
             a. Anatomical — malignancies behave differently                                        indicated
                  according to anatomic site and prognosis                                      (c) Palliative resection may be indicated for
                  worsens from anterior to posterior                                                comfort and hygiene
                  i. Lip                                                                        (d) Immediate reconstruction with
                  ii. Anterior two-thirds tongue                                                    vascularized flaps when indicated by
                  iii. Floor of mouth                                                               size and location of defect
                  iv. Buccal                                                          b. Radiation therapy
                  v. Alveolar ridge                                                        i. Preoperative
                  vi. Posterior tongue                                                          (a) To increase chance for cure, especially
                  vii. Tonsillar fossa and posterior pharynx                                        with large lesions
                  viii. Hypopharynx                                                             (b) May make an inoperable lesion
             b. Histopathologic                                                                     operable
                  i. Benign — according to site — fibroma,                                 ii. Postoperative
                        osteoma, lipoma, cyst, etc.                                             (a) If tumor-free margin is questionable
                  ii. Malignant                                                                 (b) For recurrence
                        (a) Most are squamous cell carcinoma or                                 (c) Prophylactic — controversial
                             variants                                                           (d) Chemotherapy — usually for advanced
                        (b) Palate carcinomas are often of minor                                    disease
                             salivary gland origin
                        (c) Sarcomas in mandible, tongue, other         V.   MISCELLANEOUS
                             sites are rare                                  A. Disorders of the jaw
                        (d) TNM staging is helpful for treatment                Generally, two categories: 1) Developmental; 2) Cleft-
                             planning and prognosis (i.e. tumor size,           related
                             lymph node metastases, systemic                    1. Deformities of the mandible
44                           metastases)                                                                                                        45
          a.  Classification                                                      ii. Arthritis
              i. Retrognathia — retrusion with respect to                         iii. Bone overgrowth
                   maxilla                                                        iv. Bruxism
              ii. Prognathia — protrusion with respect to                         v. Tumors
                   maxilla                                                   b. Symptoms
              iii. Micrognathia — underdeveloped, retruded                        i. Pain
                   mandible                                                       ii. Crepitus
              iv. Open bite — teeth cannot be brought into                        iii. Joint Noises
                   opposition                                                     iv. Limited opening
              v. Crossbite — lower teeth lateral to upper                         v. Occlusion change
                   teeth                                                     c. Diagnosis
              vi. Micro — and macrogenia — under- or over-                        i. Consider patient history
                   development of chin                                            ii. Examination
          b. Diagnosis                                                                  (a) Auscultation
              i. Physical examination                                                   (b) Opening
              ii. X-rays, including a cephalogram (lateral x-ray                        (c) Occlusion
                   at a fixed distance) to measure relationships                  iii. X-rays
                   of skull, maxilla and mandible                                       (a) Tomograms
              iii. Dental casts are made (usually by an                                 (b) Arthrogram/arthroscopy
                   orthodontist) and “model” or mock surgery                            (c) MRI
                   is performed on the casts to determine                    d. Treatment
                   degree of advancement/setback of bone                          i. Conservative: joint rest, analgesias, bite
          c. Treatment                                                                  plate, etc.
              i. Establishment of normal or near normal                           ii. Surgery — seldom indicated
                   occlusion of primary importance                 B.   Facial paralysis
              ii. Use of osteostomies with repositioning of             Loss of facial nerve results in very significant asymmetry
                   bone segments, bone grafts as needed, with           and deformity of the face, drooling, exposure of the
                   or without orthodontic corrective measures           cornea on the affected side. Deformity is accentuated by
                   as needed                                            muscle activity of normal side (if unilateral)
              iii. Mandibular distraction for severe                    1. Etiology
                   discrepancies                                             a. Idiopathic (Bell’s palsy)
     2.   Deformities of the maxilla                                         b. Congenital
          a. Most commonly, retrusions or under-                             c. Traumatic
              development, “dish-face”                                       d. Infectious
          b. Must also examine the vertical height of the                    e. Tumor
                                                                             f. Vascular (intracranial)
              midface (vertical maxillary excess, VME versus            2. Diagnosis
              vertical maxillary deficiency, VMD)                            a. Demonstrated by asking patient to raise
          c. Diagnosis — as for lower jaw                                         eyebrow, smile, etc.
          d. Treatment — as for lower jaw                               3. Treatment includes
     3.   Temporomandibular joint disorder                                   a. Supportive — for most Bell’s palsies
          a. Etiology                                                        b. Protect cornea by taping lids, lid adhesions —
              i. Previous trauma                                                  opthalmology consultation is critical
46                                                                                                                                   47
               c.   Re-establishment of nerve function by repair or
                    nerve graft (sural nerve common donor nerve)
               d.   Other measures, such as muscle transfers, static
                    suspension, skin resections, free tissue transfers
                    of muscle, etc.

                                                                         Fig. 4-2

                               Fig. 4-1

     Affected Relatives                    Predicted Outcomes*
        One sibling                                ≈ 4%
        One Parent                                 ≈ 4%
        Sibling and a Parent                       ≈ 16%
        One Sibling                                ≈ 2-4%
        One Parent                                 ≈ 2-4 %
        Sibling and a Parent                       ≈ 15%
     Note — If congenital lip pits, inherited as autosomal
     dominant gene with variable penetrance (Van der Woude’s
     Syndrome) — 50% incidence
     *General predictions; individual cases may vary

                               Table 4-1                                 Fig. 4-3
48                                                                                  49
                Fig. 4-6

     Fig. 4-4

     Fig. 4-5
50                         51
     CHAPTER 4 — BIBLIOGRAPHY                                                   CHAPTER 5
     HEAD AND NECK                                                              BREAST, TRUNK AND EXTERNAL GENITALIA
     1.   Sperber GH. Craniofacial Development. B.C. Decker Inc.,               Reconstructive problems of the trunk consist of restoring chest wall
          Hamilton, 2001.                                                       and abdominal wall structural integrity after major trauma or tumor
     2.   Cohen MM: Etiology and pathogenesis of orofacial clefting. Oral
          Maxillofac. Surg. Clin. No. Amer. 2000; 12: 379-397.                  I.   BREAST
                                                                                     A. Breast anatomy
     3.   Evans,G.R. and Manson, P.N. Review and current perspectives of
                                                                                        1. Breast
          cutaneous malignant melanoma. J Am Coll Surg. 1994; 178:523-
                                                                                            a. Glandular tissue enclosed by superficial fascial
                                                                                                 system and deep fascia overlying chest wall
     4.   Gruss, J.S. Advances in craniofacial fracture repair. Scand J Plast                    muscles
          Reconstr Surg Hand Surg Suppl. 1995; 27:67-81.                                    b. Cooper’s ligaments: suspensory attachment of
                                                                                                 the breast to the overlying fascia anteriorly
     5.   Manson PN, Hoopes, JE, Su CT. Structural pillars of the facial                    c. Boundaries:
          skeleton: An approach to the management of Le Fort fractures.                          i. Level of 2nd to 6th rib anteriorly
          Plast. Reconstr. Surg. 1980; 66(1): 54-61.                                             ii. Superior border is clavicle, inferior border is
     6.   Luce, E.A. Reconstruction of the lower lip. Clin Plast Surg.                                rectus abdominis fascia
          1995; 22109-21.                                                                        iii. Medial border is sternum, lateral border is
                                                                                                      anterior border of latissimus dorsi muscle
     7.   Manson, P.N. et al. Subunit principles in midline fractures: the              2. Vasculature:
          importance of sagittal buttresses, soft-tissue reductions, and                    a. Internal mammary artery perforators (60%)
          sequencing treatment of segmental fractures. Plast Reconstr                       b. Lateral thoracic artery (30%)
          Surg. 1998; 102:1821-34.                                                          c. Thoracoacromial artery: pectoral branches
     8.   Wells, M.D. et al. Intraoral reconstructive techniques. Clin Plast                     supply pectoralis major muscle and overlying
          Surg. 1995; 22:91-108.                                                                 breast tissue
                                                                                            d. Intercostal arteries 3, 4, 5
     9.   Williams, J.K. et al. State-of-the-art in craniofacial surgery:                   e. Venous drainage mainly to axillary vein but some
          nonsyndromic craniosynostosis. Cleft Palate Craniofac J. 1999;                         to internal mammary and intercostal veins
          36:471-85.                                                                    3. Lymphatics:
                                                                                            a. 97% drainage to axilla
                                                                                            b. 3% drainage to internal mammary nodes
                                                                                            c. Level I: nodes lateral to lateral border of
                                                                                                 pectoralis minor
                                                                                            d. Level II: nodes lying beneath pectoralis minor
                                                                                            e. Level III: nodes medial to medial border of
                                                                                                 pectoralis minor and extending to apex of the
                                                                                        4. Nerve supply
                                                                                            a. Cervical plexus: sensory branches of C3, 4 from
                                                                                                 supraclavicular nerve
52                                                                                                                                                     53
              b.    Lateral branches of intercostal nerves:               1.   Prosthetic:
                    i. Provide sensation to lateral side of breast             a. Gradual tissue expansion with the use of sub-
                    ii. Lateral 4th provides major sensory                         pectorally placed expanders, with eventual
                         innervation to nipple (T4 dermatome)                      breast implant insertion once adequate skin
              c. Medial branches of intercostal nerves 2-7 provide                 expansion has occurred
                    sensation to medial breast                                 b. Breast implants may be saline or silicone
     B.   Breast reconstruction                                                    (silicone implants have long been approved by
          1. All patients that have undergone mastectomy are                       the FDA for use in patients following
              entitled to breast reconstructive surgery                            mastectomy and can offer a more natural feel)
          2. The breast is a symbol of femininity                         2.   Autogenous:
          3. Surgeon needs to understand individual needs with                 a. Pedicle flaps:
              regard to acceptable results and range of preferences:               i. Latissimus dorsi myocutaneous flaps used
              a. No reconstruction                                                       widely (can be combined with breast
              b. Reconstruction to attain close to natural breast                        implant)
                    shape, feel contour                                            ii. Pedicled TRAM flap using superior
              c. With or without nipple/areolar reconstruction                           epigastric vessels for blood supply (rectus
                    i. Post-mastectomy defects are usually                               abdominus muscle is used as a “carrier” for
                         complicated by complete loss of the nipple/                     the blood vessel)
                         areolar complex and loss of skin                      b. Free flaps:
                    ii. Previous irradiation may cause difficulties                i. Technically more demanding, requiring
                         with wound healing, skin contraction, and                       microvascular technique
                         discoloration                                             ii. Recipient vessels tend to be internal
     C.   Definitions                                                                    mammary vessels (or their breast
          1. Subcutaneous mastectomy: removal of all breast                              perforators) or less commonly, the
              tissue with preservation of all skin, including nipple/                    thoracodorsal vessels
              areolar complex. High recurrence rate if used for                c. Types of flaps:
              malignant disease                                                    i. TRAM (Transverse Rectus Abdominis
          2. Simple (total) mastectomy: removal of all breast                            Myocutaneous) flap
              tissue, including nipple areola complex                              ii. Muscle sparing TRAM flap
          3. Skin-sparing mastectomy: simple mastectomy with                       iii. DIEP (Deep Inferior Epigastric Perforator)
              preservation of all skin except the nipple/areolar                         flap
              complex and a 1-2cm margin around the biopsy site                    iv. SIEA (Superficial Inferior Epigastric Artery
          4. Modified radical mastectomy: removal of all breast                          Perforator) flap
              tissue, nipple/areola complex, pectoralis fascia, as well            v. The terms above represent abdominal tissue
              as Level I and II lymph nodes                                              used to reconstruct the breast
          5. Halsted radical mastectomy: removal of all breast                     vi. The first 3 flaps use the deep inferior
              tissue, nipple/areolar complex, pectoralis major and                       epigastric vessels for blood supply, whereas
              minor muscles, muscular fascia, Level I, II, and III                       the SIEA, uses the superficial inferior
              lymph nodes (this procedure does not improve                               epigastric vessels
              disease control compared to modified radical                         vii. SIEA has to be of adequate caliber (artery
              mastectomy)                                                                with a palpable pulse, vein >1mm) to be
     D.   Methods of reconstruction                                                      used for anastomosis (only 10% of women
54                                                                                                                                      55
                will have an adequate SIEP)                                     symmetry
          viii. TRAM and the muscle sparing TRAM flaps                     e.   Nipple/areolar reconstruction can then be
                take some element of muscle tissue as well                      considered
                as the fat and skin as a “carrier” for the deep                 i. Local skin flaps +/- use of cartilage or
                inferior epigastric vessels (technically                             alloderm graft
                easier)                                                         ii. Intra-dermal color tattoo to match opposite
          ix. DIEP and SIEA flaps are technically harder                             nipple
                to do as they do not take any muscle from         E.   Breast reduction
                the abdominal wall and require dissection of           1. Indications:
                the blood vessels away from the “carrier”                  a. Physical:
                rectus abdominis muscle (advantage of no                        i. Neck, back, shoulder pain
                abdominal wall donor site weakness)                             ii. Shoulder grooving, bra straps cutting into
          x. Clinical relevance of not taking any muscle                             shoulders
                is still under debate, but may be                               iii. Infection and maceration within
                advantageous for women who are athletic                              inframammary fold
          xi. Gluteal artery perforator flap (GAP) is                           iv. Neurological sequelae
                another option, but is generally reserved for              b. Psychological:
                patients without sufficient abdominal wall                      i. Embarrassment
                tissue or patients that have previously                         ii. Self-consciousness
                undergone abdominal wall surgery (e.g.                          iii. Loss of sexual appeal and femininity
                abdominoplasty)                                        2. Techniques:
          xii. Turbocharging:                                              a. Traditional: Wise pattern (inferior or central
                (a) Vascular augmentation using the                             pedicle)
                      vascular sources within the flap                          i. Advantage: predictable outcome
                      territory                                                 ii. Disadvantages: long scar length, “bottoming
                (b) Example: performing a DIEP flap to the                           out” of breast, loss of superior pole
                      recipient internal mammary vessels                   b. Vertical reduction pattern (superior or medial
                      then anastomosing an additional vessel                    pedicle)
                      from this system                                          i. Advantage: attractive long term breast shape
          xiii. Supercharging:                                                  ii. Disadvantages: steep learning curve,
                (a) Vascular augmentation using a distant                            unattractive postoperative appearance
                      source of vessels such as axillary or                c. Large reductions may require nipple/arealor
                      thoracodorsal vessels                                     complex free grafting if pedicle is too long for
                (b) Example: performing a pedicled                              blood supply
                      superior epigastric TRAM flap, then                  d. Liposuction can assist with “touch up”
                      augmenting the flow by anastomosing              3. Outcomes:
                      the deep inferior epigastric vessels to              a. Excellent long term satisfaction
                      the thoracodorsal vessels                            b. Lactation is possible if underlying glands are
     d.   If desired, following unilateral breast                               preserved
          reconstruction, the opposite breast can be                       c. Nerve supply of nipple usually preserved, but
          contoured, using mastopexy, reduction or                              outcomes can be variable
          augmentation mammoplasty for improved
56                                                                                                                                 57
                    d.   Occult breast cancer detected in 0.4% of            D.   Sternal wound infection and dehiscence:
                         specimens                                                1. Mediastinitis and sternal wound dehiscence are
                                                                                       devastating and life threatening complications of
     II.   CHEST WALL RECONSTRUCTION                                                   median sternotomy incision
           A. Major principles:                                                   2. Occurs in 0.25-5% of cases
              1. Aim to restore structure and provide stable soft tissue          3. Sternal dehiscence involves separation of the bony
                   coverage                                                            sternum and often infection of the deep soft tissues,
              2. Obliteration of dead space is critical in                             referred to as mediastinitis
                   reconstruction of intrathoracic cavity                         4. Mortality rates in initial studies near 50%
              3. Aim is to restore skeletal stabilization if > 4 rib              5. Treatment options:
                   segments or > 5cm chest wall is resected en bloc to                 a. Early debridement/wound excision
                   avoid flail chest                                                   b. VAC therapy
              4. Small defects of skeletal chest wall are functionally                 c. Infection control with directed antimicrobial
                   insignificant                                                            therapy based on blood and tissue culture
           B. Soft tissue chest wall defects:                                          d. Development of granulation tissue
              1. VAC therapy can be utilized                                           e. Further debridement if necessary
              2. Regional muscle flaps most frequently used:                           f. Rigid sternal plate fixation (provides improved
                   a. Pectoralis major                                                      chest and respiratory function as well as
                   b. Latissimus dorsi                                                      cosmetic appearance)
                   c. Serratus anterior                                                g. Primary rigid sternal plate fixation (in lieu of
                   d. Rectus abdominis                                                      circlage wires) has been shown to decrease
              3. Microvascular free flaps (when regional flaps have                         complications
                   failed or are unavailable):                                         h. Primary wound closure +/- myocutaneous flaps
                   a. Contralateral latissimus dorsi                                        (usually pectoralis major but others have been
                   b. Tensor Fascia Lata                                                    described: rectus abdominis, latissimus dorsi and
                   c. Multiple recipient vessels are available for                          omentum)
                        microvascular anastomosis (e.g. thoracodorsal        E.   Congenital chest wall defects:
                        system)                                                   1. Pectus excavatum (sunken chest) and pectus
           C. Skeletal chest wall defects:                                             carinatum (pigeon chest)
              1. Prosthetic                                                            a. Pectus excavatum 10 times more common than
              2. Polypropylene (Prolene) mesh or Gore-tex mesh                              pectus carinatum
              3. Alloderm                                                              b. Indications for treatment:
              4. Autogenous                                                                 i. Aesthetic
                   a. Rib grafts, free or vascularized                                      ii. Relief of cardiorespiratory dysfunction in
                   b. Fascia                                                                     severe cases
                   c. Muscle flaps (can be used without development                         iii. Costal cartilage disorganized growth
                        of flail segments specifically in a radiated chest             c. Pectus excavatum treatment:
                        wall because of the rigidity of tissue)                             i. Nuss procedure:
              5. Commonly, the use of mesh, either prosthetic or                                 (a) Curved, custom-shaped, stainless steel
                   alloplastic, is used in combination with a well                                    rod is guided through the rib cage and
                   vascularized muscle flap for large chest wall                                      beneath the sternum
                   resections requiring rigid stabilization                                      (b) Rod then rotated, turning the curved
58                                                                                                                                              59
                                  portion against the chest wall, pushing                  previous procedures):
                                  the ribs and sternum out                                 a. Components separation release
                   d. Pectus carinatum treatment:                                               i. Relaxing incisions can be made unilaterally
                        i. Multiple osteotomies of sternum and                                       or bilaterally in the external oblique fascia,
                             affected ribs                                                           just lateral to rectus muscle
          F.   Poland’s Syndrome:                                                               ii. Enables medial transposition of rectus
               1. Etiology: subclavian artery hypoplasia                                             muscle sheath
               2. Features:                                                                     iii. Advancement attainable: 10cm in
                   a. Absence of sternal head of pectoralis major                                    epigastrium, 20cm at umbilicus and 6cm in
                   b. Hypoplasia of breast or nipple                                                 suprapubic region
                   c. Deficiency of subcutaneous fat and axillary hair                     b. Tissue expansion
                   d. Bony abnormalities of anterior chest wall                       6.   Pedicled muscle and myocutaneous flaps (when
                   e. Syndactyly or hypoplasia of ipsilateral extremity                    synthetic mesh and fascial separation are
                   f. Shortening of forearm                                                contraindicated)
               3. Treatment:                                                               a. Tensor fascia lata
                   a. Await full breast development in girl                                b. Rectus femoris
                   b. Breast reconstruction (flaps, implants)                              c. Vastus lateralis
                   c. Can use innervated ipsilateral latissimus to                         d. Gracilis
                        recreate anterior axillary fold                                    e. Free flaps
                                                                                      7.   Split thickness skin and/or synthetic mesh directly
     III. ABDOMINAL WALL RECONSTRUCTION                                                    over bowel (in emergency situations; requires further
          A. Clinical problems that require abdominal wall                                 hernia reconstructive surgery)
             reconstruction:                                                          8.   VAC use can be integrated into the treatment of
             1. Tumor resection                                                            patients with compromised wound healing
             2. Infection (necrotizing fasciitis)                                          a. Cases of enteric fistula formation have been
             3. Trauma                                                                          associated with the VAC, however, paradoxically,
             4. Recurrent ventral wall hernias                                                  VAC has also been used successfully for the
             5. Congenital abdominal wall defects (gastroschisis,                               management of fistulas
          B. Principles for abdominal wall reconstruction:                  IV.   PRESSURE ULCERS
             1. To protect and cover the intra=abdominal viscera                  A. Unrelieved pressure can lead to tissue ischemia in deep
             2. To repair and prevent herniation with strong fascial                 tissue layers near bony prominences leading to tissue
                  support                                                            necrosis
             3. To achieve acceptable surface contour                                1. Can develop within 2 hours of unrelieved pressure
          C. Algorithm for abdominal wall reconstruction:                            2. Decubitus was term to describe lying position,
             1. Primary closure (avoid tension)                                           however, any area that has sustained pressure can
             2. Mesh (10% hernia recurrence, 7% infection)                                develop into an ulcer, including the sitting position
             3. Allografts (Alloderm)                                                3. Term pressure ulcer is now preferred over decubitus
             4. Autogenous skin grafts (over viscera with or without                      ulcer
                  mesh and omentum)                                                  4. Pressure sores often have “iceberg phenomenon”
             5. Methods of reconstruction relying on local tissues                        a. Since skin can withstand ischemia much better
                  (not applicable in patients who have had multiple                            than fat or muscle, a small skin wound on
60                                                                                                                                                    61
                    surface can reflect a large amount of deeper                 2.  Systemic infection/sepsis unlikely with pressure ulcer
                    tissue necrosis underneath                                       (unless immunocompromised): look for other source
     B.   Common areas include:                                                      e.g. urinary tract infection or respiratory tract
          1. Occipital region                                                    3. If localized infection is present (look for signs of local
          2. Spine                                                                   cellulitis) topical antimicrobial agents (Silvadene,
          3. Sacrum                                                                  Sulfamylon) can be used
          4. Coccyx                                                              4. Bone biopsy best method to assess osteomyelitis vs.
          5. Ischial tuberosity                                                      osteitis
          6. Greater trochanter                                                  5. Can direct antibiotic therapy to treat osteomyelitis,
          7. Heel                                                                    but virtually impossible to eradicate infection
     C.   Other factors contributing to pressure sore formation:                 6. Long term antibiotics are not indicated
          1. Altered sensory perception                                          7. Ulcer closure may be accelerated using topical
          2. Incontinence                                                            protein growth factors
          3. Exposure to moisture                                                8. Stage III patients require sharp debridement, highly
          4. Altered activity and mobility                                           absorptive dressings (alginates, hydrocolloid beads,
          5. Friction and shear forces (damage to superficial layers                 foams, hydrogels)
               can allow bacteria to colonize and result in deeper               9. VAC therapy may be beneficial to assist closure
               ulceration)                                                  G.   Surgical treatment:
          6. Muscle contractures                                                 1. Due to high recurrence rates, surgery tends to be
     D.   Staging system:                                                            reserved for patients with reversible pathologies
          1. Stage I: Erythema of the skin (may be overlooked in                 2. Excisional debridement of ulcer and bursa and any
               dark-skinned patients)                                                heterotopic calcification
          2. Stage II: Skin ulceration and necrosis into                         3. Partial or complete ostectomy to reduce bony
               subcutaneous tissue                                                   prominence
          3. Stage III: Grade II plus muscle necrosis                            4. Closure of the wound with healthy, durable tissue
          4. Stage IV: Grade III plus exposed bone/joint                             that can provide adequate padding over the bony
               involvement                                                           prominence (myocutaneous vs. fasciocutaneous flap)
     E.   Incidence:
          1. Bed-bound hospital patients: 10-15%                       V.   EXTERNAL GENITALIA
          2. ICU patients: 33%                                              A. Congenital defects
          3. Hip fracture patients: up to 66%                                   1. Male child with congenital genital defect should not
     F.   Non-surgical treatment:                                                  be circumcised to preserve tissue that may be needed
          1. Prevention is the best treatment                                      for surgery
               a. Keep skin clean and dry                                       2. Hypospadias
               b. Appropriate nursing care, including turning the                  a. Urethral opening develops abnormally, usually on
                    patient ever 2 hours (avoid dragging/shearing                       the underside of the penis
                    skin of the patient while repositioning)                       b. Occurs in 1/350 male births
               c. Optimizing nutrition                                             c. Can be associated with undescended testicles
               d. Relieving pressure using air mattresses, cushions,               d. Operation around 1 year of age (stimulation with
                    heel protectors                                                     testosterone may increase penile size and aid in
               e. Air fluidized beds (Clinitron®) gold standard for                     wound healing)
                    ulcer prevention                                               e. Distal cases can be repaired using local tissue
62                                                                                                                                               63
                  flaps or urethral advancement                            3.   Penis amputation
              f.  Proximal cases can be repaired using graft                    a. Reattachment is feasible with cold ischemia time
                  urethroplasty or vascularized prepucial flap                        of up to 24 hours
                  urethroplasty                                                 b. Debride wound and opposing surfaces
          3. Epispadias and exstrophy of the bladder                                  thoroughly
              a. Failure or blockage of normal development of                   c. Microsurgical approach is preferable
                  the dorsal surface of the penis, abdomen, and                       i. Urethra reapproximated with Foley as
                  anterior bladder wall                                                    indwelling stent and suprapubic catheter for
              b. 1/30,000 births, three times more common in                               bladder drainage
                  males                                                               ii. Dorsal arteries, veins, nerves reconnected
              c. Epispadias treated similarly to hypospadias, with                    iii. Corpora reattached
                  local tissue flaps                                       4. Testicle amputation
              d. Bladder exstrophy requires staged, functional                  a. Unilateral loss: prosthetic replacement
                  reconstruction                                                b. Bilateral loss: microsurgical replantation
                  i. Neonatal period: bladder is closed               C.   Phallic reconstruction
                  ii. 1-2 years: epispadia repair                          1. Subtotal penile loss: release penile suspensory
                  iii. 3-4 years: bladder neck reconstruction                   ligament, recess scrotum and suprapubic skin, apply
          4. Ambiguous genitalia                                                skin graft to remaining stump
              a. Evaluation and management requires a team                 2. Total penile loss: tubed abdominal flap, gracilis
                  approach and great sensitivity towards the family             myocutaneous flap, groin flap, microvascular free flap
              b. Caused by adrenal hyperplasia, maternal drug                   (e.g. radial forearm, osteocutaneous fibula)
                  ingestion, hermaphrodism                                      a. Advantages of free flap: one-stage procedure,
              c. Karyotype should be attained immediately                             sensation partially restored, better appearance,
              d. Pelvic ultrasound can be performed to assess                         competent urethra, adequate rigidity
                  Müllerian anatomy                                   D.   Vaginal reconstruction
              e. Gender assignment needs to take multiple                  1. Lining
                  biopsychosocial factors into account                          a. Full-thickness skin grafts
          5. Vaginal agenesis                                                   b. Skin flaps
              a. 1 in 5000 female births                                        c. Intestinal segments
              b. Absence of proximal portion of vagina in an               2. Pudendal thigh flap
                  otherwise phenotypically, chromosomally, and             3. Rectosigmoid vaginoplasty
                  hormonally intact female                            E.   Infectious
              c. Often undiagnosed until amenorrhea noted                  1. Fournier’s gangrene and other necrotizing infections
              d. Reconstruction in puberty by progressive                       a. Multiple organs commonly cultured
                  dilation, grafts, or flaps                                    b. Infection begins at skin, urinary tract, rectum and
     B.   Trauma                                                                      spreads to penis, scrotum, perineum, abdomen,
          1. Penile and scrotal skin loss injuries                                    thighs, and flanks in the dartos, scarpas, and
              a. Can bury shaft of penis temporarily then use full                    Colles fascia
                  thickness or split thickness skin graft                       c. Corpora bodies, glans, urethra, and testes not
              b. Scrotum can have split thickness skin grafted                        usually involved
          2. Penetrating injuries to penis                                      d. Treatment primarily extensive surgical
              a. Require immediate operative repair                                   debridement of involved tissue
64                                                                                                                                        65
          e. Drains placed as deemed necessary                   CHAPTER 5 — BIBLIOGRAPHY
          f. High dose, broad-spectrum antibiotics
          g. Urinary diversion                                   BREAST, TRUNK AND EXTERNAL GENITALIA
          h. Colostomy if cause from rectal/ perirectal area     1.   Civelek B, Kargi E, Akoz T, Sensoz O. Turbocharge or
     2.   Hidradenitis suppurativa                                    supercharge? Plast Reconstr Surg. 1998 Sep;102(4):1303.
          a. Chronic condition
          b. Multiple painful, swollen lesions in the axillae,   2.   Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
              groin, and other parts of the body that contain         infected median sternotomy wound: a treatment algorithm
              apocrine glands                                         utilizing vacuum-assisted closure followed by rigid plate
          c. Can involve adjacent subcutaneous tissue and             fixation. Ann Plast Surg. 2006 Jun;56(6):680-5.
              fascia                                             3.   Song DH, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M. Vacuum
          d. Sinus tracts form (which can become draining             assisted closure for the treatment of sternal wounds: the bridge
              fistulas) in the apocrine gland body areas              between debridement and definitive closure. Plast Reconstr
          e. Treatment of infected lesions is incision and            Surg. 2003 Jan;111(1):92-7.
          f. Cure may require massive surgical excision to       4.   Greer SE, Benhaim P, Lorenz HP, Chang J, Hedrick MH.
              eliminate all apocrine glandular tissue with            Handbook of Plastic Surgery. Marcel Dekker New York 2004.
              healing by secondary intention                     5.   Aston SJ, Beasley RW, Thorne CHM. Grabb and Smith’s Plastic
          g. Antibiotics: Tetracycline and erythromycin may           Surgery 5th Edition. Lippincott Raven Philadelphia 1997.
              be helpful long-term
                                                                 6.   Heller L, Levin SL, Butler CE. Management of abdominal wound
                                                                      dehiscence using vacuum assisted closure in patients with
                                                                      compromised healing. Am J Surg. 2006 Feb; 191(2):165-72.
                                                                 7.   Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The
                                                                      "Fistula VAC," a technique for management of enterocutaneous
                                                                      fistulae arising within the open abdomen: report of 5 cases. J
                                                                      Trauma. 2006 Feb; 60(2):428-31.
                                                                 8.   Garcia AD. Assessment and management of chronic pressure
                                                                      ulcers in the elderly. Med Clin North Am. 2006;90(5):925-44.
                                                                 9.   Walsh PC. Campbell’s Urology 8th Edition. Saunders
                                                                      Philadelphia 2002.

66                                                                                                                                       67
     CHAPTER 6                                                                 C.   Muscles and tendons
                                                                                    1. Flexor system (Fig. 6-2)
     UPPER EXTREMITY                                                                    a. Long flexors — Flexor digitorum profundus
     The surgical treatment of hand problems is a specialized area of                        attaches to distal phalanx and bends the DIP
     interest in plastic surgery. The hand is a unique organ which                           (distal interphalangeal) joint. Flexor digitorum
     transmits sensations from the external environment to us as well as                     superficialis attaches to middle phalanx and
     allowing us to modify and interact with the external environment.                       bends PIP (proximal interphalangeal ) joint.
     The hand is made up of many finely balanced structures. It must                    b. Intrinsic flexors — Lumbricals bend the MCP
     function with precision, as in writing, as well as with strength, as in                 (metacarpal-phalangeal) joints
     hammering. Since the hand is a major tool of interaction with
     others, it is essential that it look as normal as possible, as well as
     function well.
          A. Surface Anatomy — Knowledge of proper terminology is
             essential to communicate the location of injuries to others
          B. Nerves
             1. Sensory — median, ulnar, radial (Fig. 6-1)
             2. Motor — intrinsic muscles of hand
                  a. Median nerve — thenar muscles, radial
                       lumbricals                                                                       Fig. 6-2
                  b. Ulnar nerve — interossei, ulnar lumbricals,
                       hypothenar muscles
                                                                                    2.   Extensor system (Fig. 6-3)
                                                                                         a. Long extensors insert on base of middle phalanx
                                                                                         b. Intrinsics (interossei and lumbricals) pass volar
                                                                                             to the axis of the MCP joint (where they act as
                                                                                             flexors) and move dorsal to the axis of the PIP
                                                                                             joint to insert on the dorsal distal phalanx. They
                                                                                             act as extensors to the PIP and DIP joints

                                     Fig. 6-1                                                           Fig. 6-3
68                                                                                                                                                69
     D.   Skeleton (Fig. 6-4 — see bibliography page 80)           II.   INITIAL EVALUATION OF THE INJURED HAND
                                                                         A. History
                                                                             1. Time and place of accident
                                                                             2. Agent and mechanism of injury
                                                                             3. First aid given
                                                                             4. Right or left hand dominance
                                                                             5. Occupation
                                                                             6. Age
                                                                         B. Examination
                                                                             1. Observation
                                                                                 a. Position of fingers — normally slightly flexed.
                                                                                      An abnormally straight finger might indicate a
                                                                                      flexor tendon injury (the unopposed extensors
                                                                                      hold the finger straight)
                                                                                 b. Sweating patterns (indicate innervation)
                                                                                 c. Anatomic structures beneath the injury
                                                                             2. Sensory — must test prior to administering
                             Fig. 6-4*                                           anesthesia
                                                                                 a. Pin to measure sharp/dull sensitivity, paper clip
     E.   Wrist — a large number of tendons, nerves and vessels                       to measure two point discrimination
          pass through a very small space, and are vulnerable to                 b. Test all sensory territories (median, ulnar, radial)
          injury (Fig. 6-5)                                                      c. Test both sides of each finger
                                                                             3. Motor
                                                                                 a. Profundus — stabilize PIP joint in extension, ask
                                                                                      patient to flex fingertip (Fig. 6-6)
                                                                                 b. Superficialis — stabilize other fingers in
                                                                                      extension. This neutralizes profundus action.
                                                                                      Ask patient to flex finger (Fig. 6-7)
                                                                                 c. Motor branch of median nerve: test palmar
                                                                                      abduction of thumb against resistance
                                                                                 d. Motor branch of ulnar nerve: ask patient to fully
                                                                                      extend fingers, then spread fingers apart
                                                                                 e. Extensor tendons
                                                                                      i. Ask patient to extend fingers at MCP joints
                                                                                           (tests long extensors)
                                                                                      ii. Ask patient to extend PIP, DIP joints with
                                                                                           MPs flexed (tests intrinsic extensors)

                              Fig. 6-5
70                                                                                                                                         71
                                                               C.   Early care
                                                                    1. Use pneumatic tourniquet or BP cuff inflated to
                                                                         250mmHg to control bleeding for examination and
                                                                         treatment. An awake patient will tolerate a
                                                                         tourniquet for 15-30 min
                                                                    2. If bleeding is a problem, apply direct pressure and
                                                                         elevate until definitive care available
                                                                         a. Do not clamp vessels
                                                                         b. Tourniquet may be used as last resort, but must
                                                                              be released intermittently
                                                                    3. Splint in safe position if possible (Fig. 6-8)
                                                                         a. Position where collateral ligaments are at
                                                                              maximum stretch, so motion can be regained
                                                                              with least effort
                        Fig. 6-6                                         b. Positioning — wrist extended (45º), MCP joints
                                                                              flexed (60º), IP joints straight, thumb abducted
                                                                              and rotated in opposing position
                                                                         c. Proper splinting prevents further injury, prevents
                                                                              vessel obstruction, prevents further tendon
                                                                    4. All flexor tendon, nerve and vascular injuries, open
                                                                         fractures, and complex injuries are managed in the
                                                                         operating room
                                                                    5. Tetanus prophylaxis and antibiotic coverage as

                        Fig. 6-7

     4.   Vascular
          a. Color — nailbed should be pink, blanch with
              pressure, and show capillary refill within one
          b. Temperature — finger or hand should be similar
              in temperature to uninjured parts
          c. Turgor — pulp space should be full without
                                                                                        Fig. 6-8
72                                                                                                                               73
          D.   Definitive treatment                                          B.   Amputation
               1. Thorough cleaning of entire hand and forearm, with              1. Indications for replantation — thumb, multiple
                   wound protected                                                   fingers. Single finger replantations often not
               2. Apply sterile drapes                                               indicated. Must discuss with replant team
               3. Inspect wound — use tourniquet or BP cuff for                   2. Care of amputated part
                   hemostasis                                                        a. Remove gross contamination and irrigate with
               4. Wound irrigation with normal saline                                     saline
               5. May need to extend wound to inspect all vital                      b. Wrap part in gauze moistened in saline, place in
                   structures                                                             clean plastic bag or specimen cup, seal
               6. Assure hemostasis with fine clamps and cautery                     c. Lay container on ice, or float on ice cubes in
               7. Nerve injuries should be repaired with magnification                    water. Don’t immerse part directly in ice water
               8. Tendons are repaired primarily, except in special                       or pack directly in ice — it may freeze
                   instances (e.g. human bite)
                   a. Flexor tendon injuries in Zone II, “no man’s land”
                         (Fig. 6-9) should be repaired by a trained hand
                   b. If a hand surgeon is not available, clean and
                         suture the skin wound, splint the hand, and refer
                         as soon as possible for delayed primary repair.
                         Repair needs to be done within 10 days
               9. Reduce fractures and dislocations, apply internal or
                   external fixation if needed
               10. Postoperative dressings
                   a. Splinting should be in safe position when
                         possible, but alternative positioning may be
                         required to protect tendon or nerve repairs
                   b. Dressings should not be tight

          A. Fingertip — most common injury
             1. Tip amputations
                 a. Basic principles — maintain length, bulk and
                 b. Treatment options include secondary healing,
                       skin graft, flap
             2. Nailbed injury
                 a. Nailbed should be repaired with fine chromic
                       gut suture
                 b. Nail can be cleaned and replaced as a splint, or
                       silastic sheet used as splint to prevent adhesion
                       of the eponychial fold to the nailbed
                                                                                                     Fig. 6-9
74                                                                                                                                          75
                3.  Care of patient                                                         c.   Treatment is drainage over point of maximal
                    a. Do not clamp vessels — use direct pressure so as                          tenderness — lateral if possible
                         not to injure digital nerve                                   3.   Subcutaneous abscess — incise and drain with care
                    b. Supportive care                                                      not to injure digital nerve. Be alert to possibility of
                    c. X-ray stump and amputated part                                       foreign body
           C.   Burned hand                                                            4.   Tenosynovitis — infection of tendon sheath
                1. Initial treatment                                                        a. Diagnostic signs (Kanavel’s signs)
                    a. Cleanse wound, debride broken blisters                                    i. Fusiform swelling of finger
                    b. Evaluate blood supply — circumferential full                              ii. Finger held in slight flexion
                         thickness burns may require escharotomy                                 iii. Pain with passive extension
                    c. Apply occlusive dressings to reduce pain                                  iv. Tenderness over flexor tendon sheath
                    d. Immobilize in safe position                                          b. Treatment is to open and irrigate tendon sheath.
                    e. Refer to plastic surgeon if burn is extensive or                          Untreated infection can destroy the tendon
                         may require grafting                                                    within hours
                2. Hand therapy may be needed to maintain motion                       5.   Human bite
                                                                                            a. Have high index of suspicion — patients are
     IV.   INFECTIONS                                                                            often unwilling to admit being in a fight. Most
           A. General principles                                                                 common site over a knuckle
               1. Infection can be localized by finding:                                    b. Debride, cleanse thoroughly, culture
                   a. The point of maximum tenderness                                       c. Must rule out penetration of joint space — may
                   b. Signs of local heat                                                        need to explore in OR
                   c. Overlying skin edema                                                  d. Broad spectrum antibiotics — often I.V.
                   d. Pain on movement                                                      e. Do not suture wound
               2. A fever usually denotes lymphatic involvement
               3. Pressure from edema and pus in a closed space can           V.   FRACTURES
                   produce necrosis of tendons, nerves and joints in a             A. General principles
                   few hours. Extreme cases can lead to amputation and                1. Inspect, palpate, x-ray in multiple planes — AP, true
                   even death                                                             lateral, oblique
           B. Treatment principles                                                    2. Reduce accurately
               1. Surgical drainage, cultures                                         3. Immobilize for healing
               2. Immobilization in safe position, elevation                          4. Hand therapy to maintain motion
               3. Antibiotics                                                      B. Specific fractures
           C. Specific infections                                                     1. Metacarpal fractures
               1. Paronychia — infection of the lateral nail fold                         a. Boxer’s fracture — fracture of 4th or 5th
                   Treatment: if early, elevation of skin over nail to                          metacarpal neck. Can accept up to 30 degrees
                   drain. If late, with pus under nail, must remove lateral                     of angulation. Treatment can range from gentle
                   portion of nail                                                              protective motion if minimally displaced to
               2. Felon                                                                         closed reduction and cast to open reduction and
                   a. Pus in pulp space of fingertip — closed space                             internal fixation
                        without ability to expand — very painful                          b. Metacarpal shaft fractures — must check for
                   b. Pressure of abcess may impair blood supply                                rotatory deformity. Flex all fingers. If involved
                                                                                                finger overlaps another, there is rotation at the
76                                                                                                                                                    77
                         fracture site which must be reduced. Unstable                       involving skin only, or complex, involving bone
                         fractures must be fixed with pins or plates and           C.   Treatment — goal to decrease deformity and improve
                         screws                                                         function
               2.   Phalangeal fractures                                                1. Some problems are treated in infancy — e.g. splinting
                    a. Unstable fractures require internal or                                for club hand, thumb reconstruction
                         percutaneous fixation                                          2. Some treated in early childhood — e.g. separation of
                    b. Joint surfaces should be anatomically reduced                         syndactyly
               3.   Tuft fractures (distal phalanx)                                     3. Some require multi-staged procedures — e.g. club
                    a. If crushed, mold to shape                                             hand
                    b. Repair associated nailbed injury if needed
                    c. Splint for comfort (DIP only) for 1-2 wks
                                                                              I.   Failure of formation of parts
     VI.   JOINT INJURIES                                                          A. Transverse
           A. Dislocation                                                          B. Longitudinal
               1. If already reduced, test for instability in range of        II. Failure of separation of parts
                   motion and with lateral stress                             III. Duplication of parts
               2. Most can be treated with closed reduction; open             IV. Overgrowth of parts
                   reduction can be necessary if supporting structures        V.   Undergrowth of parts
                   entrap the bone (e.g. metacarpal head through              VI. Congenital constriction bands
                   extensor mechanism)                                        VII. Generalized skeletal abnormalities
           B. Ligamentous injury — usually lateral force                      Adapted from Swanson, A.B.: J Hand Surg 1:8, 1976.
               1. Gameskeeper’s thumb — rupture of ulnar collateral
                   ligament of MP joint                                                                   Table 6-1
               2. Wrist injury — multiple ligaments can be involved.
                   Diagnosis may require arthrogram, arthroscopy, or
                   MRI. Clinical diagnosis by pattern of pain, x-rays,     VIII. HAND TUMORS
                   palpation for abnormal movement                               A. Benign
           C. Treatment                                                             1. Ganglion cysts — most common
               1. Try to maintain controlled protected motion                           a. Synovial cyst of joint or tendon sheath
               2. Unstable joint — immobilize for 3 wks. (some, e.g.                    b. Treatment is excision
                   thumb ulnar collateral ligament, might need operative            2. Giant cell tumor
                   repair)                                                          3. Glomus tumors — of thermoregulatory
                                                                                        neuromyoarterial apparatus. Presents with pain and
     VII. CONGENITAL DEFECTS                                                            temperature sensitivity
          A. Classification system (Table 6-1)                                      4. Bone tumors — enchondroma, osteoid, osteoma
          B. Common defects                                                      B. Malignant
             1. Polydactyly — most common. Duplication of fingers,                  1. Skin cancers (e.g. basal cell, squamous cell,
                  usually border digits. Duplication of 5th finger is                   melanoma)
                  common autosomal dominant trait in African-                       2. Malignant bone tumors are uncommon in hand
                  Americans. Thumb duplication often requires
                  reconstructive surgery
             2. Syndactyly — 2nd most common — May be simple,
78                                                                                                                                                 79
     IX. MISCELLANEOUS                                                                 CHAPTER 7
         A. Rheumatoid arthritis — synovial hypertrophy can lead to
            nerve compressions (carpal tunnel syndrome), joint                         LOWER EXTREMITY
            destruction. Hand surgeons get involved with                               The plastic and reconstructive surgeon is often called upon to treat
            synovectomy, joint replacement, carpal tunnel release                      many wound problems of the lower extremity. These include leg
         B. Dupuytren’s contracture                                                    ulcers of various etiologies, trauma with extensive soft tissue loss or
            1. Fibrous contraction of palmar fascia causes flexion                     exposed bone, vascular or neural structures, and lymphedema.
                 contractures of fingers
            2. Treatment is surgical excision of involved fascia                       I.   ULCERATIONS
         C. Nerve compressions — compression of nerve by                                    An ulcer is an erosion in an epithelial surface. It is usually due
            overlying muscle, ligament or fascia                                            to an underlying pathophysiological process. The proper
            1. Example: carpal tunnel — compression by transverse                           treatment depends upon the etiology
                 carpal ligament                                                            A. Etiology
            2. Diagnosis by symptoms and EMG                                                     1. Venous Stasis Ulcer
            3. Treatment options include splinting, steroid                                          a. Due to venous hypertension: related to venous
                 injections, surgery                                                                      valvular incompetence — usually found over the
                                                                                                          medial malleolus
                                                                                                     b. Increased edema
                                                                                                     c. Increased hemosiderin deposition (dark
     UPPER EXTREMITY                                                                                      discoloration)
                                                                                                     d. Not painful
     1.   Achauer, B.H. Plastic Surgery: Indications, Operations,
                                                                                                 2. Ischemic Ulcer
          Outcomes. St. Louis: Mosby, 2000.
                                                                                                     a. Due to proximal arterial occlusion
     2.   Aston, S.J. et al. (eds.) Grabb and Smith’s Plastic Surgery. 5th                           b. Usually more distal on the foot than venous
          Ed. Baltimore: Lippincott, Williams and Wilkins, 1997.                                          stasis ulcers
                                                                                                     c. Most often found on the lateral aspects of the
     3.   Green, D.P. Operative Hand Surgery. New York: Churchill                                         great and fifth toes, and the dorsum of the foot
          Livingstone, 1996.                                                                         d. No edema
     4.   McCarthy, J. Plastic Surgery. (8 vols). St. Louis: Mosby, 1990.                            e. No change in surrounding pigmentation
                                                                                                     f. Painful
     *Fig. 6-4 reprinted with permission from Marks, M.W., Marks, C. Fundamentals of                 g. Doppler ankle/brachial indices 0.1-0.3
     Plastic Surgery. Philadelphia: W.B. Saunders Co., 1997.
                                                                                                     h. Indicates advanced atherosclerotic disease
                                                                                                     i. Dirty, shaggy appearance
                                                                                                 3. Diabetic Ulcer
                                                                                                     a. Due to decreased sensation (neurotrophic) or
                                                                                                          occasionally decreased blood flow
                                                                                                     b. Usually located on plantar surface of foot over
                                                                                                          metatarsal heads or heel
                                                                                                     c. Edema ±
                                                                                                     d. No change in surrounding pigmentation

80                                                                                                                                                               81
          4.   Traumatic Ulcer Surgical treatment requires excision              weekly or bi-weekly basis
               of the entire area of the ulcer, scar tissue, and            g.   Surgical treatment requires excision of the entire
               surrounding                                                       area of the ulcer, scar tissue, and surrounding
               a. Failure to heal is usually due to compromised                  area of increased pigmentation (hemosiderin
                    blood supply and an unstable scar                            deposition). Subfascial ligation of venous
               b. Usually occurs over bony prominence                            perforators is also performed
               c. Edema ±                                                        i. Skin grafting of large areas is usually not a
               d. Pigmentation change ±                                                problem. Intact periosteum or paratenon
               e. Pain ±                                                               will take a graft well
          5. Pyoderma Gangrenosum                                                ii. Free flaps can be effective for recalcitrant
               a. Frequently associated with arthritis and/or                          ulcers
                    inflammatory bowel disease or an underlying             h. Pressure gradient stocking (such as Jobst™
                    carcinoma                                                    garments) and a commitment to avoiding
               b. Clinical diagnosis — microscopic appearance                    standing for long periods of time are necessary
                    non-specific                                                 for long term success
               c. Zone of erythema at advancing border of the          2.   Ischemic Ulcers
                    lesion                                                  a. Most require revascularization based upon
     B.   Treatment                                                              angiographic findings
          Each ulcer type requires accurate diagnosis, specific             b. Control associated medical problems such as
          treatment of the underlying etiology, and care of the                  congestive heart failure, hypertension, diabetes,
          wound. Not all ulcers of the lower extremity will require              etc.
          surgical intervention when appropriate management is              c. Bed rest without elevation of the foot of the bed
          pursued. The key to healing these ulcers is wound                 d. Topical and/or systemic antibiotics are usually
          hygiene, correction of the underlying problem, and                     required
          specific surgical intervention when appropriate. The              e. If possible, it is best to perform bypass surgery
          plastic surgeon is an integral member of the treatment                 first, and then healing of the ulcer by any means
          team from the onset of the problem. Remember that two                  will be easier
          different predisposing conditions may occur in the same           f. Usually a skin graft will close the wound; flap
          patient. If so, the treatment must address both conditions             closure may be required. A more proximal
          1. Venous Stasis Ulcers                                                amputation may be required if revascularization
               a. Most will heal if venous hypertension is                       is not possible
                    controlled                                         3.   Diabetic Ulcer
               b. Decrease edema with constant bed rest with                a. Debride necrotic tissue and use topical and
                    foot elevation                                               systemic antibiotics to control the infection
               c. Clean wound 2-3 times a day with soap and                 b. Be conservative in care; early amputation is
                    water                                                        detrimental since many patients will have life-
               d. Topical antimicrobials may be required                         threatening infections in the other leg within a
               e. Systemic antibiotics are required if cellulitis is             few years
                    present or bactermia occurs                             c. After control of bacterial contamination, small
               f. “Unna boots” may heal ulcers in patients who                   ulcers may be excised and closed primarily;
                    are noncompliant with bed rest or must                       larger ulcers may require flap coverage
                    continue to work. These are changed on a
82                                                                                                                                    83
                    d.  Treatment should also include resection of                        the level of injury, presence or absence of bony and
                        underlying bony prominence                                        neurological injury
                    e. Rule out proximal arterial occlusion and improve               4. Limb threatening injuries of vascular interruption or
                        arterial inflow when needed                                       open fracture are best assessed in the OR with
                    f. Postoperative diabetic foot care at home is                        radiologic backup
                        paramount to proper management. Patient                       5. Fasciotomy is often required to maintain tissue
                        education in caring for and examining their feet                  perfusion in severe high energy or crush injuries
                        is extremely important                                        6. Intra-operative evaluation for viability utilizing visual
               4.   Traumatic Ulcer                                                       and surgical techniques may be supplemented by
                    a. Nonhealing is usually secondary to local                           intravenous fluorescein to assess the viability of
                        pathology                                                         degloved tissue
                    b. Resection of the ulcer, thin skin, and unstable           B.   Level of Injury
                        scar is required                                              1. Thigh
                    c. Reconstruction with a local or distant flap is                     Usually managed with delayed primary closure or
                        required                                                          skin graft. An abundance of soft tissue in the thigh
               5.   Pyoderma Gangrenosum                                                  makes coverage of bone or vessels rarely a problem
                    a. Very difficult                                                     a. Open joint wounds are usually managed by the
                    b. May include anti-inflammatory drugs or                                   orthopedic service with profuse lavage and
                        immunosuppressives, as well as local wound care                         wound closure
                        agents                                                            b. Extensive soft tissue loss will often require flap
                    c. Success in treatment has been reported with                              rotation — the tensor fascia lata, gracilis, rectus
                        hyperbaric oxygen in conjunction with local                             femoris, vastus lateralis, and biceps femoris are
                        wound care                                                              primarily utilized
                                                                                          c. The medial and lateral heads of the
     II.   TRAUMA                                                                               gastrocnemius muscle are most often utilized to
           Lower extremity trauma is frequently very complex, and often                         cover an open knee joint
           requires a team approach involving the orthopedic, vascular                2. Lower Leg
           and plastic surgeons. Limb salvage with bipedal ambulation                     a. Paucity of tissue in the pre-tibial area results in
           and normal weight bearing is the goal of all surgical                                many open fractures which cannot be closed
           intervention                                                                         primarily
           A. Initial Management                                                          b. General principles of wound closure and
                1. All patients with lower extremity trauma should be                           achieving bacterial balance prevail
                     evaluated for associated injuries, and treated                       c. Delayed primary closure, healing by secondary
                     according to ATLS criteria                                                 intention, or skin grafts are good alternatives in
                2. All life threatening injuries (intracranial, intrathoracic,                  the management of wounds where bone or
                     and intra-abdominal) should be addressed initially in                      fractures are not exposed
                     the operating room                                                   d. Rigid fixation with vascularized tissue coverage
                3. Surgical debridement of the wound in the operating                           is necessary for bone healing
                     room and irrigation with pulsatile jet lavage of a                   e. Fractures of the lower leg are usually classified
                     physiologic solution is the proper initial                                 by the Gustilo system (Table 7-1)
                     management. Specific management depends upon                               i. Type I and II fractures usually have a good
                                                                                                     outcome with varied treatment
84                                                                                                                                                    85
                                                                                          4.   The technical feasibility of lower extremity
     Gustilo Classification of Open Fractures of the Lower Leg                                 reconstruction must be weighed against the option of
                                                                                               amputation with early prosthesis fitting and
     Type I              Open tibial fracture with a wound less than one                       ambulation. Extensive injuries may lead to
                         centimeter                                                            rehabilitation and non-weight bearing of up to two
     Type II             Open tibial fracture with a wound greater than                        years, and late complications may still require
                         one centimeter, without extensive soft tissue                         amputation
     Type IIIA           Open tibial fracture with adequate soft-tissue
                                                                                 III. LYMPHEDEMA
                         coverage despite extensive laceration or flaps,
                                                                                      Lymphedema may be a congenital or acquired problem, and
                         or high-energy injury accompanied by any size
                                                                                      results in accumulation of protein and fluid in the
                                                                                      subcutaneous tissue. It may be a very debilitating and
     Type IIIB           Open tibial fracture, extensive soft-tissue loss with
                                                                                      disfiguring disease, and at this time has no good surgical
                         periosteal stripping and bone exposure
     Type IIIC           Open tibial fracture with arterial injury requiring          A. Primary (idiopathic)
                         repair                                                            1. Female: Male = 2:1
                                                                                           2. Classification — depends on age of onset
                                                                                                a. Congenital — present at birth
                                      Table 7-1
                                                                                                     i. Milroy’s disease — familial autosomal
                                                                                                          dominant incidence
                            ii.  Gustilo Type III injuries have a worse                              ii. 10% of all primary lymphedema
                                 prognosis                                                      b. Lymphedema praecox
                    f.      Depending on the level of injury, different                              i. Usually a disease of females
                            muscle flaps can be used to close the wounds                             ii. 80% of all primary lymphedema
                            i. Proximal 1/3 of tibia                                                 iii. Appears at puberty or early adulthood
                                 Medial head of the gastrocnemius muscle                             iv. Localized swelling on dorsum of foot that
                                 Lateral head of the gastrocnemius muscle                                 gets worse with activity
                                 Proximally based soleus                                             v. Meige’s disease presents with significant
                            ii. Middle 1/3 of tibia                                                       symptoms of acute inflammation
                                 Proximally based soleus                                        c. Lymphedema tarda
                                 Flexor digitorum longus muscle                                      i. Appears in middle or later life
                                 Extensor hallucis longus muscle                           3. Diagnosis
                            iii. Lower 1/3 of tibia                                             a. By history — sometimes hard to discern a
                                 Microvascular free tissue transfer                                  component of venous stasis from the
                    g.      Fasciocutaneous flaps are another alternative for                        lymphedema
                            closure of difficult wounds in the lower leg                        b. Lymphangiogram — 70% have hypoplasia, 15%
               3.   Foot                                                                             aplasia and 15% hyperplasia
                    a. Split thickness skin grafts should be used if bone             B. Secondary: Acquired — Usually secondary to pathology in
                         not exposed                                                       the regional lymph nodes
                    b. The heel may be covered by medial or lateral                        1. Wucheria bancrofti — number one cause of
                         plantar artery flaps                                                   lymphedema worldwide
                    c. Forefoot — toe fillet and plantar digital flaps                     2. Post traumatic or post surgical
86                                                                                                                                                    87
               3.   Secondary to regional node metastases                     CHAPTER 8
               4.   Treatment
                    a. Nonoperative                                           THERMAL INJURIES
                         i. Preferable in most circumstances and many         Thermal destruction of the skin results in severe local and systemic
                              patients are managed quite well                 alterations. This destruction can occur from thermal energy,
                         ii. Elevation and elastic support are the            chemical reactions, electricity, or the response to cold. The
                              mainstays of therapy — intermittent             management of the patient with a major thermal injury requires
                              compression machines may be of benefit          understanding of the pathophysiology, diagnosis, and treatment not
                         iii. Use of steroids controversial                   only of the local skin injury but also of the derangements that occur
                         iv. Benzopyrones may be of benefit in high           in hemodynamic, metabolic, nutritional, immunologic, and
                              protein lymphedema                              psychologic homeostatic mechanisms.
                         v. Antiparasitic medications are indicated
                              when appropriate                                I.   BURNS
                         vi. Systemic antibiotics and topical antifungal           A. Pathophysiology: Amount of tissue destruction is based on
                              medications are often required                          temperature (>40˚C) and time of exposure (Fig. 8-1)
                    b. Surgical management                                         B. Diagnosis and prognosis
                         i. Ablative procedures — usually involve                     1. Burn size: % of total body surface area (TBSA) burned
                              excision of tissue and closure with a flap or               a. Rough estimate is based on rule of 9s (Fig. 8-2)
                              skin graft                                                  b. Different charts are required for adults and
                         ii. Attempted re-establishment of lymphatic                           children because of head-chest size discrepancy
                              drainage by microvascular techniques has                         and limb differentials for ages birth to seven
                              shown early improvement, but is prone to                         years (Fig. 8-3 and 8-4)
                              high, late failure rate. May offer hope for
                              patients with secondary lymphedema in the

     1.   Heller, L. and Levin, S.L. Lower extremity microsurgical
          reconstruction. Plast Reconstr Surg. 2001; 108:1029-41.

                                                                                                            Fig. 8-1
88                                                                                                                                                    89
     Fig. 8-2   Fig. 8-3

90                         91
                2.   Age: burns at the extremes of age carry a greater
                     morbidity and mortality
                3.   Depth: difficult to assess initially
                     a. History of etiologic agent and time of exposure
                     b. Classification (Fig. 8-5)
                          i. First degree: erythema but no skin breaks
                          ii. Second degree: blisters, red and painful
                               (a) Superficial partial-thickness, involves
                                    epidermis and upper dermis
                               (b) Deep partial-thickness, involves deeper
                          iii. Third degree: full-thickness-insensate,
                               charred or leathery
                          iv. Fourth degree: muscle, bone
                4.   Location: face and neck, hands, feet, and perineum
                     may cause special problems and warrant careful
                     attention; often necessitate hospitalization/burn
                5.   Inhalation injury: beware of closed quarters burn,
                     burned nasal hair, carbon particles in pharynx,
                     hoarseness, conjunctivitis
                6.   Associated injuries, e.g. fractures

     Fig. 8-4

                                    Fig. 8-5
92                                                                           93
          7.   Co-morbid factors, e.g. pre-existing cardiovascular,
               respiratory, renal and metabolic diseases; seizure       Categorization of burns (American Burn Association):
               disorders, alcoholism, drug abuse
                                                                                          Major Burn            Moderate Burn         Minor Burn
          8. Prognosis: best determined by burn size (TBSA) and
                                                                       Size-Partial       > 25% adults           15-25% adults        < 15% adults
               age of patient, inhalation injury                         thickness        > 20% children         10-20% children      < 10% children
          9. Circumferential burns: can restrict blood flow to         Size-Full          >10%                   2-10%                < 2%
               extremity, respiratory excursion of chest and may         thickness
               require escharotomy                                     Primary            major burn             not involved         not involved
     C.   Categorization of burns is used to make treatment              areas            if involved
          decisions and to decide if treatment in a burn center is     Inhalation         major burn if
                                                                         injury           present or             not suspected        not suspected
          necessary (Table 8-1, Table 8-2)                                                suspected
     D.   Treatment plan                                               Associated         major burn if          not present          not present
          1. History and physical exam                                  injury            present
          2. Relieve respiratory distress — escharotomy and/or         Co-morbid          poor risk patients     patient relatively   not present
               intubation                                               factors           make burn major        good risk
          3. Prevent and/or treat burn shock — IV — large bore         Miscellaneous      electrical injuries
               needle                                                  Treatment          usually                general hospital     often managed
          4. Monitor resuscitation — Foley catheter and hourly           environment      specialized            with designated      as out-patient
                                                                                          burn care facility     team
               urine output
          5. Treat ileus and nausea — N.G. tube if > 20% burn                                               Table 8-1
          6. Tetanus prophylaxis
          7. Baseline laboratory studies i.e. Hct., UA, FBS, BUN,
               chest x-ray, electrolytes, EKG, crossmatch, arterial
               blood gases, and carboxyhemoglobin                                   Burns That Dictate Patient Admission to a
          8. Cleanse, debride, and treat the burn wound                                     Hospital or Burn Center
     E.   Respiratory distress
                                                                            •       2˚ and 3˚ burns greater than 10% of BSA in patients
          1. Three major causes of respiratory distress in the
                                                                                    under 10 or over 50 years of age
               burned patient:
               a. Unyielding burn eschar encircling chest                   •       2˚ and 3˚ burns greater than 20% BSA in any age group
                    i. Distress may be apparent immediately                 •       2˚ and 3˚ burns posing a serious threat of functional or
                    ii. Requires escharotomy (cutting into the                      cosmetic impairment, e.g. the face, hands, feet, genitalia,
                         eschar to relieve constriction)                            perineum, and about major joints)
               b. Carbon monoxide poisoning                                 •       3˚ burns greater than 5% BSA in any age
                    i. May be present immediately or later
                                                                            •       Electrical burns including lightning
                    ii. Diagnosed by carboxyhemoglobin levels
                         measured in arterial blood gas                     •       Chemical burns posing a serious threat of functional or
                    iii. Initial Rx is displacement of CO by 100% O2                cosmetic impairment
                         by facemask                                        •       Inhalation injury
                    iv. Hyperbaric oxygen treatment may be of               •       Burns associated with major trauma

                                                                                                            Table 8-2
94                                                                                                                                                     95
               c.   Smoke inhalation leading to pulmonary injury            2.   Resuscitation requires replacement of sodium ions
                    i. Insidious in onset (18-36) hours                          and water to restore plasma volume and cardiac
                    ii. Due to incomplete products of combustion,                output
                         not heat                                                a. Many formulas have been reported to achieve
                    iii. Causes chemical injury to alveolar basement                  resuscitation
                         membrane and pulmonary edema                                 i. This can be given by prescribing 4cc
                    iv. Initial Rx is humidified O2 but intubation                         Ringer’s lactate/Kg/%TBSA burn over the
                         and respiratory support may be required                           first 24 hours (Baxter or Parkland Hospital
                    v. Secondary bacterial infection of the initial                        formula)
                         chemical injury leads to progressive                         ii. 1/2 of the first 24 hour fluid requirement
                         pulmonary insufficiency                                           should be given in the first eight hours
                    vi. Severe inhalation injury alone or in                               postburn and the remaining 1/2 over the
                         combination with thermal injury carries a                         next 16 hours
                         grave prognosis                                         b. A plasma volume gap may remain restored
                    vii. Three stages of presentation have been                       between 24-30 hours postburn by administering
                         described:                                                   .35-.50cc plasma/Kg/% TBSA burn
                         (a) Acute pulmonary insufficiency                       c. After 30 hours D5W can be given at a rate to
                              (immediately post burn to 48 hours)                     maintain a normal serum sodium
                         (b) Pulmonary edema (48-72 hours)             G.   Monitoring resuscitation
                         (c) Bronchopneumonia (25 days)                     1. Urine output 30-55cc/hr in adults and 1.2cc/Kg/hr in
     F.   Burn shock                                                             children < age 12
          1. Massive amounts of fluid, electrolytes, and protein are        2. A clear sensorium, pulse <120/min, HCO3 > 18
              lost from circulation almost immediately after                     meq/L, cardiac output >3.1 L/M2
              burning (Table 8-3)                                           3. CVP in acute major burns is unreliable
                                                                       H.   Treatment of the burn wound (Table 8-4)
                                                                            1. Wound closure by the patient’s own skin is the
            Burn or Associated Condition Dictating                               ultimate goal of treatment
                  Extra Fluid Administration                                     a. By spontaneous healing
                                                                                 b. Autograft
     •    Underestimation of the % TBSA burn                                     c. Allograft
     •    Burn greater than 80% TBSA                                             d. Xenograft
     •    Associated traumatic injury                                            e. Artificial skin
                                                                                 f. Cultured epithelial cells
     •    Electrical burn                                                   2. Specific treatment of the burn wound differs from
     •    Associated inhalation injury                                           one burn center to another
     •    Delayed start of resuscitation                                         a. The most commonly employed topical
                                                                                      antibacterials are silver sulfadiazine (Silvadene®)
     •    4º burn
                                                                                      and mafenide acetate (Sulfamylon®)
     •    Administration of osmotic diuretics                                    b. Status of burn wound bacterial colonization and
     •    Pediatric burns                                                             effectiveness of topical antibacterial treatment
                                                                                      can be monitored by biopsies of wound for
                              Table 8-3                                               quantitative and qualitative bacteriology
96                                                                                                                                          97
                                                                                         3.  Necrotic tissues may be removed by any of several
                              Sample Orders                                                  techniques:
     For a 70 Kg 40 year old patient with a 40% flame burn:                                  a. Formal excision
                                                                                             b. Tangential (layered) debridement
     1.    Admit to ICU portion of burn center                                               c. Enzymatic debridement
     2.    Strict bedrest with head elevated 45˚                                             d. Hydrotherapy — a useful adjunct
     3.    Maintain elevation of burned extremities                                      4. Autografts should be applied to priority areas first,
     4.    Vital signs: pulse, BP respiration q 15 min, temperature q 2 h                    such as the hands, face and important joints
     5.    Check circulation of extremities (capillary refill or                         5. Once healed, pressure is usually necessary with
           Doppler) q 30 min                                                                 elastic supports to minimize hypertrophic scarring
     6.    100% O2 face mask                                                             6. Physical therapy — important adjunct in burn care
     7.    Infuse Ringer’s lactate at 700cc for first hour, then reassess         I.     Complications: can occur in every physiologic system or
     8.    Measure urinary output by Foley catheter to closed                            secondary to burn injury (Table 8-5)
           drainage                                                                      1. Renal failure
     9.    Notify physician of first hour’s urine output (must be 30-                        a. From hypovolemia
           50cc: 1.2-1.5cc in pediatric patient)                                             b. Beware of nephrotoxic antibiotics in the burn
     10.   N.P.O.                                                                                 patient
     11.   N.G. tube to intermittent low suction
     12.   Measure pH of gastric content q 2 h — stress ulcer
           prophylaxis (e.g. Zantac)
     13.   Morphine sulfate 4 mg intravenously q 2-3 hr prn pain —
                                                                                              Risk Factors in Burn Wound Infection
           no intramuscular narcotics (unreliable absorption)
     14.   Tetanus toxoid 0.5cc IM (if patient previously immunized)        I.         Patient Factors
     15.   Send blood for Hct., glucose, BUN, cross match 2 units,                     A. Extent of burn > 30% of body surface
           electrolytes                                                                B. Depth of burn: full-thickness vs. partial-thickness
     16.   Urine for U.A. and culture                                                  C. Age of patient (very young or very old at higher risk)
     17.   Chest x-ray                                                                 D. Pre-existing disease
     18.   EKG                                                                         E. Wound dryness
     19.   Arterial blood gases q 6 h and prn                                          F. Wound temperature
     20.   Cleanse wounds with Betadine solution, debride all                          G. Secondary impairment of blood flow to wound
           blisters, map injury on Lund-Browder chart, and                             H. Acidosis
           photograph wounds                                                II.        Microbial Factors
     21.   Apply silver sulfadiazine to all wounds with sterile gloved                 A. Density >105 organisms per gram of tissue
           hand (use reverse isolation technique when burn wounds                      B. Motility
           are exposed)                                                                C. Metabolic products
     22.   Dress wounds with burn gauze and surgifix                                        1. Endotoxin
     23.   Splint extremities as per physical therapist                                     2. Exotoxins
     24.   Change all dressings, cleanse wounds, and reapply topical                        3. Permeability factors
           antibacterial q 8 h or q 12 h                                                    4. Other factors
     25.   Bronchoscopy — If inhalation injury suspected                               D. Antimicrobial resistance

                                  Table 8-4                                                                 Table 8-5
98                                                                                                                                                  99
      2.   Gastrointestinal bleeding                                                 i.   Splints are used to prevent joint
           a. More likely in burns over 40%                                               contractures, e.g. elbow and knee are kept
           b. Usually remains subclinical                                                 in extension, and MCP joints of fingers in
           c. Antacids and H2 blockers                                                    flexion
           d. Increased risk with burn wound sepsis                             c.   Timely wound closure with adequate amounts of
      3.   Burn wound sepsis                                                         skin should largely eliminate these problems
           a. Monitored by tissue biopsy — qualitative and                      d.   Continued postoperative splinting and elastic
               quantitative                                                          pressure supports are of value in the remolding
           b. Must keep bacterial count < 105 bacteria/gm of                         of collagen with prevention of hypertrophic
               tissue                                                                scars
           c. Clinically suspect sepsis with
               i. Sudden onset of hyper or hypothermia           II.   CHEMICAL BURNS
               ii. Unexpected congestive heart failure or              A. Pathophysiology
                     pulmonary edema                                      1. Tissue damage secondary to a chemical depends on:
               iii. Development of acute respiratory distress                  a. Nature of agent
                     syndrome                                                  b. Concentration of the agent
               iv. Ileus occurring after 48 hours postburn                     c. Quantity of the agent
               v. Mental status change                                         d. Length of time the agent is in contact with tissue
               vi. Azotemia                                                    e. Degree of tissue penetration
               vii. Thrombocytopenia                                           f. Mechanism of action
               viii. Hypofibrinogenemia                                B. Diagnosis
               ix. Hyper or hypoglycemia is especially suspect            1. Chemical burns are deeper than initially appear and
                     if burn > 40% TBSA                                        may progress with time
               x. Blood cultures may be positive but in many                   a. Fluid resuscitation needs often underestimated
                     cases are not                                             b. Watch for renal/liver/pulmonary damage
      4.   Progressive pulmonary insufficiency                         C. Treatment
           a. Can occur after:                                            1. Initial treatment is dilution of the chemical with
               i. Smoke inhalation                                             water
               ii. Pneumonia                                              2. Special attention to eyes — after copious irrigation
               iii. Cardiac decompensation                                     with saline, consult ophthalmologist
               iv. Sepsis from any cause                                  3. After 12 hours initial dilution, local care of the wound
           b. Produces:                                                        with debridement, topical antibacterials, and eventual
               i. Hypoxemia                                                    wound closure is same as for thermal burn
               ii. Hypocarbia                                          D. Of particular note are:
               iii. Pulmonary shunting                                    1. Gasoline
               iv. Acidosis                                                    a. Excretion by lung
      5.   Wound contracture and hypertrophic scarring                         b. May cause large skin burn, if immersed
           a. Largely preventable                                              c. Watch for atelectasis, pulmonary infiltrates;
           b. Since a burn wound will contract until it meets                      surfactant is inhibited
               an opposing force, splinting is necessary from             2. Phenol
               the outset                                                      a. Dull, gray color to skin, may turn black
                                                                               b. Urine may appear smoky in color
100                                                                                                                                     101
                    c. Spray water on burn surface                                             (b) Vessels thrombose as current passes
                    d. Wipe with polyethylene glycol                                                rapidly along them
                    e. Direct renal toxicity                                              ii. Effects of current may not be immediately
               3.   Hydrofluoric acid                                                          seen
                    a. Irrigate copiously with water                       C.   Special effects of electrical injury
                    b. Subcutaneous injections of 10% of calcium                1. Cardiopulmonary
                        gluconate                                                    a. Anoxia and ventricular fibrillation may cause
                    c. Monitor EKG patients — may become                                  immediate death
                        hypocalcemic                                                 b. Early and delayed rhythm abnormalities can
                    d. Pulmonary edema may occur if subjected to                          occur
                        fumes                                                        c. EKG changes may occur some time after the
               4.   White phosphorous                                                     burn
                    a. Do not allow to desiccate — may ignite                   2. Renal
                    b. Each particle must be removed mechanically                    a. High risk of renal failure due to hemoglobin and
                    c. Copper sulfate (2%) may counteract to make                         myoglobin deposits in renal tubules
                        phosphorous more visible (turns black in color)                   i. Requires higher urine flow (75cc/hr in
                    d. Watch for EKG changes (Q – T+ interval and                              adults)
                        S – T and T wave changes)                                         ii. Must alkalinize urine to keep hemoglobin
                    e. May cause hemoglobinemia and renal failure                              and myoglobin in more soluble state
                                                                                          iii. Mannitol may be useful to clear heavy
      III. ELECTRICAL INJURIES                                                                 protein load
           A. Pathophysiology                                                   3. Fractures:
              1. Effects of passage of electric current through the                  a. Tetanic muscle contractions may be strong
                  body depend on:                                                         enough to fracture bones, especially spine
                  a. Type of circuit                                            4. Spinal cord damage
                  b. Voltage of circuit                                              a. Can occur secondary to fracture or
                  c. Resistance offered by body                                           demyelinating effect of current
                  d. Amperage of current flowing through tissue                 5. Abdominal effects
                  e. Pathway of current through the body                             a. Intraperitoneal damage can occur to G.I. tract
                  f. Duration of contact                                                  secondary to current
              2. Tissue resistance to electrical current increases from         6. Vascular effects
                  nerve (least resistant) to vessel to muscle to skin to             a. Vessel thrombosis progresses with time
                  tendon to fat to bone                                              b. Delayed rupture of major vessels can occur
           B. Diagnosis                                                         7. Cataract formation — late complication
              1. Types of injury                                                8. Seizures
                  a. Arc injury: localized injury caused by intense        D.   Treatment
                       heat                                                     1. CPR if necessary
                  b. Injury due to current                                      2. Fluids — usually large amounts
                       i. Due to heat generated as current flows                     a. No formula is accurate because injury is more
                            through tissue                                                extensive than can be predicted by skin damage
                            (a) Injury more severe in tissue with high               b. Alkalinize with NaHCO3, if myoglobinuria or
                                 resistance (i.e. bone)                                   hemoglobinuria present
102                                                                                                                                        103
                3.   Monitoring                                                                              (ii) Daily whirlpool and exercise
                     a. CVP or pulmonary wedge pressure helpful since                                   (d) Sympathectomy, anti-coagulants, and
                          total capillary leak does not occur as it does in a                                early amputation of questionable value
                          thermal burn                                                                       in controlled studies
                     b. Maintain urine output at 75-100cc/hr until all                            ii.   Usually wait until complete demarcation
                          myoglobin and/or hemoglobin disappears from                                   before proceeding with amputations. Non-
                          urine                                                                         viable portions of extremities will often
                4.   Wound Management                                                                   autoamputate with good cosmetic and
                     a. Topical agent with good penetrating ability is                                  functional results.
                          needed [i.e. silver sulfadiazine (Silvadene®) or           B.   Hypothermia
                          mafenide acetate (Sulfamylon®)]                                 1. Diagnosis
                     b. Debride non-viable tissue early and repeat as                        a. Core temperature < 34˚C
                          necessary (every 48 hrs) to prevent sepsis                         b. Symptoms and signs mimic many other diseases
                     c. Major amputations frequently required                                c. High level of suspicion necessary during cold
                     d. Technicium-99 stannous pyrophosphate                                      injury season
                          scintigraphy may be useful to evaluate muscle                   2. Treatment
                          damage                                                             a. Must be rapid to prevent death
                5.   Treat associated injuries (e.g. fractures)                              b. Monitor EKG, CVP, and arterial blood gases and
                                                                                                  pH during warming and resuscitation, maintain
      IV.   COLD INJURIES                                                                         urine output of 50cc/hr
            The two conditions of thermal injury due to cold are local                       c. Begin Ringer’s Lactate with 1 ampule NaHCO3
            injury (frostbite) and systemic injury (hypothermia)                             d. Oral airway or endotracheal tube if necessary
            A. Frostbite                                                                     e. Rapidly rewarm in 40˚ hydrotherapy tank
                 1. Pathophysiology                                                               (requires 1-2 hours to maintain body
                      a. Formation of ice crystals in tissue fluid                                temperature at 37˚C)
                           i. Usually in areas which lose heat rapidly                       f. Treat arrhythmias with IV Lidocaine drip if
                                (e.g. extremities)                                                necessary
                      b. Anything which increases heat loss from the                         g. Evaluate and treat any accompanying disease
                           body such as wind velocity, or decreases tissue                        states
                           perfusion, such as tight clothing, predisposes
                           patient to frostbite                                 V.   LIGHTNING INJURIES
                      c. Ability of various tissue to withstand cold injury          A. Cutaneous effects — lightning strikes may cause
                           is inversely proportional to their water content             cutaneous burn wounds
                 2. Treatment                                                           1. Contact burns from clothing on fire or contact with
                      a. The key to successful treatment is rapid                            hot metal (i.e. zippers, etc)
                           rewarming in a 40˚C waterbath                                2. Entry and exit burns are usually small, may be partial
                           i. Admission to hospital usually required                         or full thickness
                                (a) Tetanus prophylaxis                                 3. Lightning burns are not the same as electrical burns
                                (b) Wound management                                         — don’t get deep tissue injury
                                (c) Physical therapy                                 B. May have temporary ischemic effects on extremity —
                                      (i) Maintenance of range of motion                pallor or neurologic deficits. Spontaneous recovery after a
                                           important                                    few hours is the rule — probably due to local
104                                                                                                                                                   105
                vasoconstriction                                               CHAPTER 9
           C.   Systemic effects can occur such as arrhythmias, cataracts,
                CNS symptoms                                                   AESTHETIC SURGERY
                                                                               Aesthetic surgery includes those procedures that provide an
      CHAPTER 8 — BIBLIOGRAPHY                                                 enhancement of one’s appearance to improve one’s self-esteem. The
                                                                               goals of patients should be realistic and their motivation should be
      THERMAL INJURIES                                                         appropriate. Unrealistic expectations and/or personality disorders
      1.   Gibran, N.S. and Heimbach, D.M. Current status of burn wound        should alert the surgeon to the possibility of refusing to accept the
           pathophysiology. Clin Plast Surg. 2000; 27:11-22.                   patient or to refer the patient for psychiatric evaluation.

      2.   Matthews, M.S. and Fahey, A.L. Plastic surgical considerations in   There are many valid reasons for seeking aesthetic surgery. A
           lightning injuries. Ann Plast Surg. 1997; 39:561-5.                 teenager may desire a more pleasing nose, a young woman may
                                                                               want her breasts enlarged so she is able to wear certain clothing or
      3.   van Zuijlen, P.P. et al. Dermal substitution in acute burns and     swimming attire, a balding man may want his hair restored, a public
           reconstructive surgery: a subjective and objective long-term        relations person may want to have a more youthful appearance with
           follow-up. Plast Reconstr Surg. 2001; 108: 1938-46.                 a facelift, etc. The common denominator of these examples is the
                                                                               reasonable desire to improve one’s outward appearance for oneself
                                                                               rather than for another person or reason.
                                                                               If patients are selected carefully and their expectations are realistic,
                                                                               then well-executed surgical procedures generally will result in a
                                                                               happy patient and a gratified surgeon. The patient’s self-image is
                                                                               improved and self-confidence is increased. If patients, on the other
                                                                               hand, are poorly selected, even if the procedure is performed
                                                                               flawlessly, the outcome may be tragic for both the patient and the
                                                                               surgeon. If the deformity is minimal and the concern of the patient
                                                                               is great, the chances for a successful outcome are small and the
                                                                               chance for an untoward result is great. Do not operate on these
                                                                               Commonly performed aesthetic surgical procedures can be
                                                                               classified in many ways. One way is by anatomic location.
                                                                               I.   FACIAL REJUVENATION
                                                                                    A. Facelift
                                                                                       1. Anatomy
                                                                                           a. Facial Nerve trunk, rami, branches and their
                                                                                                relations to surface landmarks
                                                                                                i. Innervation, position of muscle of facial
                                                                                           b. Parotid gland/duct anatomy
                                                                                           c. SMAS
                                                                                                i. SMAS (superficial myoaponeurotic system):

106                                                                                                                                                       107
                          superficial muscle-fascial layer in the head           E. Neck Lift
                          and neck; originating as the platysma in the              1. Open
                          neck extending superiorly as a thin layer of              2. Endoscopic
                          fascia just below the subcutaneous fat in the             3. Platysmal plication
                          face and terminating superior to that as the              4. Lipectomy (direct or suction)
                          superficial temporal fascia                               5. Repositioning of submandibular glands
           2.. Operative Options                                                F. Facial Augmentation
               a. Skin Only                                                         1. Cheek Implants
               b. SMAS Plication/Excision Deep plane                                2. Fat Transfer
               c. Mini
           3. Post-Operative Issues                                       II.   Rhinoplasty
               a. Hematoma                                                      A. Terminology
               b. Facial Nerve Injury                                               1. Rostral
               c. Scarring                                                          2. Caudal
               d. Alopecia                                                      B. Anatomy
      B.   Upper Blepharoplasty                                                     1. Surface Anatomy
           1. Anatomy                                                                  a. Supra-tip
               a. Anterior Lamella                                                     b. Tip
               b. Posterior Lamella                                                    c. Valves (internal and external)
           2. Pre-Operative Evaluation                                                 d. Vascular supply
               a. Ptosis vs. Levator dysfunction                                       e. Innervation
      C.   Lower Blepharoplasty                                                        f. Musculature
           1. Operative Options                                                 C. Deformities
               a. Transconjunctival                                                 1. Saddle nose
               b. Sub-ciliary/transcutaneous                                        2. Septal Deviation (Crooked nose)
               c. Canthopexy/Canthoplasty
               d. Fat pads (medial, middle and lateral) need to be        III. BREASTS
                     addressed                                                 A. Augmentation mammoplasty to increase size of breasts
                     i. Removal or repositioning                                  1. Incisions are made to keep scars as inconspicuous as
      D.   Brow Lift                                                                  possible, and may be located in the breast crease,
           1. Operative Options                                                       around the nipple or in the axilla. Breast tissue and
               a. Endoscopic                                                          skin is lifted to create a pocket for each implant
                     i. Fixation techniques                                       2. The breast implant may be inserted under breast
                     ii. Cortical Tunnel                                              tissue or beneath the chest wall muscle
                     iii. Endotines®                                              3. After surgery, breasts appear fuller and more natural
                     iv. Resorbable Screw fixation                                    in contour. Scars will fade in time
               b. Hairline incision                                            B. Mastopexy to reposition ptotic breasts
               c. Browline                                                        1. Incisions outline the area of skin to be removed and
                                                                                      the new position for the nipple
                                                                                  2. Skin formerly located above the nipple is brought
                                                                                      down and together to reshape the breast

108                                                                                                                                           109
               3.   Sutures close the incision, giving the breast its new                      i.   polymethlmethacrylate speheres suspended
                    contour and moving the nipple to its new location                               in bovine collagen
               4.   After surgery, the breasts are higher and firmer, with
                    sutures located around the areola, below it, and         V.   SKIN REJUVENATION
                    sometimes in the crease under the breast                      A. Chemical peels for facial wrinkles
                                                                                      1. Alphahydroxy acids — lightest peels
      III. SOFT TISSUE FILLERS                                                        2. Trichloroacetic acid — intermediate in strength
           A. Non-permanent                                                           3. Phenol/croton oil — most efficacious
              1. Autologous                                                           4. Chemical peel is especially useful for the fine
                   a. Fat                                                                  wrinkles on the cheeks, forehead and around the
                   b. Dermafat grafts                                                      eyes, and the vertical wrinkles around the mouth
                   c. Fascial grafts (i.e., — fascia lata)                            5. The chemical solution can be applied to the entire
                   c. Isolagen                                                             face or to a specific area — for example around the
                      i. A suspension cultured autologous fibroblasts                      mouth — sometimes in conjunction with a facelift
                           harvested by skin biopsy of pt.                            6. At the end of the peel, various dressings or ointments
              2. Homologous                                                                may be applied to the treated area
                   a. Alloderm®                                                       7. A protective crust may be allowed to form over the
                      i. accellular dermal graft is derived from skin                      new skin. When it’s removed, the skin
                           obtained from tissue banks                                       underneath will be bright pink
                      ii. can be micronized                                           8. After healing, the skin is lighter in color, tighter,
              3. Human collagens                                                           smoother, younger looking
                   a. Cosmoderm®                                                  B. Laser Resurfacing
                   b. Cosmoplast®                                                     1. Laser surfacing is also used to improve facial wrinkles
              4. Allograft                                                                 and irregular skin surfaces
                   a. Bovine collagens                                                2. In many cases, facial wrinkles form in localized areas,
                      i. Zyderm®                                                           such as near the eyes or around the mouth. The
                      ii. Zyplast®                                                         depth of laser during treatment can be tightly
              5. Synthetic                                                                 controlled so that specific areas are targeted as
                   a. Radiesse™ (formerly marketed as Radiance™)                           desired
                      i. microspheres of calcium hydroxylapatite-                     3. When healing is complete, the skin has a more
                           based implant                                                   youthful appearance
                      ii. stimulate natural collagen growth, actually             C. Dermabrasion to improve raised scars or irregular skin
                           causing new tissue development                             surface
                      iii. is also useful in the treatment of facial                  1. In dermabrasion, the surgeon removes the top layers
                           lipoatrophy (a stigmatizing effect of HIV),                     of the skin using an electrically operated instrument
                           vocal cord deficiencies, oral and                               with a rough wire brush or diamond impregnated
                           maxillofacial defects, as well as scars and                     bur
                           chin dimples
                   b. Hyaluronic acid
                      i. Restylane® (Q-med)
              6. Permanent
                   a. Artecoll /Artefil
110                                                                                                                                                111
      CHAPTER 9 — BIBLIOGRAPHY                                                  CHAPTER 10
      AESTHETIC SURGERY                                                         BODY CONTOURING
      1.   American Society of Plastic Surgeons. Statement on                   Body contouring may be considered a component of Aesthetic
           Liposuction. June 2000.                                              surgery by utilization of techniques and procedures that will clearly
                                                                                improve and enhance one’s appearance and potentially one’s self-
      2.   Clinics in Plastic Surgery. Selected issues.
                                                                                esteem. Additionally, body contouring procedures are also utilized to
           Facial aesthetic surgery. 24:2, 1997.
                                                                                improve on general health, such as the removal of chronically
           Aesthetic laser surgery. 27:2, 2000.
                                                                                macerated and infected skin and subcutaneous tissues. There has
           New directions in plastic surgery, part I. 28:4, 2001.
                                                                                been a dramatic rise in the number of body contouring patients
           New directions in plastic surgery, part II. 29:1, 2002.
                                                                                which correlates well with the increased number of gastric bypass
      3.   LaTrenta, G. Atlas of Aesthetic Breast Surgery. New York:            patients. These patients will generally have very dramatic weight
           Elsevier Science, 2003.                                              loss without the benefit of enough elastic recoil of the skin.
                                                                                Unfortunately, bariatric surgery patients are not simply left with
      4.   Peck, G.C. and G.C, Jr. Techniques in Aesthetic Rhinoplasty.         familial fat bulges, but rather display aprons of excess skin. This may
           New York: Elsevier Science, 2002.                                    lead to hygiene issues under the aprons with tissue maceration, skin
      5.   Plastic Surgery Educational Foundation. Patient Education            breakdown and even chronic or recurrent infections. Two basic
           Brochures, by topic. Arlington Heights, Il. 1-800-766-4955.          methods — liposuction and excisional surgery — are utilized for
                                                                                body contouring.
      6.   Rees, T.D. and LaTrenta, G.S. Aesthetic Plastic Surgery, 2 vol.
           New York: Elsevier Science, 1994.                                    I.   LIPOSUCTION
                                                                                     A. This is true body contouring and is not utilized for weight
      7.   Spinelli, H. Atlas of Aesthetic Eyelid Surgery. New York: Elsevier            loss
           Science, 2003.                                                            B. Best results obtained when there is localized excess fat
      8.   Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:            3. Generalized excess fat (mildly or moderately overweight)
           safety and efficacy. Plast Reconstr Surg. 2007 Mar;119(3):775-                may still benefit, but may assume potentially less dramatic
           85; discussion 786-7                                                          results and potentially involve more risk
                                                                                     C. Utilizes suction (vacuum pumps for larger volumes and
                                                                                         syringe suction for smaller volume), and cannulas (various
                                                                                         aspiration apertures are available)
                                                                                     D. Surgical techniques:
                                                                                         1. Cannulas may be moved by the surgeon alone
                                                                                         2. power-assisted liposuction (electric or pneumatic
                                                                                              reciprocating cannulas)
                                                                                         3. ultrasound-assisted liposuction (cavitation for adipose
                                                                                              disruption prior to removal) or
                                                                                         4. Laser assisted liposuction (energy disruption of the
                                                                                              adipose prior to absorbtion)
                                                                                     E. Precise and accurate preoperative markings are essential
                                                                                         to quality results — mark topographically, estimate
                                                                                         volumes to remove, mark areas to avoid
                                                                                     F. Postoperative support garments often utilized
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                                                                                     a.   Usually performed to improve hygiene issues
        Operative       Infiltrate               Estimate of Blood Loss              b.   Tissue under pannus frequently macerated,
        technique                                (as a % of volume aspirated)             ulcerated or infected
                                                                                2.   Abdominoplasty — excision of excess abdominal skin
        Dry             No infiltrate            20-45
                                                                                     and fat, and usually involves plication of the fascia for
        Wet             200-300 cc’s/area        4-30                                abdominal wall tightening/contouring
                                                                                3.   Abdominoplasty — Anterior vs. Circumferential
        Superwet        1 cc / 1 cc aspirate     1                              4.   Anterior Abdominoplasty
        Tumescent       2-3 cc infiltrate        1                                   a. Removal of tissue frequently from the umbilicus
                        per 1 cc aspirate                                                 to the pubis
                                                                                     b. Tissue undermined up to costal margin
                                                                                     c. Abdominal wall fascia usually plicated for
                                        Table 10-1
                                                                                          abdominal wall tightening /contouring
      II.     EXCISIONAL BODY CONTOURING SURGERY                                     d. Patient marked standing
              Designed to treat skin quality problems including laxity,              e. Umbilicus is preserved on its stalk and delivered
              pannus formations and cellulite                                             through the flap after caudal mobilization of the
              A. Breast                                                                   flap
                  1. May involve breast reduction or mastopexy (breast               f. Closure involves the superficial fascial system
                       lift procedure)                                                    and skin
                  2. Significant excess skin may require continuation of             g. Achieves excess tissue removal, abdominal and
                       the scar onto the lateral chest wall or onto the back              waist contouring
                       to remove the “dog ears”                                 5.   Circumferential Abdominoplasty — Abdominoplasty
                  3. Repositions the nipple at the inframammary fold and             with transverse flank, thigh and buttock lift — lower
                       re-supports ptotic breast tissue                              body lift (abdominoplasty, transverse flank, thigh and
              B. Arms                                                                buttock lift and possibly medial thigh lift)
                  1. Indicated for moderate to severe skin laxity of the             a. Benefits patients with abdominal as well as flank
                       arms with or without associated arm fat deposits                   and posterior trunk skin excess and laxity
                  2. Mild skin laxity with fat deposits — consider                   b. Abdominal tissue undermined and plicated as
                       liposuction instead of excision                                    noted under Abdominoplasty
                  3. Mark with arms abducted 90 degrees                              c. Excess lateral and posterior skin measured and
                  4. Mark generous vertical (axillary) elipse                             marked preoperatively by pinch testing – final
                  5. Longitudinal (arm) incision line marked                              excision volume determined intraoperatively
                       approximately 4 cm above and parallel to the medial                similar to brachioplasty
                       biciptal sulcus toward medial epicondyle                      d. Lateral and posterior skin-subcutaneous flaps are
                  6. Inferior excision line estimated by pinching, but final              dissected in cephalic and caudal directions
                       determination done in the operating room                      e. No direct or discontinuous undermining is
                  7. Axillary fascial anchoring sutures utilized to gain long             performed over the buttocks
                       term support                                                  f. Direct undermining of the skin-subcutaneous
              C. Abdomen                                                                  flaps done anteriorly only through the superficial
                  Panniculectomy vs. Abdominoplasty                                       fascial system zones of adherence
                  1. Panniculectomy — excision of excess apron of tissue
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                     g.  Discontinuous cannula undermining is                    NOTES
                         performed distally if aesthetic deformity extends
                         into lower half of the thighs
           D.   Medial thigh lift
                1. Classic medial thigh lift plagued with problems such
                    as inferior migration and widening of the scars, lateral
                    traction deformities of the vulva, and early ptosis
                2. Results improved with suspension of the superficial
                    fascial system to Colles fascia along the pubic ramus
           E.   Back
                1. Direct excision of back rolls can be achieved
                2. Incisions and excisions are separate from buttock
                3. Excisions may be combined with breast procedures
           F.   Buttock
                1. Excision may be superior or inferior aspect of the
                2. Inferior tissue excision may lead to flattening of the
                    buttock and an inferior buttock scar as opposed to
                3. Excision may be combined with the lower body lift

      1.   Achauer, BM, Eriksson, E, Guyuron, B, Coleman III, JJ, Russell, RC,
           and Vander Kolk, CA, Plastic Surgery Indications, Operations,
           and Outcomes, 5 vol. Mosby, 2000
      2.   Aston, SJ, Beasley, RW, and Thorne, CNM, Grabb and Smith’s
           Plastic Surgery, Vol. 5, Lippincott-Raven, 1997
      3.   McCarthy, JG, Galiano, RD, Boutros SG, Current Therapy in
           Plastic Surgery, Saunders, Elsevier, 2006
      4.   Shestak, KG (editor) Abdominoplasty, Clinics in Plastic Surgery,
           31 (4) October 2004

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